慢性肾功能不全患者腹主动脉腔内修复术的策略和技术要点

Strategies and technical considerations for endovascular aortic repair in patients with chronic renal insufficiency

摘要:

随着人口老龄化加速，腹主动脉瘤（AAA）合并慢性肾功能不全（CRI）的患者比例逐年升高。两种疾病并存显著增加围术期管理难度并对患者预后造成不利影响。腹主动脉腔内修复术（EVAR）作为AAA的主要微创治疗方式，其术前增强CT及术中造影剂的应用对CRI患者存在明确的肾毒性风险，可诱发对比剂肾病及急性肾损伤，进而增加心力衰竭和死亡风险。针对上述临床难点，本文提出“ACIER”肾保护策略，围绕术前评估肾功能、控制肾高危因素、增加肾储备，术中减少肾损害及术后尽早肾挽救五个关键环节，构建覆盖“术前-术中-术后”全过程的系统化、个体化管理路径。该策略整合精细化风险评估、优化对比剂使用、替代造影技术及围术期肾功能监测等措施，旨在最大限度降低EVAR相关肾损伤风险、改善高危患者预后，为AAA合并CRI患者的安全治疗提供可操作的临床参考。

Abstract:

With the accelerating aging of the population, the coexistence of abdominal aortic aneurysm (AAA) and chronic renal insufficiency (CRI) has become increasingly common, posing substantial challenges to perioperative management and adversely affecting patient outcomes. Although endovascular aortic repair (EVAR) is the standard minimally invasive treatment for AAA, the routine use of contrast-enhanced computed tomography and intraoperative angiography carries a significant risk of nephrotoxicity in CRI patients, potentially leading to contrast-induced nephropathy and acute kidney injury, and consequently increasing the risks of heart failure and mortality. To address these challenges, we propose the "ACIER" renal protection strategy, a structured perioperative management framework encompassing five key components: assessment of renal function, control of renal high-risk factors, enhancement of renal reserve, intraoperative reduction of renal injury, and early postoperative renal salvage. This strategy integrates refined risk stratification, contrast-sparing techniques, alternative imaging modalities, and dynamic postoperative renal monitoring, aiming to minimize contrast-related renal injury and improve outcomes in high-risk patients undergoing EVAR. The ACIER strategy provides a practical and individualized approach for the safe application of EVAR in patients with AAA complicated by CRI.