Clinical application effect of vascular imaging technology in repairing limb wounds with free transplantation of superficial circumflex iliac artery perforator flaps
-
摘要:
目的 探讨血管成像技术在旋髂浅动脉（SCIA）穿支皮瓣游离移植修复四肢创面中的临床应用效果。 方法 该研究为回顾性队列研究。2019年3月—2023年8月,华北医疗健康集团邢台总医院收治40例符合入选标准的四肢皮肤软组织缺损患者,其中男26例、女14例,年龄19~60岁。根据对拟切取皮瓣区域中血管的探查方式,将患者分为行彩色多普勒血流成像（CDFI）探查的CDFI组和行三维CT血管成像（3D-CTA）探查的3D-CTA组,每组20例。术前根据CDFI结果,估算CDFI组患者SCIA、旋髂浅静脉（SCIV）起始部位血管直径及血管长度,所得数值即为其估算值。术前根据3D-CTA结果,估算3D-CTA组患者SCIA、SCIV起始部位血管直径及血管长度,所得数值即为其估算值；探查腹股沟区SCIA与旋髂深动脉、腹壁浅动脉之间的解剖学关系,并基于此将SCIA穿支分为5个类型,即1、2、3、4、5型。四肢创面清创后面积为3.0 cm×3.0 cm~16.0 cm×8.0 cm。设计并切取SCIA穿支皮瓣,修复创面。术中寻找术前行3D-CTA或CDFI探查时定位的穿支血管,观察SCIA与旋髂深动脉、腹壁浅动脉之间的解剖学关系,并测量SCIA、SCIV起始部位血管直径及血管长度,所得数值即为其实际测量值。皮瓣切取面积为4.0 cm×4.0 cm~17.0 cm×9.0 cm。直接拉拢缝合供区创面。统计3D-CTA组患者术前行3D-CTA探查到的SCIA穿支分型,并与术中观察到的结果进行比较。统计2组患者采用CDFI或3D-CTA技术探查的SCIA和SCIV起始部位血管直径及血管长度的估算值,并将其与术中实际测量值进行比较。术后观察2组患者皮瓣存活情况。随访时,观察2组患者皮瓣外观并评估其感觉恢复情况,观察供区创面愈合情况。 结果 3D-CTA组患者术前行3D-CTA探查显示,SCIA穿支分型为1型者6例、2型者5例、3型者4例、4型者3例、5型者2例,与术中观察到的结果一致。与CDFI组比较,3D-CTA组患者SCIA、SCIV起始部位血管直径的估算值均明显变小（t值分别为2.83、2.23,P<0.05）；与估算值比较,CDFI组患者SCIA、SCIV起始部位血管直径的实际测量值均明显变小（t值分别为3.12、2.16,P<0.05）,组间均数差值（95%置信区间）分别为0.25（0.12~0.38）、0.26（0.14~0.38）mm。与CDFI组比较,3D-CTA组患者SCIA、SCIV血管长度的估算值均明显变短（t值分别为2.43、2.18,P<0.05）；与估算值比较,CDFI组患者SCIA、SCIV血管长度的实际测量值均明显变短（t值分别为2.06、2.10,P<0.05）,组内均数差值（95%置信区间）分别为1.5（1.0~2.0）、1.5（1.0~2.0）cm。术后,CDFI组2例患者皮瓣出现部分坏死,经换药后愈合,其余患者皮瓣存活良好；3D-CTA组患者皮瓣均存活良好。术后12~18个月随访时,2组患者皮瓣外观及感觉恢复情况均可；供区创面均愈合良好,仅存留线性瘢痕。 结论 术前应用3D-CTA技术探查血管情况,可明确SCIA穿支类型及其起始部位血管直径与血管长度等,指导SCIA穿支皮瓣的设计,实现其精准切取。 Abstract:Objective To investigate the clinical application effect of vascular imaging technology in repairing limb wounds with free transplantation of superficial circumflex iliac artery (SCIA) perforator flaps. Methods This study was a retrospective cohort study. Forty patients (26 males and 14 females, aged 19-60 years) with skin and soft tissue defects of the limbs who met the inclusion criteria were admitted to Xingtai General Hospital of North China Medical Health Group from March 2019 to August 2023. According to the exploration method for blood vessels in the flap area to be cut, the patients were divided into color Doppler flow imaging (CDFI) group with CDFI exploration and three-dimensional computed tomography angiography (3D-CTA) group with 3D-CTA exploration, with 20 cases in each group. Preoperatively, based on the CDFI results, the vessel diameter at the origin and the length of SCIA and superficial circumflex iliac vein (SCIV) were measured in CDFI group of patients, and the resulting values were recorded as the estimated values. Preoperatively, the vessel diameter at the origin and the length of SCIA and SCIV were measured in 3D-CTA group of patients based on the 3D-CTA results, and the resulting values were recorded as the estimated values; the anatomic relationship between the SCIA and the deep circumflex iliac artery as well as the superficial inferior epigastric artery in the inguinal region was identified, and the SCIA perforators were classified into 5 types (type 1, 2, 3, 4, and 5) based on this. The wound area of the limbs ranged from 3.0 cm×3.0 cm to 16.0 cm×8.0 cm after debridement. SCIA perforator flaps were designed and harvested to repair the wounds. During surgery, the preoperatively located perforator vessels (detected by 3D-CTA or CDFI) were identified, the anatomic relationship between the SCIA and the deep circumflex iliac artery as well as the superficial inferior epigastric artery was observed, the actual vessel diameter at the origin and the length of the SCIA and SCIV were measured, and the resulting values were recorded as the actual measured values. The area of the harvested flaps ranged from 4.0 cm×4.0 cm to 17.0 cm×9.0 cm. The wounds at donor sites were closed directly. In 3D-CTA group, the SCIA perforators classification of patients identified by preoperative 3D-CTA technology was statistically analyzed and compared with the intraoperative findings. The estimated values of vessel diameter at the origin and the length of SCIA and SCIV detected by either CDFI or 3D-CTA in the two groups of patients were recorded and compared with the actual values measured intraoperatively. Postoperatively, the flap survival was observed in the two groups of patients. During follow-up, flap appearance and sensory recovery were evaluated in the two groups of patients, and the wounds healing at donor site was observed. Results Preoperative 3D-CTA exploration in the 3D-CTA group of patients showed the SCIA perforators were type 1 in 6 cases, type 2 in 5 cases, type 3 in 4 cases, type 4 in 3 cases, and type 5 in 2 cases, which was consistent with the results in intraoperative observation. Compared with those in CDFI group, the estimated values of vessel diameter at the origin of SCIA and SCIV in 3D-CTA group of patients were significantly smaller (with t values of 2.83 and 2.23, respectively, P<0.05). Compared with the estimated values, the actual measured values of vessel diameter at the origin of SCIA and SCIV in CDFI group of patients were significantly smaller (with t values of 3.12 and 2.16, respectively, P<0.05), and the mean differences between the groups (95% confidence intervals) were 0.25 (0.12-0.38) and 0.26 (0.14-0.38) mm, respectively. Compared with those in CDFI group, the estimated values of vessel length of SCIA and SCIV in 3D-CTA group of patients were significantly shorter (with t values of 2.43 and 2.18, respectively, P<0.05). Compared with the estimated values, the actual measured values of vessel length of SCIA and SCIV in CDFI group of patients were significantly shorter (with t values of 2.06 and 2.10, respectively, P<0.05), and the mean differences within groups (95% confidence intervals) were 1.5 (1.0-2.0) and 1.5 (1.0-2.0) cm, respectively. In CDFI group, 2 patients developed partial flap necrosis postoperatively, which healed well after dressing change, and the remaining patients exhibited satisfactory flap survival. All flaps in 3D-CTA group of patients survived completely. During postoperative follow-up of 12 to 18 months, both groups of patients showed favorable flap appearance and sensory functional recovery. The wounds in donor sites healed well, with only linear scars remaining. Conclusions Preoperative application of 3D-CTA technology for vascular exploration can clarify the type of SCIA perforators and the vessel diameter at the origin and the length of SCIA, thereby guiding the design of the SCIA perforator flap and enabling its precise harvest. -
参考文献
(39) [1] 何晓清,石岩,杨曦,等. 精准皮瓣外科理念在膝关节创面修复中的应用[J].中华创伤骨科杂志,2023,25(3):219-225. DOI: 10.3760/cma.j.cn115530-20221014-00512. [2] 田敏涛,李苗钟,胡浩良,等. 不同动脉吻合方式的游离旋髂浅动脉穿支皮瓣移植修复四肢皮肤软组织缺损[J].中华创伤杂志,2022,38(2):149-154. DOI: 10.3760/cma.j.cn501098-20210922-00508. [3] ScaglioniMF, MeroniM, MeschinoA,et al. The superficial circumflex iliac artery perforator flap for head and neck reconstruction[J].Oral Maxillofac Surg Clin North Am, 2024,36(4):489-495. DOI: 10.1016/j.coms.2024.07.008. [4] BarnhillCW, GreysonMA, IorioML. Superficial circumflex iliac artery perforator flap reconstruction of the upper extremity[J].Hand Clin, 2024,40(2):179-187. DOI: 10.1016/j.hcl.2023.10.001. [5] HongJP. The superficial circumflex iliac artery perforator flap in lower extremity reconstruction[J].Clin Plast Surg, 2021,48(2):225-233. DOI: 10.1016/j.cps.2020.12.005. [6] 刘洋洋,吴敏,朱军,等. 游离旋髂浅动脉浅支穿支皮瓣联合皮瓣供区以远全厚皮片修复四肢较大创面的临床效果[J].中华烧伤与创面修复杂志,2024,40(1):72-77. DOI: 10.3760/cma.j.cn501225-20230727-00018. [7] HussainT, KhanFH, RahmanOU, et al. Superficial circumflex iliac artery free flap for coverage of hand injuries[J].Cureus,2022,14(11):e31520. DOI: 10.7759/cureus.31520. [8] IshibashiS, MiyazakiT, KanasakiM, et al. Knacks and pitfalls for superficial circumflex iliac artery perforator flap[J].J Hand Microsurg, 2025,17(5):100296. DOI: 10.1016/j.jham.2025.100296. [9] 吴双江,王雷,刘一秀,等. CT血管成像及三维重建辅助设计与彩色多普勒超声在口腔癌术后缺损股前外侧皮瓣修复重建中的应用比较[J].中华整形外科杂志,2022,38(10):1102-1110. DOI: 10.3760/cma.j.cn114453-20210428-00189. [10] 何晓清,杨曦,石岩,等. 精准皮瓣外科理念下逆行股前外侧皮瓣修复膝关节前方创面的临床效果[J]. 中华烧伤与创面修复杂志,2023,39(7):648-654. DOI: 10.3760/cma.j.cn501225-20221020-00461. [11] 董凯旋,张俊裕,罗浩天,等. CT血管成像和彩色多普勒超声在腓动脉穿支皮瓣术前穿支评估的对比研究[J].中华显微外科杂志,2023,46(1):76-81. DOI: 10.3760/cma.j.cn441206-20220711-00143. [12] 彭睿,章伟文,王晓峰,等. 三维重建术前优化设计腹前外侧跨区游离穿支皮瓣修复四肢皮肤软组织缺损[J].中华显微外科杂志,2023,46(3):291-296. DOI: 10.3760/cma.j.cn441206-20221107-00228. [13] 陶先耀,薛明宇,周晓,等. 旋髂浅动脉穿支接力皮瓣修复大面积股前外侧皮瓣供区缺损的疗效评价[J].中华手外科杂志,2024,40(3):269-272. DOI: 10.3760/cma.j.cn311653-20230924-00045. [14] 徐军辉,张伟,周锦秀,等. 游离移植腹股沟皮瓣修复四肢电烧伤创面的临床效果[J].中华烧伤与创面修复杂志,2023,39(11):1030-1037. DOI: 10.3760/cma.j.cn501225-20230804-00039. [15] 张龙春,朱雷,袁云发,等. 游离旋髂浅动脉穿支皮瓣修复踇甲瓣供区创面[J].中华显微外科杂志,2023,46(5):558-562. DOI: 10.3760/cma.j.cn441206-20230511-00083. [16] DanielRK, TaylorGI. Distant transfer of an island flap by microvascular anastomoses. A clinical technique[J]. Plast Reconstr Surg,1973, 52(2):111-117. DOI: 10.1097/00006534-197308000-00001. [17] KoshimaI, NanbaY, TsutsuiT, et al. Superficial circumflex iliac artery perforator flap for reconstruction of limb defects[J]. Plast Reconstr Surg, 2004, 113(1):233-240. DOI: 10.1097/01.PRS.0000095948.03605.20. [18] HongJP, SunSH, Ben-NakhiM. Modified superficial circumflex iliac artery perforator flap and supermicrosurgery technique for lower extremity reconstruction: a new approach for moderate-sized defects[J]. Ann Plast Surg, 2013, 71(4):380-383.DOI: 10.1097/SAP.0b013e3182503ac5. [19] LaiYM, EongJTWA, TanBK. Pedicled SCIA and SIEA Mega groin flap-a staged reconstructive approach for large forearm defects[J]. J Plast Reconstr Surg, 2023,3(2):64-70. DOI: 10.53045/jprs.2022-0052. [20] PereiraN, VenegasJ, OñateV, et al. Extremity reconstruction with superficial circumflex iliac artery perforator free flap: refinements and innovations after 101 cases[J]. J Plast Reconstr Aesthet Surg,2023,85(10):1-9.DOI: 10.1016/j.bjps.2023.06.048. [21] YoshimatsuH, KarakawaR, FuseY, et al. Superficial circumflex iliac artery perforator flap elevation using preoperative high-resolution ultrasonography for vessel mapping and flap design[J]. J Reconstr Microsurg,2022,38(3):217-220. DOI: 10.1055/s-0041-1736317. [22] ZublerC, HaberthürD, HlushchukR, et al. The anatomical reliability of the superficial circumflex iliac artery perforator (SCIP) flap[J]. Ann Anat, 2021,234:151624. DOI: 10.1016/j.aanat.2020.151624. [23] KwonJG, PereiraN, TonareeW, et al. Long Pedicled superficial circumflex iliac artery flap based on a medial superficial branch[J]. Plast Reconstr Surg, 2021,148(4):615e-619e. DOI: 10.1097/PRS.0000000000008388. [24] OuCL, LiJ, ZhouX, et al. Repair of multiple hand defects with superficial circumflex iliac artery perforator flap[J]. Injury, 2023,54(3):940-946. DOI: 10.1016/j.injury.2023.01.016. [25] 梁晓宗,王昌义,李曼丹,等. 游离显微削薄旋髂浅动脉穿支皮瓣修复手足部软组织缺损[J].中华手外科杂志,2022,38(6):534-536. DOI: 10.3760/cma.j.cn311653-20220303-00054. [26] 赵书明,刘娜,刘学亮,等. 三维CT血管造影在辅助游离胸外侧穿支皮瓣修复四肢创面中的应用[J].中华创伤骨科杂志,2024,26(2):149-155. DOI: 10.3760/cma.j.cn115530-20231107-00188. [27] KatsushimaC, YamanakaH, TsugeI, et al. Free superficial circumflex iliac artery perforator flow-through flap transfer for reconstruction after excision of arteriovenous malformations of the hand: a case report[J]. Microsurgery, 2023,43(5):516-521. DOI: 10.1002/micr.31045. [28] BajusA, StreitL. Superficial circumflex iliac artery perforator flap on extremity defects - case series[J]. Acta Chir Plast, 2022,64(1):39-43. DOI: 10.48095/ccachp202239. [29] RochlinDH, LinW, ReitzRJ, et al. Phalloplasty flap salvage using a superficial circumflex iliac artery perforator propeller flap[J]. Plast Reconstr Surg Glob Open, 2024,12(1):e5522. DOI: 10.1097/GOX.0000000000005522. [30] 张伟,张卫东,徐军辉,等. 分叶腹股沟皮瓣游离移植的临床应用效果[J].中华烧伤与创面修复杂志,2025,41(1):36-44. DOI: 10.3760/cma.j.cn501225-20241014-00384. [31] 杨曦,何晓清,徐永清,等. CTA辅助下精准设计分叶股前外侧皮瓣修复上肢复杂软组织缺损1例中期随访[J].中华显微外科杂志,2023,46(1):117-119. DOI: 10.3760/cma.j.cn441206-20211207-00288. [32] 张文桐,杨勇,李峰,等. 基于彩色多普勒超声定位的分层削薄旋髂浅动脉穿支皮瓣的临床疗效[J].中华烧伤与创面修复杂志,2025,41(1):45-52. DOI: 10.3760/cma.j.cn501225-20240927-00358. [33] AhmedH, Thomas-JonesI, JessopZM, et al.Evolving role of staging CT scans during CT-angiography for DIEP flap reconstruction planning[J]. J Plast Reconstr Aesthet Surg, 2024,98:342-347. DOI: 10.1016/j.bjps.2024.09.009. [34] 蓝波,傅尚俊,刘涛,等. CTA三维重建技术在游离双叶股前外侧穿支皮瓣移植修复四肢创面中的效果[J].中华医学美学美容杂志,2025,31(2):148-154. DOI: 10.3760/cma.j.cn114657-20241206-00207. [35] 张月恒,崔文举,宋坤修,等. 改良CT血管造影术辅助基于浅筋膜穿支的股前外侧皮瓣穿支评估与偏心设计的前瞻性研究[J]. 中华烧伤与创面修复杂志,2023,39(2):141-149. DOI: 10.3760/cma.j.cn501225-20220902-00376. [36] ManasyanA, StantonEW, WolfeE, et al.Evaluating the role of digital subtraction angiography in traumatic lower extremity flap reconstruction: a comparative analysis with CT angiography[J]. Microsurgery, 2025,45(4): e70063. DOI: 10.1002/micr.70063. [37] 李云成,李裕国,杨君琳,等.应用深度学习图像重建算法提高低辐射剂量肝脏能谱CT图像质量和病灶诊断信心的临床研究[J].中华放射学杂志, 2025, 59(1):43-49.DOI: 10.3760/cma.j.cn112149-20240327-00160. [38] 张雅颖,侯雨希,刘日,等.PEG包裹纳米金粒子作为新型CT造影剂的初步探索[J].生物医学工程学进展, 2022, 43(1):1-6.DOI: 10.3969/j.issn.1674-1242.2022.01.001. [39] 卿黎明,唐举玉,吴攀峰,等. 胸背动脉嵌合穿支皮瓣修复合并深部死腔的四肢皮肤软组织缺损的疗效分析[J].中华创伤骨科杂志,2021,23(12):1076-1081. DOI: 10.3760/cma.j.cn115530-20210603-00257. -
图 1 3D-CTA技术下基于SCIA与DCIA、SIEA之间解剖学关系的SCIA穿支分型。1A.1型SCIA穿支,SCIA与DCIA均独立起源于股动脉,且两者起始点间距较小；1B.2型SCIA穿支,SCIA与DCIA及SIEA均独立起源于股动脉,且各自起始点之间的距离均较大；1C.3型SCIA穿支,SCIA与DCIA共干起源于股动脉,且共干段长度较短；1D.4型SCIA穿支,SCIA与DCIA共干起源于股动脉,共干段长度较长；1E.5型SCIA穿支,SCIA与SIEA共干起源于股动脉；1F、1G、1H、1I、1J.分别为图1A、1B、1C、1D、1E的3D-CTA中SCIA与DCIA、SIEA之间解剖学关系的示意图
注：红色箭头或线条指示股动脉,绿色箭头或线条指示旋髂浅动脉（SCIA）,黄色箭头或线条指示旋髂深动脉（DCIA）,蓝色箭头或线条指示腹壁浅动脉（SIEA）；3D-CTA为三维CT血管成像
图 2 旋髂浅动脉穿支皮瓣游离移植修复患者右下肢踝前部位创面的效果。2A.清创后创面情况,可见骨质、肌腱外露；2B.术前行三维CT血管成像探查,显示旋髂浅动脉穿支分型为2型；2C.设计皮瓣；2D.切取皮瓣中；2E.将皮瓣与创面缝合后即刻；2F、2G.分别为术后12个月随访时,患肢自然平放、勾直脚背观；2H.术后12个月随访时,可见供区创面愈合好,仅存留线性瘢痕
Table 1. 基于血管成像技术采用旋髂浅动脉穿支皮瓣游离移植修复2组四肢创面患者的一般资料比较
组别 例数 性别（例） 年龄（岁, 创面位置（例） 体重指数（kg/m2, 创面面积（cm2, 皮瓣面积（cm2, 男 女 左侧 右侧 CDFI组 20 12 8 47±12 8 12 23±4 73±20 94±25 3D-CTA组 20 14 6 45±13 7 13 23±4 71±20 92±24 统计量值 χ²=0.44 t=0.36 χ²=0.11 t=0.24 t=0.44 t=0.34 P值 0.507 0.721 0.744 0.812 0.662 0.738 注：彩色多普勒血流成像（CDFI）组和三维CT血管成像（3D-CTA）组患者的拟切取皮瓣区域中血管的探查方式分别为CDFI和3D-CTA 
下载: 导出CSV
Table 2. 2组四肢创面患者旋髂浅动脉和旋髂浅静脉起始部位血管直径的估算值与实际测量值比较（mm,
组别 例数 旋髂浅动脉 旋髂浅静脉 均数差值（95%置信区间）1 t1值 P1值 均数差值（95%置信区间）2 t2值 P2值 估算值 实际测量值 估算值 实际测量值 CDFI组 20 0.98±0.29 0.73±0.21 1.45±0.41 1.19±0.35 0.25（0.12~0.38） 3.12 0.003 0.26（0.14~0.38） 2.16 0.037 3D-CTA组 20 0.75±0.22 0.72±0.23 1.20±0.29 1.17±0.32 0.03（-0.05~0.11） 0.42 0.676 0.03（-0.05~0.11） 0.31 0.758 t值 2.83 0.14 2.23 0.19 P值 0.007 0.887 0.032 0.851 注：彩色多普勒血流成像（CDFI）组和三维CT血管成像（3D-CTA）组患者的拟切取皮瓣区域中血管的探查方式分别为CDFI和3D-CTA；均数差值（95%置信区间）1、t1值、P1值为旋髂浅动脉起始部位血管直径的估算值与实际测量值比较所得；均数差值（95%置信区间）2、t2值、P2值为旋髂浅静脉起始部位血管直径的估算值与实际测量值比较所得
下载: 导出CSV
Table 3. 2组四肢创面患者旋髂浅动脉和旋髂浅静脉血管长度的估算值与实际测量值比较（cm,
组别 例数 旋髂浅动脉 旋髂浅静脉 均数差值（95%置信区间）1 t1值 P1值 均数差值（95%置信区间）2 t2值 P2值 估算值 实际测量值 估算值 实际测量值 CDFI组 20 9.7±2.6 8.2±1.9 9.8±2.4 8.3±2.2 1.5（1.0~2.0） 2.06 0.046 1.5（1.0~2.0） 2.10 0.042 3D-CTA组 20 7.9±1.8 8.0±1.8 8.3±2.0 8.2±2.1 0.1（-0.4~0.2） 0.14 0.890 0.1（-0.2~0.4） 0.11 0.915 t值 2.43 0.14 2.18 0.12 P值 0.020 0.890 0.035 0.906 注：彩色多普勒血流成像（CDFI）组和三维CT血管成像（3D-CTA）组患者的拟切取皮瓣区域中血管的探查方式分别为CDFI和3D-CTA；均数差值（95%置信区间）1、t1值、P1值为旋髂浅动脉血管长度的估算值与实际测量值比较所得；均数差值（95%置信区间）2、t2值、P2值为旋髂浅静脉血管长度的估算值与实际测量值比较所得
下载: 导出CSV
-
张路 8月28日.mp4
-
下载:
图(3) / 表(3)
计量
- 文章访问数: 148
- HTML全文浏览量: 75
- PDF下载量: 19
- 被引次数: 0
