分支型覆膜支架修复腹主、双髂动脉瘤1例报告

本文报道2012年2月使用分支型覆膜支架成功治疗1例腹主动脉瘤同时伴有双侧髂动脉瘤病例。术后1个月复查,动脉瘤隔绝良好,腹主动脉和双髂动脉瘤腔内均形成血栓,无内漏发生,支架形态位置良好,左侧髂内动脉血流通畅。     

腹主动脉瘤合并左髂总动脉纤细行腔内修复1例北大核心CSCD

血管腔内动脉瘤修复术(endovascular aneurysm repair,EVAR)已广泛应用于腹主动脉瘤(abdominal aortic aneurysm,AAA)的治疗,微创,安全,即使高危患者也可实施。然而,高达40%的患者因为瘤颈解剖、内脏动脉或血管通路问题不适合行标准EVAR手术[1,2]。2020年我们采用自制髂内动脉分支支架重建髂内动脉1例[3]。2021年7月,我院对1例腹主动脉瘤合并左髂总动脉纤细患者采用术中自制带左髂总动脉分支支架的覆膜支架行腔内治疗,报道如下。     

手术治疗腹主动脉瘤腔内隔绝术后左髂动脉破裂1例

患者男,69岁.因腹主动脉瘤腔内隔绝术后5年,腹部疼痛2个月于2005年5月入院.5年前因腹主动脉瘤在外院行分叉型带内支架人工血管腔内隔绝治疗.体查:体温37.3℃,脉搏100次/min,呼吸20次/min,血压130/90mmHg(1mmHg=0.133kPa).心肺正常.腹部平软,左下腹压痛,无反跳痛,未及明显包块,肠鸣音正常.辅助检查:腹部CTA三维重建成像示既往植入支架的左髂血管支远端有血肿形成(图1).诊断:腹主动脉瘤腔内隔绝术后、支架下端左髂动脉瘤破裂.行急症剖腹手术.     

腹主动脉瘤合并髂动静脉瘘1例MDT讨论

目的总结探讨1例腹主动脉瘤合并髂动静脉瘘患者的诊断过程及治疗经验。方法回顾性分析南充市中心医院于2019年12月收治并在术前进行MDT讨论的1例累及髂动脉的腹主动脉瘤合并左髂动静脉瘘的病例资料,对患者的诊疗经过及MDT讨论结果进行总结。结果该患者的临床表现为难治性心功能衰竭,收治于南充市中心医院心内科,后行CT血管造影(CTA)后诊断为累及髂动脉的腹主动脉瘤合并左髂动静脉瘘,经MDT讨论后行腹主动脉腔内覆膜支架隔绝术(EVAR),术后造影显示腹主动脉瘤瘤腔及左髂动静脉瘘瘘口完全封闭,术后患者心功能衰竭症状迅速缓解。整个手术顺利,手术用时约120 min,术中出血量约100 mL。术后第7天患者出院。术后3个月复查CTA及彩超,见支架内血流通畅,未见内漏,左髂动脉假性动脉瘤消失。继续随访。结论对于难治性心功能衰竭患者,如果合并下肢肿胀时,要考虑到大血管动静脉瘘可能,应全面收集病史和查体,及时进行必要的检查,避免造成漏诊或误诊。同时,与传统外科手术对比,EVAR是腹主动脉瘤合并髂动静脉瘘的一种可靠、微创及安全的治疗手段。     

腔内修复术中应用Viabahn支架重建肠系膜下动脉——2例报告

2015年5~12月我科行主动脉腔内修复术(endovascular aortic repair,EVAR)治疗腹主动脉瘤(abdominal aortic aneurysm,AAA),同期应用Viabahn支架重建肠系膜下动脉(inferior mesenteric artery,IMA)2例。1例肾下型AAA合并双髂总动脉瘤样扩张,Riolan动脉弓形成,行EVAR治疗AAA,同期采用"烟囱"技术IMA内植入Viabahn支架成功,术后3个月随访复查CTA示支架位置良好,瘤体隔绝成功,Viabahn支架通畅。1例右侧髂总动脉巨大动脉瘤,行EVAR治疗髂总动脉瘤,髂内动脉弹簧圈栓塞,IMA内植入Viabahn支架成功,术后6个月随访复查CTA示支架位置良好,瘤体隔绝成功,Viabahn支架通畅。我们认为复杂AAA应用Viabahn支架合理重建IMA预防肠缺血,简化手术操作,近期疗效满意。     

腹主动脉瘤腔内修复术后急性髂动脉血栓形成致多器官功能衰竭一例北大核心CSCD

患者男,81岁,“体检发现腹主动脉瘤1周”2014年5月21日入院.既往高血压病史.入院查体：血压152/87 mmHg,心肺腹未见异常.双侧胫后动脉、足背动脉搏动可扪及.CTA示：肾动脉下型腹主动脉瘤,累及右侧髂总动脉和双侧髂内动脉;右侧髂总起始部明显扭曲,横断面CT可见双影征（图1）.完善术前检查后,局麻下行腹主动脉瘤腔内隔绝术（endovascular aneurysm repair,EVAR）,术中见：瘤颈直径28 mm,瘤颈长22.5 mm,瘤体最大直径80 mm,右侧髂总动脉最大直径40 mm,累及右侧髂总动脉分叉部,左侧髂总动脉直径15 mm,右侧髂内动脉最大直径35 mm,左侧髂内动脉最大直径19 mm.术中切开双侧股动脉行支架植入,封闭右侧髂内动脉,保留左侧髂内动脉（图2）.     

应用G-iliac?髂动脉分支支架治疗髂总动脉瘤的临床应用分析

目的分析应用G-iliac?髂动脉分支支架治疗髂总动脉瘤的安全性和有效性。方法回顾性分析2021年6月—2022年6月于首都医科大学附属北京友谊医院血管外科应用G-iliac?髂动脉分支支架治疗并保留髂内动脉(IIA)的7例髂总动脉瘤患者的临床资料, 分析手术效果及相关并发症发生情况。结果 7例患者均为男性, 年龄57～80岁, 平均70.9岁。腹主动脉瘤合并髂总动脉瘤6例, 单纯髂总动脉瘤1例, 均成功应用G-iliac?髂动脉分支支架保留IIA。术后1例患者出现心源性休克。7例患者随访时间为3～15个月, 平均8个月。随访期间, 髂动脉及IIA支架均通畅, 无髂动脉分支支架相关内漏发生, 无支架移位, 无臀肌跛行, 无性功能障碍症状, 无主动脉相关死亡。腹主动脉瘤最大径及髂总动脉瘤最大径均稳定。结论对于髂总动脉瘤患者, 通过G-iliac?髂动脉分支支架保留IIA是一种安全、有效的技术。其技术成功率和IIA通畅率高, 并发症发生率低, 但长期效果仍需更多的患者及更长时间的随访数据支持。     

腔内修复术治疗孤立性髂动脉瘤14例

目的探讨腔内治疗孤立性髂动脉瘤的疗效。方法回顾性分析2004年10月至2006年5月腔内修复孤立性髂动脉瘤14例的临床资料。其中,右髂总动脉瘤8例,左髂总动脉瘤5例,左髂内动脉瘤破裂1例。髂动脉瘤腔内修复的标准是瘤体直径〉3．0cm。结果14例均取得技术成功。8例右髂总动脉瘤,钢圈栓塞右髂内动脉后选用分叉支架型人工血管行腔内修复术。其中1例右髂总动脉瘤累及腹主动脉下端,选用AUl支架型人工血管腔内修复加股．股动脉旁路术。5例左髂总动脉瘤栓塞同侧髂内动脉后选用直型支架型人工血管。1例左髂内动脉瘤破裂急诊行钢圈栓塞后选用直型支架覆盖左髂内动脉开口。术后即刻数字减影血管造影显示动脉瘤消失,远近端支架型人工血管与宿主动脉结合处均未见明显渗漏。1例术后出现急性左心功能不全和肺水肿,经抢救痊愈,其余13例无手术并发症。术后CTA随访10．2个月（3～19个月）,瘤体无增大,支架无移位,无内漏,旁路人工血管通畅。结论腔内修复术治疗孤立性髂动脉瘤具有可行、安全、微创等特点,近期疗效较好,远期效果需进一步随访。     

腹主动脉瘤腔内隔绝术中髂动脉的处理

目的:总结腹主动脉瘤(AAA)行腔内隔绝术时髂动脉的处理方式。方法:2004年7月至2010年11月共对43例瘤体累及单侧或双侧髂动脉分叉的AAA行腔内隔绝术,其中单侧髂动脉分叉受累27例,双侧髂动脉分叉受累16例。根据髂动脉病变情况,分别采取髂内动脉单纯覆盖、髂内动脉栓塞后覆盖、髂动脉外环结扎、一侧髂内动脉重建等不同的处理方法。结果:所有病例均操作成功,手术结束时无Ⅰ型内漏存在。术后出现臀部间歇性跛行6例(14.0%),便血1例(2.3%),无病例发生臀部或会阴部皮肤坏死、肠坏死及死亡。结论:术中避免同时封闭双侧髂内动脉,尽量保留一侧髂内动脉是很重要的。     

髂动脉成形术中发生髂动脉破裂的处理

目的 探讨覆膜支架在髂动脉成形术中发生髂动脉破裂时的应用价值.方法 回顾性分析郑州大学第一附属医院腔内血管外科2010年1月至2012年1月运用覆膜支架行腔内髂动脉成形术中髂动脉破裂9例的临床资料.结果 9例患者覆膜支架均置入成功,8例即刻复查髂动脉造影显示,髂动脉管腔通畅,无造影剂外溢;1例患者覆膜支架近心端出现Ⅰ型内漏,立即开腹行“髂动脉人工血管置换术”.9例患者术后临床症状均缓解,术后失访1例,8例患者随访14 ～45个月,平均(22±9)个月.1例患者术后1年覆膜支架远心端(髂外动脉)狭窄,行髂外动脉球囊扩张裸支架成形术,继续随访5个月,无不良事件发生;人工血管置换术患者1例随访18个月,彩超复查人工血管通畅良好.结论 髂动脉成形术中发生髂动脉破裂时,首选置入覆膜支架治疗.对治疗不满意者,外科治疗是最后的保障.     

External iliac artery-to-internal iliac artery endograft: a novel approach to preserve pelvic inflow in aortoiliac stent grafting.

PURPOSE: To describe four patients with abdominal aortic aneurysm and bilateral common iliac artery aneurysms repaired by coil embolization of the ipsilateral internal iliac artery, aortouniiliac endograft extended to the ipsilateral external iliac artery, femorofemoral bypass grafting, and a contralateral external iliac to internal iliac stent graft to preserve pelvic perfusion. METHODS: Four patients with multiple risk factors, abdominal aortic aneurysm (mean diameter, 6.6 cm), and bilateral common iliac artery aneurysms were evaluated with contrast-enhanced computed tomography scanning, arteriography, and intravascular ultrasonography. Aortobiiliac endovascular abdominal aortic aneurysm repair was not feasible because of extension of the common iliac artery aneurysms to the iliac bifurcation bilaterally. RESULTS: The abdominal aortic aneurysms were repaired with an aortouniiliac endograft. The ipsilateral common iliac artery aneurysms were treated by coil embolization of the internal iliac artery and extension of the endograft to the external iliac artery. The contralateral common iliac artery aneurysms were excluded by a custom-made stent graft (n = 2) or a commercial stent graft (n = 2) from the external iliac artery to the internal iliac artery, which preserved pelvic inflow via retrograde perfusion from the femorofemoral bypass. Mean length of stay was 3.5 days. One patient had hip claudication. Follow-up (mean 10 months, range 6 to 17) demonstrated exclusion of the abdominal aortic aneurysm and common iliac artery aneurysms with no endoleak and patent external iliac artery-to-internal iliac artery endografts in all patients. CONCLUSION: Patients with bilateral common iliac artery aneurysms that extend to the iliac bifurcation may be excluded from endovascular abdominal aortic aneurysm repair because of concerns regarding pelvic ischemia after occlusion of both internal iliac arteries. External iliac artery-to-internal iliac artery endografting is a feasible alternative to maintain pelvic perfusion and still allow endograft repair of the abdominal aortic aneurysm in these patients.     

Technical tips for endovascular repair of common iliac artery aneurysms

Isolated common iliac artery aneurysms are rare, comprising <2% of all aneurysm disease. These aneurysms present as either isolated disease, .03% of the population, or, in conjunction with abdominal aortic aneurysm, in approximately 20% to 25% of such cases. Common iliac artery aneurysms are defined as any localized dilatation of the common iliac artery >1.5 cm in diameter. Elective repair for isolated common iliac artery aneurysms is generally not undertaken for aneurysms <3 cm in diameter unless they are part of an abdominal aortic aneurysm repair. Most common iliac artery aneurysms are found incidentally during abdominal/pelvic diagnostic imaging studies or at the time of pelvic or abdominal surgery. As with abdominal aortic aneurysms, endovascular repair of common iliac artery aneurysms follows techniques similar to those used for endovascular repair of abdominal aortic aneurysm. Management includes aneurysm exclusion with an endograft, which seals at sites within the proximal and distal common iliac artery and may involve coil occlusion of the hypogastric artery with extension of the reconstruction into the proximal external iliac artery, or use a "bell-bottom" endograft limb placed at the common iliac bifurcation. Technical tips for successful outcome are described here, and all US Food and Drug Administration approved endografts have been used for repair. There were no statistically significant differences in outcomes that correlated with device or repair techniques used for management of common iliac artery aneurysms. Mid-term 54-month outcome has been excellent, with no common iliac artery ruptures or aneurysm-related deaths and the need for secondary interventions was gratifyingly small.     

Can the Internal Iliac Artery Be Safely Covered during Endovascular Repair of Abdominal Aortic and Iliac Artery Aneurysms?

Aneurysmal involvement of the common iliac (CIA) or the internal iliac arteries (IIA) have been relative contraindications for safe endovascular aortic aneurysm (AAA) repair. Our goal was to review our experience in dealing with this problem by performing permanent coverage of one or both IIA during endoluminal repair of aneurysms of the aortoiliac region and to develop a safe, durable strategy. Of the 228 consecutive patients who had endoluminal repair of abdominal aortic (AAA) and iliac artery (IAA) aneurysms between 4/1999 and 4/2001 at our institution, 49 patients underwent coverage and/or coil embolization of one or both IIA during repair because of complex aortoiliac anatomy. These patients were evaluated prospectively for short-term adverse outcome. These results showed that CIA or IIA aneurysms can be managed safely during endoluminal repair of AAA. The IIA can be covered or embolized with minimum adverse consequences in patients who have inadequate CIA for deployment of the aortic or iliac endograft. Unilateral IIA occlusion is well tolerated. We advocate that whenever bilateral IIA occlusion is necessary during endovascular aneurysm repair, one of the IIAs should be revascularized if it is not aneurysmal.     

Internal iliac artery preservation during endovascular aortic repair using in situ laser fenestration

ObjectiveThe purpose of the present study was to evaluate the technical and short-term clinical outcomes of internal iliac artery (IIA) reconstruction during endovascular aortic repair (EVAR) with in situ laser-assisted fenestration in cases of abdominal aortic aneurysm (AAA) in which the iliac artery is unfit for an internal branched device (IBD).MethodsIn the present single-institution retrospective study, we analyzed patients with AAAs who had undergone EVAR with in situ laser-assisted fenestration for IIA reconstruction between January 2018 and April 2021. The study included patients with iliac artery anatomy unfit for the use of commercial IBDs. The primary safety end point was freedom from major adverse events and unplanned reinterventions within 30 days. The primary efficacy end point was freedom from IIA restenosis, reintervention, and symptoms due to pelvic ischemia at 1 year after the procedure.ResultsA total of 20 patients requiring IIA reconstruction but with anatomy unfit for IBD placement were treated with in situ laser-assisted fenestration during EVAR for aortoiliac aneurysms during the study period. The mean age of our patients was 72 years, and 90% were men. The technical success rate was 100%. No patient had died within 30 days after the procedure. A suspicious IIA perforation had occurred in one patient, which was treated with an additional covered stent, for a primary safety end point of 95.0%. After a mean follow-up of 11 months, all except for one of the reconstructed IIAs were patent. Three patients reported symptoms of buttock claudication on the IIA occluded side at their 3-month follow-up after the procedure. However, these symptoms had subsided in two of these patients at 6 months. Type II endoleaks without sac expansion had occurred in two patients owing to retrograde blood flow from the inferior mesenteric artery and lumbar artery. Both patients were kept under close surveillance. The rate of freedom from major adverse events and unplanned reinterventions within 30 days (primary efficacy end point) was 86.3% at 1 year after procedure.ConclusionsIn situ laser-assisted fenestration was found to be a safe and effective alternative method for IIA reconstruction during EVAR for aortoiliac aneurysms in patients with anatomy unfit for IBD.     

Endovascular repair of an aortoiliac aneurysm with bilateral bifurcated branched iliac stent‐grafts

Extension of abdominal aortic aneurysms to involve one or both common iliac arteries occurs in 20–30% of patients. In treating aneurysmal diseases involving the common iliac arteries, preservation of blood flow to the pelvic circulation is desirable. The development of branched stent‐grafts has made this possible with the endovascular approach. We herein describe our technique of endovascular repair of an aortoiliac aneurysm with bilateral bifurcated branched iliac stent‐grafts.     

Special iliac artery considerations during aneurysm endografting.

BACKGROUND: The feasibility of endograft exclusion of abdominal aortic aneurysms (AAA) has been established. However, the technical challenges of graft delivery through tortuous or diseased iliac arteries and the treatment of associated iliac aneurysmal disease have received little attention. METHODS: Over 19 months, 74 patients underwent endoluminal repair of AAA and/or iliac artery aneurysms. Iliac anatomy that required special consideration during endografting was reviewed. RESULTS: Of the 74 patients, 35 (47%) had iliac anatomy that required special attention. Thirteen patients (18%) had aneurysmal involvement of a common iliac artery. Eleven of these patients required endograft extension into the external iliac artery (EIA) and hypogastric coil embolization due to the proximity of the aneurysm to the hypogastric origin. Eleven patients with ectatic, nonaneurysmal iliac arteries required aortic cuffs to achieve a distal seal in these oversized vessels. Iliac artery tortuosity or stenosis were complicating factors in 27 of the 74 patients (36%), requiring the use of brachial guidewire tension in 2 patients to facilitate tracking of the delivery device. Five patients with severely splayed aortic bifurcations required crossed placement of the iliac limbs to prevent kinking of the endograft. Occlusive atherosclerotic disease of the EIA mandated preprocedural dilatation and stenting in 3 patients and postprocedural surgical EIA reconstruction in another 5 patients. Three patients who underwent successful endograft placement required subsequent endovascular repair of traumatized EIAs. CONCLUSIONS: Iliac artery anatomy plays a significant role in the endoluminal treatment of infrarenal abdominal aortic aneurysms, complicating the procedure in up to 47% of patients with otherwise suitable anatomy. A variety of supplemental procedures, both surgical and endovascular, may be required to facilitate endograft placement. A special understanding of these constraints and proper planning is required for optimal therapy.     

腔内治疗腹主动脉瘤髂内动脉重建方法及其评价

腹主动脉瘤的腔内治疗已成为其治疗的主流方法,有相当部分的腹主动脉瘤涉及到髂内动脉的处理,而重建髂内动脉的必要性也逐渐得到了学界的认可。髂内动脉的解剖决定了其重要临床意义,早期多应用杂交手术重建方案,后逐渐出现了基于非专用器材的Sandwich技术、Crossover烟囱技术、Trifurcated endograft技术、Bell-bottom技术等腔内治疗方案以及近期出现的专用的髂动脉分叉装置等。各种方法都有其特点和适用条件,血管外科医生应熟知和掌握各种方法,为病人制定最优治疗方案。     

Internal iliac artery revascularization as an adjunct to endovascular repair of aortoiliac aneurysms.

PURPOSE: Endovascular repair of aortoiliac aneurysms may be limited by extension of the aneurysm to the iliac bifurcation, necessitating endpoint implantation in the external iliac artery. In such cases the circulation to the internal iliac artery is interrupted. Bilateral internal iliac artery occlusion during endovascular repair may be associated with significant morbidity, including gluteal claudication, erectile dysfunction, and ischemia of the sigmoid colon and perineum. We have employed internal iliac artery revascularization (IIR) to allow endograft implantation in the external iliac artery while preserving flow to the internal iliac artery in patients with aneurysms involving the iliac bifurcation bilaterally. METHODS: A total of 11 IIR procedures were performed in 10 patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (9 men, 1 woman; mean age, 74 years). IIR was accomplished via a retroinguinal incision in 9 cases and a retroperitoneal incision in 2 cases. Six-mm polyester grafts were used for external-to-internal iliac artery bypass in 10 cases and internal iliac artery transposition onto the external iliac artery was used in one case. Endovascular AAA repair was performed using a modular bifurcated device (Talent-LPS, Medtronics, Minneapolis, Minn) after IIR. Bypass graft patency was determined immediately after the surgery, at 1 month, and every 3 months thereafter, using duplex ultrasound scanning and computed-tomography angiography. Mean aneurysm diameters were as follows: AAA, 6.4 +/- 0.7 cm; ipsilateral common iliac, 3.7 +/- 1.0 cm; contralateral common iliac, 3.9 +/- 0.8 cm. RESULTS: Successful IIR and endovascular AAA repair were accomplished in all cases. No proximal, distal, or graft junction endoleaks occurred. Two patients demonstrated retrograde aneurysm side-branch endoleaks originating from the lumbar arteries. One thrombosed spontaneously within 3 months. One perioperative myocardial infarction occurred. Reduction in aneurysm size was documented in 5 aortic, 5 ipsilateral iliac, and 3 contralateral iliac aneurysms. Gluteal claudication, erectile dysfunction, colon and perineal ischemia, and mortality did not occur. All IIRs have remained patent during a follow-up period of 4 to 15 months (mean, 10.1 months). CONCLUSIONS: IIR may be used with good short-term to intermediate-term patency to prevent pelvic ischemia in patients whose aneurysm anatomy requires extension of the endograft into the external iliac artery. This may allow endovascular AAA repair to be performed in patients who might otherwise be at risk for developing complications associated with bilateral internal iliac artery occlusion.     

Adverse consequences of internal iliac artery occlusion during endovascular repair of abdominal aortic aneurysms

OBJECTIVE: Embolization of the internal iliac artery (IIA) may be performed during endovascular abdominal aortic aneurysm (AAA) repair if aneurysmal disease of the common iliac artery precludes graft placement proximal to the IIA orifice. The IIA may also be unintentionally occluded because of iliac trauma or coverage by the endograft. The purpose of this study was to determine the incidence, etiology, and consequences of IIA occlusion during endoluminal AAA repair. METHODS: Over 2 years, 96 patients have undergone endoluminal AAA repair. The details of the operative procedure, reasons for IIA occlusion, perioperative complications, and clinical follow-up were recorded. RESULTS: The IIA was intentionally occluded in 15 patients (16%) to treat 13 common iliac artery aneurysms, one IIA aneurysm, and one external iliac artery aneurysm. The IIA was unintentionally occluded in 9 patients (9%), resulting from traumatic iliac dissection in 5 patients and coverage of the IIA by the endograft in the remaining 4 patients. Three patients had colon ischemia. One patient with a unilateral IIA occlusion had sigmoid infarction necessitating resection. The other two patients underwent intentional occlusion of one IIA followed by unintentional occlusion of the contralateral IIA because of a traumatic iliac dissection. Both had postoperative abdominal pain and distention; rectosigmoid ischemia was revealed through colonoscopy. Conservative treatment with bowel rest and broad-spectrum antibiotics was successful in both cases. Nondisabling hip and buttock claudication occurred in seven patients (32%) at 1 month but resolved by 6 months in three of these patients. CONCLUSION: Embolization of the IIA for iliac aneurysmal disease and unintentional IIA occlusion due to trauma or graft coverage occurs in a considerable number of patients undergoing endoluminal AAA repair. Most patients with unilateral occlusion do not experience colon ischemia or disabling claudication. Therefore, unilateral embolization of the IIA is well tolerated and allows for the endoluminal treatment of patients with both an AAA and an iliac artery aneurysm, thereby expanding the number of patients who can be managed with an endovascular approach. Although acute, bilateral IIA occlusions should be avoided, significant consequences were not observed in our small series of patients.