复杂性腹主动脉瘤腔内治疗:问题与对策

目的探讨人工覆膜支架腔内修复术(EVAR)治疗复杂性腹主动脉瘤(AAA)的可行性与安全性。方法回顾性分析35例接受EVAR治疗的复杂性AAA的患者资料。结果 35例均接受EVAR治疗,2例失败(1例入路血管严重狭窄,支架不能释放,2天后死亡;1例术中瘤体破裂,手术中断,术后1天死亡),手术成功率为94.29%(33/35)。6例术前瘤体已破裂,术后死亡2例。结论对于复杂性AAA,通过改良技术进行腔内治疗,能够取得良好疗效。     

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96例的诊断与手术治疗

摘要：目的 探讨腹主动脉瘤(AAA)的诊断、手术方式的选择及并发症的防治。方法 回顾性分析14年余收治的96例AAA的诊断和手术治疗的临床资料。对82例肾动脉水平以下型AAA行动脉瘤切除人工血管置换术，12例肾下型行涤纶片动脉瘤体包裹术，2例肾动脉上型腹主动脉假性动脉瘤行側壁瘤体切除修补术。结果 主动脉造影、MRA或EBT可确定动脉瘤上界与肾动脉间的距离。93例获得临床治愈。手术死亡3例，手术病死率3.1%(3/96)；其中急诊手术病死率50.0%(2/4)，限期手术病死率1.1%(1/92)，两者差异显著（P<0.05）。6例术后出现乙状结肠缺血症状，2例肢体远端有缺血症状，2例急性肾功能不全，均经非手术治疗痊愈。手术并发症发生率21.3％。82例获随访，随访时间6个月至15年。术后5年生存率为81.7%。 结论 AAA切除人工血管置换术是治疗AAA的基本方法。     

腹主动脉瘤治疗进展

腹主动脉瘤(AAA)的发病率因年龄和性别而异,在年龄小于65岁的人群中,约1.7%的女性和5%的男性腹主动脉直径大于3.0cm[1].此后,直径大于3cm的动脉瘤的患病率每10岁增加6%.英国科学家发现女性AAA患者就诊时年龄更大,瘤体破裂的比例更高[2].     

腹主动脉瘤的腔内修复治疗

腹主动脉瘤 (abdominalaorticaneurysms ,AAA)是血管外科常见的严重疾病 ,发病高峰年龄在 6 0～ 70岁之间 ,发病率男性是女性的 4～ 6倍 ,95 %的病例位于肾动脉平面以下。AAA最大的危险是瘤体破裂引起的致死性出血。通常认为 :瘤体 <5cm的AAA破裂发生率每年约 3% ;直径在 5～ 6cm的破裂发生率每年上升 10 %。一旦发生破裂 ,病死率高达 90 % ,手术死亡率 4 1%～ 70 % ,而择期手术死亡率仅 3%～ 5 %。因此只要无心、肺、肾功能不全等手术禁忌 ,本病均有手术适应证。最近的文献报告 ,AAA直径≥ 5 5cm是手术适应证[1] 。195 2年 ,Dubost[…     

肾动脉下腹主动脉瘤九例治疗体会

近2年我院收治肾动脉以下腹主动脉瘤患者9例,并手术治疗,均获成功。报告如下。临床资料本组9例,均为男性。年龄67~80岁,平均75.4岁。主要临床表现均有腹部搏动性包快,病程最长3年,最短20d。5例伴有脐周疼痛。本组均有高血压病史,合并慢性阻塞性肺部疾病2例,冠心病2例,糖尿病1例。9例术前均行彩色多普勒超声检查、6例行CTA检查、3例行MRIA检查。动脉瘤均位于肾动脉以下,瘤体直径最大为6.5cm,最小5.0cm,7例双侧髂总动脉受累呈瘤样扩张。9例均行腹主动脉瘤切除,分叉或直筒型人工血管(德国B/BRAUN)移植术,吻合口外涂医用OB胶(广州白云医药…     

腔内隔绝术治疗腹主动脉瘤1例的护理

随着人们生活水平的提高和平均寿命的延长 ,以动脉硬化为病因的腹主动脉瘤 (abdominal aorticaneurysm,AAA)逐年增加。传统的手术方式为瘤体切除、人工血管置换术 ,其手术时间长、创伤大、病死率高。近年来在腔内血管外科技术基础上又发展了腔内隔绝术治疗 AAA。我院 2 0 0 1年 3月 3 1日完成西北地区首例 AAA腔内隔绝术 ,报道如下。1　病例介绍男 ,71岁。因发现腹部搏动性肿块 1年余入院。入院诊断腹主动脉瘤。既往有高血压病史十余年 ,血压 1 3 5 /75～ 1 5 0 /98mm Hg(1 mm Hg=0 .1 3 3 k Pa) ;吸烟史近 5 0年。心电图检查提示心肌…     

腹主动脉瘤生物标记物研究进展

正腹主动脉瘤(abdominalaorticaneurysm,AAA)是腹主动脉壁的局限性永久性扩张,直径超过正常主动脉150%或扩张3 cm~([1]),发病时多无症状,但一旦发生破裂几乎致命~([2])。据统计,年龄60岁的人群AAA发病率为2%～4%,随着人口老龄化,其发病率逐年上升~([3])。目前对AAA的干预决策主要取决于瘤体直径,指南推荐通过超声随访瘤体直径变化进而评估破裂风险,并以此作为进一步临床决策的主要依据,对于无症状的AAA,直径4 cm时破裂风险较     

14例腹部巨大肿瘤的麻醉

我院1976年至1984年共施行腹部巨大肿瘤(下简称巨腹症)手术麻醉14例(巨腹症标准为超过足月妊娠或肿瘤占据大部分腹腔)。现将麻醉处理小结如下。临床资料 (一) 男6例,女8例,年龄3(1/2)～66岁。其中<10岁2例,13～50岁7例,>50岁5例。囊性肿瘤(卵巢囊肿、假性胰腺囊肿、腹腔巨大淋巴管瘤等)9例,实质性肿瘤(腹膜后平滑肌瘤,卵巢内胚窦瘤、肾胚胎瘤     

腹主动脉瘤合并马蹄肾的外科治疗：要点与难点

腹主动脉瘤(AAA)合并马蹄肾(HSK)是一种罕见疾病。外科治疗需首要考虑肾脏的异常解剖,包括HSK峡部骑跨瘤体,以及起源于腹主动脉的副肾动脉等。目前的治疗方法有开放手术(经腹或腹膜后)、腔内修复术及杂交手术,但3种手术方法应用的适应证、具体处理方式尚未统一。笔者总结分析AAA合并HSK外科治疗要点与难点,以为临床实践提供参考。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.