自制髂动脉分支装置治疗腹主动脉瘤腔内修复术后髂动脉瘤1例

髂动脉分支装置（iliac branch device, IBD）是专为髂动脉分叉设计的分支支架,为主-髂动脉瘤、孤立性髂动脉瘤腔内治疗时重建髂内动脉血流的理想解决方案。北京大学人民医院血管外科利用自制的一枚IBD,成功治疗腹主动脉瘤腔内修复术（endovascular aneurysm repair, EVAR）后髂动脉瘤1例,其设计及植入较既往报道［1-3］均有独到之处,现将病例分享如下。     

Using a Surgeon-modified Iliac Branch Device to Preserve the Internal Iliac Artery during Endovascular Aneurysm Repair: Single-center Experiences and Early Results

Background:

To evaluate the feasibility of a new surgeon-modified iliac branch device (IBD) technique to maintain pelvic perfusion in the management of common iliac artery (CIA) aneurysm during endovascular aneurysm repair (EVAR).

Methods:

From January 2011 to December 2013, a new surgeon-modified IBD technique was performed in department of vascular surgery of Peking Union Medical College Hospital in five patients treated for CIA aneurysm with or without abdominal aortic aneurysm. A stent-graft limb was initially deployed in vitro, anastomosed with vascular graft, creating a modified IBD reloaded into a larger sheath, with or without a guidewire preloaded into the side branch. The reloaded IBD was then placed in the iliac artery, with a covered stent bridging internal iliac artery and the branch. Finally, a bifurcated stent-graft was deployed, and a limb device was used to connect the main body and IBD.

Results:

Technical successes were obtained in all patients. The mean follow-up length was 24 months (range: 6–38 months). All grafts remained patent without any sign of endoleaks. There were no aneurysm ruptures, deaths, or other complications related to pelvic flow.

Conclusions:

Using the surgeon-modified IBD to preserve pelvic flow is a feasible endovascular technique and an appealing solution for personalized treatment of CIA aneurysm during EVAR.     

开窗覆膜支架腔内修复髂动脉瘤

正髂动脉瘤往往与腹主动脉瘤并存,单发者少见。髂动脉位于盆腔腹膜后、位置深,开放手术难度大,而腔内修复术操作简便、创伤小,但往往以牺牲同侧髂内动脉为代价。我们应用覆膜支架开窗技术,在腔内修复髂动脉瘤的同时保留了同侧髂内动脉。     

腹主动脉瘤腔内修复术患者早期及中期并发症

目的 观察腹主动脉瘤腔内修复术后早期及中期的并发症发生情况,探讨其原因和防治措施.方法 2002年11月至2007年3月期间山东大学附属省立医院血管外科收治的因高龄及心肺功能等原因不能进行开腹手术的26例腹主动脉瘤患者,行腔内修复治疗、跟踪随访,观察其术后30 d以内的早期、30 d至5年的中期并发症发生情况.结果 早期结果包括心肌梗死1例,死亡1例,腹膜后血肿2例,移植物反应2例,切口感染2例,I型内漏1例,Ⅱ型内漏1例,股动脉闭塞1例;中期结果包括心肌梗死1例,死亡3例,股动脉瘤2例,近端瘤颈扩张1例,I型内漏2例,Ⅱ型内漏2例,不明原因双下肢乏力2例.结论 腹主动脉瘤腔内修复术是一种治疗腹主动脉瘤的有效手段,但由于主动脉病理结构、支架的径向张力、血管壁的术中损伤、高压血流的不断冲击等原因,可造成支架移位、内漏形成、瘤颈扩张等严重并发症,术后需要严密随访.     

腹主动脉瘤患者腔内修复术后Ⅱ型内漏的处理分析

目的 探讨腹主动脉瘤腔内修复术(EVAR)后Ⅱ型内漏的处理.方法 选择解放军总医院血管外科2009年1月至2011年7月10例确诊肾下腹主动脉瘤EVAR术后Ⅱ型内漏的病例,根据内漏罪犯血管不同,选择腔内途径超选择栓塞结合CT引导下经皮穿刺瘤腔内注射纤维蛋白胶进行治疗,并随访观察.结果 10例患者中9例接受治疗,8例接受随访,平均随访时间(2.4±1.6)个月(1～6个月),二次干预年限平均(62±39)个月(11～132个月);罪犯血管肠系膜下动脉来源3例,2例经肠系膜上动脉入路弹簧圈栓塞治疗,1例未治;髂内动脉来源1例,髂内动脉-腰动脉来源3例,均经弹簧圈栓塞;腰动脉来源3例,2例经皮穿刺球囊内注射治疗,1例弹簧圈栓塞.随访期因心脑血管意外死亡2例;初期技术成功率44％,再干预率33％,总体治疗有效率89％.结论 腹主动脉瘤腔内修复术后Ⅱ型内漏整体自然预后较温和,对造成瘤体持续显著增长者可积极干预,腔内栓塞结合瘤腔内注射术是一种近期效果尚可.     

肾下型腹主动脉瘤腔内修复术后并发脊髓缺血的回顾分析

目的 探讨国内肾下型腹主动脉瘤(IAAA)腔内修复术(EVAR)术后脊髓缺血(SCI)并发症的发病率及其可能的病因机制.方法 回顾2008年1月至2014年10月在第二军医大学长海医院及长征医院血管外科收治的400例行EVAR的IAAA病例,分析EVAR术中髂内动脉封堵及术后SCI发生情况.结合现有文献资料,回顾分析EVAR术后SCI的发病率及可能的病因机制.结果 术中同期封堵双侧髂内动脉60例(8例同期弹簧圈栓塞单侧髂内动脉瘤),封堵单侧髂内动脉70例(10例同期弹簧圈不完全栓塞髂内动脉瘤).术后急性下肢动脉缺血2例,急性SCI 1例,慢性下肢间跛1例(＞3个月),SCI发病率为0.25％(1/400).总结现有文献,EVAR术后SCI发病率为0.21％～0.38％,14例SCI病例中仅1例明确可能与术中髂内动脉栓塞有关.结论 SCI是IAAA EVAR术后极为罕见的并发症,目前机制尚未明确.术中同期封堵髂内动脉在其中可能起到一定作用,但目前资料及文献可能更倾向于非核心作用的观点.除脊髓血供血管封堵、栓塞造成的缺血原因外,围手术期患者一般情况也需考虑在内.     

腹主动脉瘤腔内修复术中髂内动脉封堵后盆腔缺血症状发生的危险因素

目的: 分析腹主动脉瘤腔内修复术（EVAR）中封堵髂内动脉后发生盆腔缺血症状的危险因素。方法: 收集2014年1月—2018年6月南京大学医学院附属鼓楼医院血管外科EVAR中行单侧髂内动脉封堵的腹主动脉瘤患者82例，根据随访结果将患者分为盆腔缺血组（20例）和对照组（62例），采用单因素和多因素Logistic回归分析患者术后发生盆腔缺血的危险因素，并通过ROC曲线分析其预测髂内动脉封堵术后发生盆腔缺血症状的价值。结果: 单因素分析结果显示，盆腔缺血组和对照组封堵对侧髂内动脉分支显影数和同侧股深动脉狭窄率差异有统计学意义（均P < 0.05），随着显影分支条数增加，盆腔缺血症状的发生率下降。多因素Logistic回归分析结果显示，对侧髂内动脉分支显影数降低时发生盆腔缺血症状的危险度增加（OR=8.383，95%CI：1.469~47.841，P < 0.05）。ROC曲线分析结果显示，对侧髂内动脉分支显影数预测髂内动脉封堵后盆腔缺血症状的AUC为0.816，临界值为3.5，敏感度为0.861，特异度为0.167。结论: 术前封堵对侧髂内动脉分支显影数降低是术后发生盆腔缺血的危险因素，然而其预测特异性较低，有待积累病例研究。     

腹主动脉瘤腔内修复术后Ⅱ型内漏的临床分析

目的:探讨腹主动脉瘤腔内修复术后Ⅱ型内漏的相关因素. 方法:回顾28例腹主动脉瘤腔内修复术后的内漏发生情况及转归,分析Ⅱ型内漏病例的肠系膜下动脉、Riolan弓以及腰动脉的特点. 结果:28 例中有8 例(28. 6%)发生Ⅱ型内漏,其中Ⅱa型2例,Ⅱb型6例. 形成内漏的肠系膜下动脉起始部直径[平均(4. 03 ± 1. 00) mm]明显大于未形成内漏者[平均(2. 89 ± 0. 50) mm,P=0. 007];发生Ⅱ型内漏病例的瘤腔发出腰动脉支数[平均(3. 4 ± 0. 8)支]明显多于无内漏者[平均(1. 9 ± 1. 5)支,P=0. 017];内漏的形成与腰动脉起始部直径、Riolan弓形态不相关. 平均随访14. 5个月,8例Ⅱ型内漏中1例瘤腔缩小,2例无变化,5例增大,其中仅1例增大明显而接受栓塞治疗. 结论:增强CT静脉期延迟扫描可更好地发现低流量内漏,肠系膜下动脉起始部直径越粗大,从瘤腔直接发出的腰动脉越多,越易形成Ⅱ型内漏. 对于Ⅱ型内漏动脉瘤腔明显增大者,应积极栓塞治疗.     

Multidetector CT Evaluation in Arterial Stenting

Background

Multidetector CT (MDCT) represents breakthrough in CT technology, significantly improving CT Angiography applications.

Methods

Twenty one patients with aortoiliac & branch aneurysms or stenosis were evaluated by Digital Subtraction Angiography (DSA) and Multidetector CT (MDCT) before and after endovascular repair.

Results

There were eight cases of aortic & branch aneurysms and 13 with stenosis. Four cases had aortic aneurysms, while one case had left subclavian artery aneurysm, thoracic aneurysm, femoral and popliteal artery pseudoaneurysms. Of the 13 cases with stenotic lesions, iliac stenosis was seen in eight patients. The others included carotid, vertebral, aortic, renal and aortic bifurcation stenotic. MDCT offered accurate information on shape and size of aneurysm, shape and patency of graft, the presence or absence of perigraft thrombosis or endoleaks, while in stenotic lesions it provided useful information on shape of graft, its location, its patency and the presence and quantity of distal flow.

Conclusion

MDCT was found to be a potentially useful modality during initial evaluation and follow up of patient undergoing endovascular repair.Key Words: Multidetector Computed Tomography, Endovascular stents, Arterial disease     

带膜支架腔内搭桥治疗动脉瘤六例报告

目的 探讨带膜支架腔内治疗动脉瘤的临床应用疗效。方法 应用直筒状及分叉状带膜支架通过外科及血管介入技术对降主动脉瘤,腹主动脉瘤,髂动脉瘤共６例患者进行腔内治疗。结果 ６例７个部位动脉瘤通过腔内介入治疗效果满意。２例术后有延迟性发热。１例术后３个月复查发现瘤腔内有少理漏血。结论动脉瘤的腔内治疗具有创伤小,恢复快,技术操作可行,效果肯定诉     

血管内栓塞治疗颅内动脉瘤

目的探讨血管内栓塞治疗颅内动脉瘤的临床价值。方法选择不同血管内栓塞治疗方案,对27例33个颅内动脉瘤进行栓塞,并总结分析其临床资料。结果 （1）弹簧圈栓塞22例27个动脉瘤,术中动脉瘤破裂出血1例。（2）支架辅助栓塞2例2个动脉瘤,无神经功能缺失。（3）球囊及支架辅助栓塞1例2个动脉瘤,无神经功能缺失。（4）载瘤动脉闭塞2例2个动脉瘤：术后出现神经功能损害1例。结论血管内栓塞治疗颅内动脉瘤是一种微创、安全、有效的治疗方法。     

血管内支架结合电解可脱卸弹簧圈治疗颅内椎动脉宽颈动脉瘤

目的：总结血管内支架结合电解可脱卸弹簧圈治疗颅内椎动脉宽颈动脉瘤的初步经验。方法：通过股动脉途径，采用将血管内支架跨动脉瘤颈放置，通过其网孔将微导管送入动脉瘤腔后填塞GDC的技术治疗6例椎动脉颅内段宽颈动脉瘤。结果：1例支架置入术失败，其余5例支架均准确到位。4动脉瘤达到致密填塞，1例大部填塞，载瘤动脉通畅。1例采用弹簧圈同时闭塞动脉瘤及载瘤动脉，无手术并发症，患均恢复良好。结论：血管内支架联合微弹簧圈是治疗颅内宽颈动脉瘤的有效方法，但仍需要远期随访。     

应用跨肾动脉支架人工血管腔内修复术治疗腹主动脉瘤

目的 应用跨肾动脉支架人工血管腔内修复术治疗腹主动脉瘤,并探讨其手术适应证,操作要点及并发症的预防。方法 采用全麻,在动态数字式减影血管造影（ＤＳＡ）监测下用跨肾动脉支架分叉型人工血管对腹主动脉瘤进行腔内修复术。结果 术中数字式减影血管造影提示动脉瘤消失,没有内漏存在。术后１周螺旋ＣＴ检查提示腔内人工血管无移位扭曲,血流通畅无内漏发生。结论 腹主动脉瘤腔内修复术手术创伤小,病人恢复快。跨肾动脉支架     

髂股动脉区域非创伤性动脉瘤患者的外科治疗

目的 探讨髂股动脉区域非创伤性动脉瘤的诊治经验.方法 回顾性分析中国医科大学附属第一医院1985年1月至2010年11月61例髂股动脉区域非创伤性动脉瘤患者的临床资料.结果 本组髂动脉瘤29例,股动脉瘤32例,共有髂股动脉区域动脉瘤76个,其中43个髂动脉瘤和33个股动脉瘤;17例(27.9％)为多发性动脉瘤,8例(13.1％)发生髂动脉瘤或股动脉瘤破裂,4例(6.6％)合并动脉硬化闭塞症.本组中50例择期行动脉瘤切除、人工血管或自体血管移植;7例破裂性动脉瘤急诊行动脉瘤切除、血运重建术,另1例抢救无效死亡;1例髂动脉瘤行腔内修复和1例髂内动脉瘤行栓塞术;1例髂动脉瘤保守治疗.1例股动脉瘤术后因急性动脉血栓形成导致下肢缺血、坏死而截肢,其余未发生围手术期下肢及盆腔脏器缺血等并发症.随访期间7例死亡,存活患者移植血管通畅,无新生动脉瘤形成.结论 髂股动脉区域的非创伤性动脉瘤重在早期诊断和治疗,并注意多发性动脉瘤.动脉瘤切除及血运重建可获得良好疗效,术后应长期随访,观察有否新生动脉瘤.     

补片扩大成型术构建猪腹主动脉瘤腔内治疗模型

目的 探索使用补片扩大成型技术建立猪腹主动脉瘤模型,验证其作为动脉瘤腔内修复动物模型的可行性。方法 实验猪在全身麻醉下接受腹人工血管补片扩大成型术构建腹主动脉瘤模型,随即进行动脉造影,并实施覆膜支架动脉瘤腔内修复术,术后随访3个月复查造影。结果 完成腹主动脉瘤模型建立及腔内修复10例,所有模型建立均获得成功,术中测量肾下腹主动脉直径平均为(10.5±0.4)mm;动脉瘤模型最大直径平均为(26.3±3.1)mm,直径平均增加(15.7±3.1)mm;动脉瘤模型建立前、后的动脉直径差异有统计学意义(P＜0.001)。除1例因腔内修复时支架遮盖肾动脉于术后24 h死亡,其余实验猪手术过程平稳,术后恢复良好,随访3个月未发生意外死亡,围手术期1个月及术后3个月生存率均为90%。腔内修复发生Ⅱ型内漏1例(10%),随访3个月造影均无内漏。结论 全身麻醉下开腹人工血管补片扩大成型技术构建猪腹主动脉瘤模型安全有效,该模型可作为腹主动脉瘤腔内修复的动物模型。     

Contrast-enhanced Ultrasound in Detecting Endoleaks with Failed Computed Tomography Angiography Diagnosis after Endovascular Abdominal Aortic Aneurysm Repair

Background:

Endovascular aneurysm repair (EVAR) is one of the first-line therapies of abdominal aortic aneurysms. Postoperative endoleak is the most common complication of EVAR. Computed tomography angiography (CTA), which is routine for follow-up, has side effects (e.g., radiation) and also has a certain percentage of missed diagnosis. Preliminary studies on contrast-enhanced ultrasound (CEUS) have shown that the sensitivity of CEUS for detecting endoleak is no lower than that of CTA. To investigate the advantages of CEUS, we conducted CEUS examinations of post-EVAR cases in which CTA failed to detect endoleak or could not verify the type of endoleak.

Methods:

Post-EVAR patients, who were clinically considered to have endoleak and met the inclusion criteria were enrolled between March 2013 and November 2014. All of the patients underwent color Doppler flow imaging (CDFI) and a CEUS examination. Size, location, microbubble dispersion, and hemodynamic characteristics of leaks were recorded. Comparison between the diagnosis of CEUS and CDFI was conducted using Fisher''s exact test and clinical outcomes of all patients were followed up.

Results:

Sixteen patients were enrolled, and 12 (75%) had endoleaks with verified types by CEUS. Among 12 cases of endoleaks were positive by CEUS, 10 were CDFI-positive, and the four CEUS-negative cases were all negative by CDFI. The diagnostic values of CEUS and CDFI were statistically different (P = 0.008). Six patients with high-pressure endoleaks received endovascular re-intervention guided by CEUS results. One patient with type III endoleak had open surgery when endovascular repair failed.

Conclusions:

CEUS is a new, safe, and effective means for detection of endoleaks post-EVAR. This technique can be used as a supplement for routine CTA follow-up to provide more detailed information on endoleak and its category.     

21例锁骨下动脉瘤(SAA)腔内诊治经验

 目的  总结锁骨下动脉瘤(subclavicular artery aneurysm, SAA)患者腔内治疗的效果。方法  复旦大学附属中山医院血管外科2013年1月至2016年 6月共诊治SAA患者21例,男11例,女10例,平均年龄(39±9)岁。所有SAA患者均行腔内治疗,回顾分析围手术期和术后效果及不良事件。结果  技术成功率为100%。术中1例SAA患者支架植入后,近端Ⅰ型内漏明显,改行平行支架植入术;2例Ⅱ型内漏和2例SAA瘤腔巨大分别行侧支和瘤腔钢圈栓塞;中位随访时间19(6～42)个月。随访期间3例SAA患者发生支架内狭窄,1例右SAA患者在释放支架时未覆盖锁骨下动脉开口,在第2年出现支架近端严重狭窄;2例患者SAA位于锁骨下动脉第3段,左右各1例,分别在第2年和第3年出现支架远端严重狭窄。患者2年和3年支架通畅率分别为90.5%和85.7%。结论  腔内治疗SAA操作简单,效果明确;右SAA治疗中应在右锁骨下动脉和右颈总动脉分叉处的切线位角度,使分叉部位完全展开,尽量覆盖开口;对于短瘤颈平行支架植入效果较好;锁骨下动脉瘤位于第3段时,术后易出现支架内狭窄,要注意远期随访。     

脑动脉瘤栓塞疗法完美实施的基础

目的：探索栓塞疗法治疗脑动脉瘤达到理想结果的条件。方法：１９９６年４月至２０００年４月间栓塞治疗３３例动脉瘤患者。以球囊栓塞４例,以机械解脱式钨丝弹簧圈栓塞２０例,以电解脱式铂金弹簧圈栓塞９例。结果：闭塞载瘤动脉４例,１００％闭塞８例,９５％闭塞１５例,９０％闭塞６例。无手术并发症。随访（门诊或信访）３３例无再出血。造影随访８例,其中术后１个月复查造影的２例均保持术后栓塞程度,术后３个月复查的３例     

腔内修复治疗腹主动脉瘤20例临床分析

目的:探讨腔内修复治疗腹主动脉瘤的短期临床疗效以及并发症,总结腔内修复的技术要点和难点。方法:回顾性分析我院2008年9月至2012年7月期间20例腹主动脉瘤患者的临床资料。结果:术中20例(100%)动脉瘤消失,支架形态良好,2例(10%)出现少量Ⅱ型内漏;术后20例(100%)临床痊愈出院。结论:在严格遵循腔内修复指征,掌握腔内修复的技术要点和难点的前提下,腔内修复治疗腹主动脉瘤有手术时间短、出血量少、并发症少、恢复快、微创等优点,远期疗效有待进一步随访。     

Endovascular repair of abdominal aortic aneurysms

In September 1999, the Food and Drug Administration approved two devices for the endovascular repair of abdominal aortic aneurysms. The endografts are placed from within the arteries using fluoroscopic guidance. The minimally invasive technique is performed using bilateral femoral artery cut-downs and has significant advantages over open surgical repair, including a reduction in morbidity, hospital stay and blood loss, with a much quicker return to normal activities. Endoleaks are the main complication following endovascular repair, and close follow-up of patients with CT is recommended to confirm adequate exclusion of the aneurysm.