感染性腹主动脉瘤诊疗体会

目的 总结感染性腹主动脉瘤的诊疗体会.方法 回顾性分析我院2009年6月～2012年5月收治的8例感染性腹主动脉瘤患者的临床资料.2例采用外科手术治疗,行原位血管重建;3例采用腔内修复术,3例未行手术.结果 成功手术5例,随访6～12个月,中位随访时间10个月.原位血管重建2例:1例术后2个月出现吻合口破裂大出血致死;1例出现人工血管-肠瘘,切除左髂支人工血管,两端缝扎,随访1年,未出现不良事件.腔内治疗3例,随访期间均未出现复发、支架再感染、支架移位、内漏等不良事件.未手术3例,均因感染性腹主动脉瘤破裂死亡.结论 感染性腹主动脉瘤罕见,术前诊断率低,死亡率极高.按照其特有的症状、体征及影像学和病原学检查,明确诊断后,应先抗生素治疗,并根据不同情况选择个体化治疗方案.     

主动脉支架移植物感染的诊治体会（附4例报道）

目的 探讨主动脉支架移植物感染的诊断和治疗方法.方法 回顾性分析1998～2008年期间我科收治的4例主动脉腔内治疗术后发生支架移植物感染患者的临床资料.结果 2例患者原手术为胸主动脉腔内修复术,2例为腹主动脉瘤腔内修复术.4例感染患者临床均有非特异性发热表现,CT检查均有感染征象,2例细菌培养为猪霍乱沙门菌.实施清创引流联合抗感染治疗2例,单纯行抗感染治疗2例,均获得成功,随访期间无再感染发生.结论 支架移植物感染发生率低但产生的后果严重,结合影像学检查可提高诊断的准确性,在合适的患者中可以实施保留移植物的保守治疗.     

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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。方法对２例病人采用全麻,在动态数字减影血管造影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了腔内修复术,结果手术中ＤＳＡ提示动脉瘤消失,无内漏发生。术后１周及分别随访３和９个月,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,跨肾动支架人工     

腔内修复术治疗胸腹主动脉夹层动脉瘤

目的 介绍血管内支架技术治疗胸腹主动脉夹层动脉瘤的经验。方法 对2000年10月－2001年6月间6例胸腹主动脉夹层动脉瘤的治疗经过进行回顾性分析。结果 6例均为男性,年龄42－72岁。Standford A型胸腹主动脉夹层动脉瘤1例,B型5例。其中5例经行腔内人工血管支架修复成功,1例中转腹主动脉夹层开窗手术。术后1例发生髂外动脉夹层破裂,行腹主动脉夹层开窗人工血管移植术;1例术后3d因严重心肌梗塞抢救无效死亡。5例随访1－9个月,情况良好。结论 腔内人工血管治疗主动脉夹层动脉瘤简化了手术操作,减小了手术风险。腹主动脉夹层开窗手术是治疗主动脉夹层的辅助手段。     

主动脉瘤40例治疗体会

目的介绍外科与腔内隔绝术治疗主动脉瘤的体会。方法手术与腔内隔绝术治疗主动脉瘤40例,手术治疗30例,Bentall术9例,Bentall 部分弓置换3例,主动脉瘤切除人工血管置换6例,主动脉瘤切除补片修补4例,升主动脉 部分弓置换、主动脉瓣二尖瓣置换 升主动脉折叠缝合术各2例,主动脉瓣置换 升主动脉置换、主动脉瓣置换升主动脉折叠缝合术、主动脉瘤切除直接缝合、主动脉瘤切除人工血管置换 左全肺切除术各1例。腔内隔绝术治疗假性胸降主动脉瘤1例、假性腹主动脉瘤1例、夹层主动脉瘤ⅢA型1例、ⅢB型7例,经股动脉切口植入32~38mm覆膜支架。结果手术后因低心排出量综合征和出血各死亡1例,死亡率6.7%,无截瘫、偏瘫和感染。覆膜支架腔内隔绝术后1~2周内低热8例,无大出血、内漏和死亡。生存38例,随访1个月~5年,无死亡和远期并发症。结论升弓部主动脉瘤的手术治疗效果满意,覆膜支架腔内隔绝治疗DeBakeyⅢ型夹层主动脉瘤创伤小、并发症少、恢复快。     

腹主动脉-人工血管吻合口感染性假性动脉瘤的腔内治疗1例报告

目的:总结腹主动脉-人工血管吻合口处的感染性假性动脉瘤患者的治疗经验。方法:回顾1例发生在腹主动脉-人工血管吻合口处的感染性假性动脉瘤患者的临床资料。结果:经血管腔内放置覆膜支架和手术引流等治疗,抢救成功;出院后随访6个月,情况良好。结论:对于巨大的感染性假性动脉瘤,先放置覆膜支架,再手术引流感染灶的治疗思路是可行的治疗方法,尽管存在争议。     

白塞病并发动脉瘤12例的外科治疗体会

目的总结白塞病并发动脉瘤的外科手术和腔内治疗经验。方法对1977年6月至2006年3月收治的12例白塞病患者并发21个动脉瘤进行回顾性分析。腹主动脉瘤3个,升主动脉瘤1个,髂动脉瘤4个,髂动脉吻合口假性动脉瘤1个,股总动脉瘤3个,股浅动脉瘤2个,腘动脉瘤2个,椎动脉瘤1个,锁骨下动脉瘤2个。颈动脉瘤1个和肠系膜上动脉瘤1个。21个动脉瘤中,行外科手术14个,包括动脉瘤切除、人工血管或自体大隐静脉移植术12个,动脉瘤切除、病变动脉结扎术2个;行支架型人工血管腔内修复术6个;1个升主动脉瘤因患者全身情况差,行保守治疗。结果围手术期死亡患者2例,其中1例行外科手术,1例行腔内修复术。术后吻合口假性动脉瘤1例（1个）,其他部位新动脉瘤形成7个,下肢血管移植物闭塞2例,但患肢无明显缺血坏死。6例患者随访3-293个月,随访中位时间28个月,1例死于肺癌。结论白塞病动脉瘤一旦发生,需积极处理。术前、术后积极免疫抑制治疗可降低外科手术和腔内修复术后并发症发生。因术后有吻合口和其他部位假性动脉瘤复发及血管移植物闭塞可能,需长期随访、及时处理。     

瘤颈捆扎治疗腹主动脉瘤腔内修复术后持续内漏的疗效分析

目的总结瘤颈捆扎治疗腹主动脉瘤腔内修复术后持续内漏的疗效。方法回顾性分析2019年6月至2022年4月北京大学人民医院10例行瘤颈捆扎手术患者的临床及随访资料。结果手术指征为术后持续Ⅰ型内漏6例、Ⅱ型内漏3例、存在内张力1例, 均合并动脉瘤增大或破裂。全麻下经腹入路套带控制肾下近端瘤颈后使用捆扎带进行加固。10例患者均获得手术成功, 无内漏残留, 无支架移植物闭塞。围手术期并发症包括1例伤口愈合延迟和1例不完全性肠梗阻, 无围手术期死亡。中位随访时间13个月, 未发现内漏复发。1例患者术后6个月因胸降主动脉瘤接受胸主动脉瘤腔内修复术;无其他主动脉相关二次手术或主动脉相关死亡。结论瘤颈捆扎治疗腹主动脉瘤腔内修复术后持续内漏相对微创, 可以有效消除内漏。     

腔内修复术治疗孤立性髂动脉瘤7例分析

目的总结腔内修复术治疗孤立性髂动脉瘤的经验。方法回顾性分析2004年10月至2006年3月复旦大学附属中山医院血管外科收治的腔内修复孤立性髂动脉瘤7例的临床资料。其中,右髂总动脉瘤4例,左髂总动脉瘤2例,左髂内动脉瘤破裂1例。结果7例均取得技术成功。3例右髂总动脉瘤累及右髂内动脉,选用分叉支架型人工血管行腔内修复术。1例右髂总动脉瘤累及腹主动脉下端,选用AUI(Aortouniiliac)支架型人工血管腔内修复加股动脉旁路术。2例左髂总动脉瘤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(DSA)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6例无手术并发症。术后随访1～19个月(平均10.6±6.42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,远期效果尚须进一步随访。     

腔内修复术治疗感染性主动脉瘤

目的 探讨腔内修复术治疗感染性主动脉瘤(IAA)的方法及其疗效.方法 回顾性分析2006年5月～2007年7月经腔内修复治疗7例IAA患者的临床资料.结果 7例均获得技术成功,术后行数字减影血管造影显示动脉瘤消失,无内漏,术后无并发症.随访8～22个月,瘤体无增大,人工血管支架通畅无移位、无内瘘及感染发生.结论 腔内修复术治疗IAA具有安全、微创等特点,近期疗效较好,远期效果尚需进一步随访.     

Beware of Infection before Treating Aneurysms with Stent-grafts

A 51-year-old man with abdominal aortic aneurysm was treated endovascular placement of stent-grafts fabricated from expanded polytetrafluoroethylene and Z-stents. Exclusion of the aneurysm was achieved at the end of the procedure. However, a stent-graft infection developed two months after the procedure. We performed a surgical excision of the aneurysm with stent-grafts and an extra-anatomical reconstruction. The patient is alive and well after 4 years with no signs of infection. The preop angiography shows all features of a false aneurysm and the cultures at the open procedure revealed Salmonella. We must assume that the stent-graft has been implanted in a primarily mycotic aneurysm, even if there were no signs of infection initially.     

Mycotic aneurysm presenting as acute pyelonephritis

This report describes a 56-year-old man with a ruptured infected abdominal aortic aneurysm secondary to Salmonella bacteremia, initially presenting as acute pyelonephritis. Spike fever with severe back pain continued despite empiric antibiotic treatment at a local hospital. Hypotension with a sudden hemoglobin drop was observed on the second hospitalization day. Abdominal computed tomography to further examine the bleeding focus confirmed a rupture of the mycotic abdominal aortic aneurysm. This case was successfully treated through prompt surgical intervention and aggressive protracted antibiotic therapy. The case presented herein raises concerns about the uncommon but life-threatening mycotic aneurysm presented initially as acute pyelonephritis. Early diagnosis and appropriate surgical and antibiotic treatment of the Salmonella mycotic aortic aneurysm is crucial for a satisfactory outcome.     

Mycotic aneurysm of the infrarenal abdominal aorta infected by Clostridium septicum: a case report of surgical management and review of the literature

We report a surgical case of mycotic aneurysm of the infrarenal abdominal aorta infected by Clostridium septicum. The patient was first treated with an in situ prosthetic graft replacement. When the infection recurred 5 weeks after the aortic surgery, the patient was successfully treated by transposition of rectus abdominis muscle flap around the graft. Only 19 cases of mycotic aneurysm or aortic dissection caused by Clostridium septicum have been reported. Ten of 12 patients who underwent vascular surgery survived, whereas all 7 patients who did not undergo surgery died. Surgical treatment should be undertaken since the surgical results seem satisfactory.     

Mediastinal rupture of a thoracoabdominal mycotic aneurysm caused by Salmonella typhimurium in an immunocompromised patient

A case is presented of rupture of a mycotic thoracoabdominal aneurysm caused by Salmonella typhimurium in a patient on immunosuppressive therapy following kidney transplantation. After initial medical treatment, surgery consisted of local debridement and implantation of an aortic prosthesis. Lifelong antibiotic treatment was prescribed because of the combination of immunosuppressive therapy, the history of recurrent S. typhimurium bacteremia and the presence of an aortic prosthesis.     

Arteritis due to Salmonella with aneurysm formation: two cases.

Although arterial infection due to Salmonella is rare, it remains one of the most common causes of primary mycotic aneurysms. The presentation is one of sepsis, cultures positive for Salmonella and rapid expansion or rupture of the aneurysm. The authors' experience at Victoria Hospital, London, Ont., includes two cases of aneurysms infected with Salmonella--one aneurysm of the aorta and the other of the common femoral artery. Both patients were treated by excision of the aneurysm, extra-anatomic reconstruction in an area remote from the infected field and long-term administration of appropriate antibiotics. One patient was alive and well 36 months after resection. The other died of multiple organ failure 10 days after resection. From a review of the English and French literature since 1948, 64 cases of abdominal aortic aneurysms infected with Salmonella were found; half of the patients survived the perioperative period. The diagnosis of mycotic aneurysm must be considered in any patient with an aneurysm and culture specimens positive for Salmonella. The authors favour wide débridement of the infected aneurysm with extra-anatomic reconstruction. This view is supported by a review of the literature. The appropriate antibiotic therapy is bactericidal rather than bacteriostatic.     

Once bitten, twice shy: an unusual case report of a mycotic aortic aneurysm

Primary mycotic aneurysms of the aorta are a rare, but potentially lethal condition comprising less than 1% of all aortic aneurysms. All age groups are affected but patients younger than 50 years are most susceptible. Organisms commonly implicated in aortitis and mycotic aortic aneurysms include Salmonella species and Staphylococcus aureus(1). We present the first case report of a primary aortic mycotic aneurysm caused by Capnocytophaga canimorsus, a commensal organism found in the mouth of dogs and cats and occasionally associated with serious human infections.     

Endovascular repair for multiple Salmonella mycotic aneurysms of the thoracic aorta presenting with Cardiovocal syndrome.

Salmonella mycotic thoracic aortic aneurysm is a rare but life-threatening condition. We report a 59-year-old man with two Salmonella mycotic thoracic aortic aneurysms, presented with fever and chills associated with hoarseness due to left vocal cord palsy (Cardiovocal syndrome). Successful endovascular repair was performed using two Talent thoracic stent-graft devices deployed separately to cover the two mycotic aneurysms. Subsequent computed tomography at 12 months after the operation confirmed exclusion of the two pseudoaneurysms with no endoleak. With potent antibiotics and careful surveillance program, endovascular repair is a possible alternative to conventional open surgery in the management of mycotic thoracic aortic aneurysms, especially in high-risk patients.     

支架型人工血管临床应用的初步经验

目的探讨支架型人工血管治疗各类动脉瘤的临床效果。方法本组包括夹层动脉瘤 4 8例 ;腹主动脉瘤 13例 ;降主动脉、左锁骨下动脉、肾下和肾上腹主动脉假性动脉瘤分别为 4例、1例、2例和 1例 ;左、右髂动脉瘤各 1例。对夹层动脉瘤和假性动脉瘤均行破口封堵术 ,真性腹主动脉瘤行隔绝术。结果本组均获技术成功。围手术期死亡 2例。 5例夹层动脉瘤术后近侧有少量残余漏 ,但 4例半年后近侧渗漏消失 ,9例残存远侧破口少量返流。腹主动脉瘤 6例术后即时有轻度内漏 ,3个月后 5例内漏消失。结论支架型人工血管治疗夹层动脉瘤、假性动脉瘤和真性动脉瘤手术微创、安全 ,但其远期疗效需进一步观察。     

Mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer: report of a case

We report a case of mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer (PAU). An 81-year-old woman was admitted to a local hospital with fever and abdominal pain, and when her symptoms were not improved by antibiotics, she was referred to our department. Computed tomography (CT) and angiography showed a saccular aneurysm below the renal arteries, and an emergency laparotomy was performed because we suspected a mycotic abdominal aortic pseudoaneurysm. An abscess was found on the proximal side of the jejunum, caused by an aneurysm penetrating the serosa. We diagnosed a mycotic pseudoaneurysm after finding the anterior wall of the aorta penetrated by intense calcification. The pseudoaneurysm was resected with the abscess and the area was covered with a pedicled omental flap to prevent infection. An axillofemoral bypass was also done. The patient recovered well.     

应用一体式分叉支架型人工血管腔内治疗腹主动脉瘤42例

目的总结应用一体式分又支架型人工血管治疗腹主动脉瘤初步经验。方法本组42例，其中腹主动脉瘤39例，腹主动脉假性动脉瘤1例，Ⅲ型夹层动脉瘤1例，降主动脉瘤合并腹主动脉瘤1例。除均在腹主动脉放置一体式分又支架型人工血管外，1例降主动脉瘤合并腹主动脉瘤者共放置5枚支架型人工血管，其中4枚直型支架用于隔绝降主动脉瘤；1例Ⅲ型夹层动脉瘤者，降主动脉近侧破口用直型支架型人工血管封堵；1例因一侧髂外动脉闭塞需先经腹膜外切口行人工血管搭桥后才能放置一体式分叉支架。结果平均手术时间50min。1例死亡，8例附加近侧短的覆膜支架，1例附加远侧Cuff，1例近侧和远侧均加Cuff。8例术后有少量内漏，1周后内漏均消失。5例封堵了双侧髂内动脉，20例封堵了单侧髂内动脉，但均未导致臀肌坏死或疼痛等并发症。2例瘤颈与瘤体呈90度角也获得成功。结论一体式分又支架型人工血管可以达到隔绝腹主动脉瘤的作用，且操作更快捷。