胸主动脉夹层动脉瘤腔内隔绝术手术入路的探讨

目的 探讨为胸主动脉夹层动脉瘤(TAD)行腔内隔绝术(EVE)选择合适的导入动脉。方法 以彩超，CTA或MRA为检查手段，评估导入动脉(股动脉、髂总动脉、腹主动脉下段等)的直径大小(≥8mm)、有否硬化斑块、狭窄、是否被夹层累及、有否扭曲及其程度，从而选择具体的手术入路。结果 本组37例TAD行EVE术所选择经股动脉手术入路23例、经髂总动脉手术入路14例。未选择经腹主动脉下段手术入路。即时操作成功率为100％。结论 合理的选择导入动脉作为手术入路，是EVE手术治疗TAD顺利完成的要点。     

腔内修复术治疗胸腹主动脉瘤经验总结(附6例报告)

目的总结腔内修复术治疗胸腹主动脉瘤的经验。方法回顾性分析2004年12月-2006年5月6例降主动脉瘤及夹层动脉瘤患者施行腔内修复术的病例资料。结果真性动脉瘤2例,假性动脉瘤1例,夹层动脉瘤3例,共植入支架8枚。术后内瘘大出血死亡1例,腹股沟血肿1例,其余患者均于术后2 d下床活动。未发生肺部感染、肺不张、截瘫、腹胀、肾衰、脑梗塞、心功能不全、心律失常等并发症。术后1周复查CT,支架无扭曲移位,封堵效果满意。结论腔内修复术的近期治疗效果确切,创伤小,并发症少,其远期效果还有待进一步观察。短瘤颈者,DeBakeyⅠ、Ⅱ型夹层动脉瘤患者,累及重要血管的主动脉瘤患者如何进行腔内修复术还有待进一步研究。     

ENDOSCOPIC MUCOSAL RESECTION AND SUBMUCOSAL DISSECTION METHOD FOR LARGE COLORECTAL TUMORS

The goal of endoscopic mucosal resection (EMR) is to allow the endoscopist to obtain tissue or resect lesions not previously amenable to standard biopsy or excisional techniques and to remove malignant lesions without open surgery. In this article, we describe the results of conventional EMR and EMR using an insulation‐tipped (IT) electrosurgical knife (submucosal dissection method) for large colorectal mucosal neoplasms and discuss the problems and future prospects of these procedures. At present, conventional EMR is much more feasible than EMR using IT‐knife from the perspectives of time, money, complication, and organ preservation. However, larger lesions tend to be resected in a piecemeal fashion; and it is difficult to confirm whether EMR has been complete. For accurate histopathological assessment of the resected specimen en bloc EMR is desirable although further experience is needed to establish its safety and efficacy. Further improvements of in EMR with special knife techniques are required to simply and safely remove large colorectal neoplasms.     

Evaluation of blood flow patterns of true and false lumens in dissecting aneurysms using MR phase-contrast techniques

The magnetic resonance phase-contrast technique for the measurement of flow velocity and volume in true and false lumens was studied in six patients with chronic dissecting aneurysms. Phase-contrast images were obtained at a level perpendicular to the dissecting aneurysms of the descending aorta. As the maximum diameter of aneurysms increased, the ratio of the cross-sectional area of the false to the true lumen increased and the peak average velocity in the true lumen during systole was decreased. This technique proved invaluable for determining prognosis and operability for this condition.     

Extensive replacement of the aorta from the ascending aorta to the supraceliac abdominal aorta during a one-stage operation

A successful replacement of the aorta from the ascending aorta to the supraceliac abdominal aorta in one operation is herein reported. The patient was 66-year-old woman who had DeBakey type I chronic aortic dissection with a pre-disseminated intravascular coagulation (DIC) condition. The image diagnosis revealed a markedly enlarged false lumen with a narrow true lumen in the ascending aorta extending to the diaphragm level while below the diaphragm level, the aortic dilatation was mild. The operation was performed through both a thoracoabdominal incision and a median sternotomy to expose the whole thoracic aorta, and the aorta was replaced from the ascending aorta to the supraceliac abdominal aorta. Selective cerebral perfusion was used for cerebral protection and this was a useful adjunct since no time limitations were thus required during repair of the aortic arch. Although the patient developed several complications postoperatively, she eventually recovered and was discharged from the hospital without any neurological disorders.     

Closed cervicocranial trauma, "false aneurysm" of the internal carotid artery and brain infarction

A 17-year-old man developed acute hemiparesis 6 months after a motor cycle accident. In the accident he had a closed trauma on the contralateral side of the head and the neck, with multiple bone fractures. Aortocervical angiography, performed after the infarction, revealed a 2.5 cm long aneurysmatic dilatation in the internal carotid artery, the presumably source of embolic infarction. This and the 24 other cases gathered from the literature support the notion that closed neck trauma may create "false aneurysm" which again may cause neurological deficits.     

Different roles of arteriosclerosis in the rupture of intracranial dissecting aneurysms

AIMS: Although intracranial dissecting aneurysm (IDA) is a newly described variant of the brain aneurysms that affects mainly the vertebrobasilar arterial system, its pathogenesis remains obscure. We aimed to clarify the role of arteriosclerosis in the pathogenesis of IDA based on histopathological findings in seven autopsy cases of IDA. METHODS AND RESULTS: All cases exhibited systemic hypertension or left ventricular hypertrophy. Macroscopically, all cases exhibited subarachnoid haemorrhage. Two types of dissection were recognized in the vertebral artery. Six of seven IDA cases showed a widespread disruption of the entire thickness of the arterial wall with the formation of a dilated pseudoaneurysm, which consisted of thin adventitia (arterial wall disruption type). Medial disruption of the arterial wall and subadventitial dissecting haemorrhage were also found, resulting in the formation of a false lumen and stenosis of the 'true' lumen of the artery. However, these lesions were connected to the site of rupture of the entire arterial wall. Within 1 day after onset of IDA, the autopsy cases showed formation of fibrin thrombus, marked leucocyte infiltration and necrosis of the arterial wall at the site of the lesion. Cases that survived more than 1 week showed smooth muscle cell proliferation, macrophage accumulation and lymphocytic infiltration in the lesions. These cases showed no atherosclerotic plaque, but non-atherosclerotic fibrocellular intima. The thickness of intima and media was significantly less in the vertebral artery of IDA patients than that of non-IDA patients with systemic hypertension. On the other hand, the remaining case showed severe atherosclerosis with haemorrhage into the lipid core without connection to the arterial lumen (intra-atheromatous plaque haemorrhage type). However, unusual arterioles and neovascularization of the intra-and peri-arterial walls were observed. CONCLUSIONS: Our results suggest that disruption of the entire arterial wall may be a critical event in the development of IDA and result in the medial disruption and subadventitial haemorrhage. Non-atheromatous intima might function as a protective factor in arterial wall disruption. On the other hand, atherosclerosis may predispose to intra-atheromatous plaque haemorrhage type of IDA through intramural haemorrhage originating from the newly formed vessels.     

Exposure to formaldehyde and phenol during an anatomy dissecting course: sensitizing potency of formaldehyde in medical students

BACKGROUND: The sensitizing potency of formaldehyde and phenol during anatomy dissecting was investigated. The objective was to determine whether exposure induces specific IgE or IgG against formaldehyde-albumin or phenol-albumin. METHODS: In 27 medical students, specific IgE against formaldehyde-albumin by RAST plus ELISA and specific IgE against phenol-albumin by ELISA were assessed. In addition, specific IgG against formaldehyde-albumin was assessed in 23 students. Symptoms before and during dissecting were assessed, and indoor formaldehyde and phenol were measured. RESULTS: Mean indoor formaldehyde was 0.265 +/- 0.07 mg/m3, and mean indoor phenol was 4.65 +/- 2.96 mg/m3. Specific IgE/IgG against formaldehyde-albumin was not found at the beginning. Four students developed specific IgE against formaldehyde-albumin (RAST classes of > or =2.0), and all four also had specific IgE in the ELISA, but IgG against formaldehyde-albumin was not found. Specific IgE against phenol-albumin was not seen. Itch and paresthesia of the hands (P<0.00001), dizziness (P<0.008), burning eyes (P<0.01), headache, sneezing, epistaxis, gingival bleeding, oral or pharyngeal itch, and shortness of breath were experienced. CONCLUSIONS: Formaldehyde exposure during dissecting may induce specific IgE, but not IgG, against formaldehyde-albumin. Sensitization did not correlate with symptoms.     

颅内后循环夹层动脉瘤的临床表现及影像学特点

目的：通过病例分析总结颅内后循环夹层动脉瘤的典型临床表现及影像学特点。方法：回顾分析1996－1999年收治的32例颅内后环非囊状动脉瘤患者的数字减影血管造影（DSA）主磁共振成像（MRI）表现,根据“珠线征”动脉假腔（“双腔征”）,内膜瓣等影像学表现诊断夹层动脉瘤,并分析其临床表现及影像学特点,结果：8例患者被诊断为夹层动脉瘤,蛛网膜下腔出血者3例,吞咽困难及偏瘫（Wallenberg综合征）者1例,头痛或颈后部痛者3例,1例无症状,此8例患者中有1例合并高血压,1例同时患血友病,DSA及MRI检查发现“珠线征”者6例,动脉假腔者4例,MRI发现1例动脉壁内血肿。结论：椎－基底动脉夹层动脉瘤症状轻重 一,单凭临床表现诊断较难,但其影像学表现较为典型,DSA及MRI中的“珠线征”,“双腔征”或内膜瓣为常见的影像学表现。     

A ruptured dissecting aneurysm of the anterior radiculomedullary artery caused by vertebral angiography

We report here a 54-year-old man with an aneurysm arising on a cervical anterior radiculomedullary artery. The aneurysm ruptured just after vertebral angiography for a vascular anomaly of the brain, and it appeared to be fusiform, with thrombosis following angiography. Considering the sequential radiological studies and clinical course, it was assumed to be a dissecting aneurysm caused by the angiography. MRI showed severe swelling of the cervical spinal cord and an infarct in the territory of the anterior spinal artery. The mechanism of this rare complication is discussed. Received: 29 March 1999 Accepted: 18 August 1999