腹主动脉瘤腔内修复术单中心治疗经验

目的 评价腔内修复术(endovascular aneurysm repair,EVAR)治疗肾下型腹主动脉瘤(abdominal aortic aneurysm,AAA)的围术期和中远期效果.方法 回顾性分析131例AAA行EVAR的临床资料,评价EVAR治疗AAA的安全性和中远期疗效.结果 手术时间(137±29) min,术中出血(142±20) ml、输血(46±26) ml、ICU恢复时间为(17±4)h.围术期主要并发症包括重度心功能不全8例、心肌梗死2例、肺部并发症5例,内漏4例等;随访中发现内漏15例,Ⅰ型8例,Ⅱ型5例,Ⅲ型和Ⅳ型各1例,死亡2例;Kaplan-Meier生存分析无并发症生存率及再次处理率提示60个月后仍有并发症发生,其中40％是需要再次处理的并发症.结论 EVAR是AAA的安全治疗方法,但需要长期严格随访并及时处理并发症.     

Endovascular repair of abdominal aortic aneurysms: the Cleveland Clinic experience with five different devices

The endovascular repair of abdominal aortic aneurysms is associated with long-term durability that is inferior to that of traditional open surgical repair. Device migration, endoleak, and limb thrombosis continue to plague currently available devices, culminating in an unacceptably high rate of secondary procedures and, in rare cases, failure to protect the patient from rupture. A review of the available literature yields a few caveats: certain correlations that exist between device design features and the risk of graft-related complications during and after implantation. Noteworthy in this regard are associations between bulky deployment systems and iliofemoral arterial injury, unsupported (nonstented) graft limbs and thrombotic occlusion, fabric/stent motion and fabric degeneration, rigid endoskeletons and limb disunion, as well as passive proximal attachment and device migration. Whereas the last decade has witnessed improvement in endograft device design, endovascular aneurysm repair still must be considered a technology in evolution. Early benefit of reduced periprocedural morbidity is negatively affected by inferior long-term durability of current technology. Nevertheless, many patients, particularly those who are elderly or infirm, may choose to accept the limitations of current endovascular technology to avoid the increased morbidity of traditional open surgical aneurysm repair.     

Natural history of the residual infrarenal aorta after infrarenal abdominal aortic aneurysm repair

Purpose: We determined the natural history of the residual native infrarenal aortic segment after conventional abdominal aortic aneurysm (AAA) repair. Methods: For the retrospective arteriographic case series, 800 hundred translumbar aortograms (TLAs) were obtained for 272 patients, before and after conventional AAA repair. The main outcome measures were changes in the aortographic diameter and the length of the infrarenal aortic segment, corrected and uncorrected for magnification by normalization to the first lumbar vertebral body height. Results: The mean follow-up time from the preoperative TLA to the most recent postoperative TLA was 42 months (range, 1 to 257 months). Vertebral body height did not change p = 0.35). The length of the native infrarenal aorta cephalad to the proximal anastomosis increased a mean of 3 mm, from 23 to 26 mm p = 0.001). However, in 115 patients (43%), this aortic segment elongated more than 5 mm, and in 63 patients (24%), it elongated more than 10 mm. The native residual infrarenal aorta above the proximal anastomosis dilated a mean of 1 mm, from 23 to 24 mm p = 0.001), but in 21 patients (8%), it dilated more than 5 mm. There was a weak positive correlation between the increase in residual native aortic diameter and duration of follow-up. There was a negative correlation between this increase and the initial size. The diameters of the proximal anastomosis and proximal graft did not change. Marked variability in the changes in aortic dimensions was observed. Conclusions: A mean period of 42 months after conventional AAA repair, the native infrarenal aortic segment elongates and dilates. Although such enlargement is statistically significant, the average increase appears to be small. However, residual aortic cuff diameter increased more than 5 mm and neck length more than 10 mm in a significant number of patients, with potentially serious implications for endovascular treatment of AAA. (J Vasc Surg 1998;27:805-12.)     

Improved long-term survival following infrarenal abdominal aortic aneurysm repair

Background. The aim was to investigate early and long-term results following AAA repair during a 20-year period. Method. One thousand and forty one patients with AAA were treated with open surgery (905) or EVAR (136) during the period 1983–2002. Comorbidity and factors influencing early and long-term results were investigated. Data were collected retrospectively from the patients’ medical records. A complete follow-up was obtained. Results. Women had a significantly higher 30-day mortality following repair of ruptured AAA than men. The degree of emergency, advancing age and renal failure were significantly associated with 30-day mortality. We observed an improvement in long-term survival during the study period. Time interval of surgery, cerebrovascular disease, diabetes, COPD and renal failure influenced long-term survival negatively. Conclusion. Women with ruptured AAA have a higher early mortality than men, which needs to be investigated further. Long-term survival has improved during the study period. Age, diabetes, chronic obstructive pulmonary disease, renal failure and cerebrovascular insufficiency influenced the long-term survival negatively. EVAR is used to an increasing extent and the results are improving.     

Thoracovisceral segment aneurysm repair after previous infrarenal abdominal aortic aneurysm surgery

OBJECTIVE: Repair of thoracovisceral aortic aneurysms (TVAA) after previous open repair of an infrarenal abdominal aortic aneurysm (AAA) poses significant challenges. We sought to better characterize such recurrent aneurysms and to evaluate their operative outcome. METHODS: We reviewed the records and radiographs of 49 patients who underwent repair of TVAAs between 1988 and 2002 after previous repair of an AAA. Visceral artery reconstructions were completed with combinations of beveled anastomoses, inclusion patches, and side arm grafts. In 14 patients visceral endarterectomy was required to treat associated occlusive disease. Sixteen patients had cerebrospinal fluid drainage, and 10 patients had distal perfusion during cross-clamping. RESULTS: Patient mean age was 72 years, and 80% were men. Fifty-one percent of patients had symptomatic disease, and average TVAA diameter was 6.2 cm. Mean time between AAA and TVAA repair was 77 months. Twenty-six percent of aneurysms were restricted to the lower visceral aortic segment, 35% extended to the diaphragm, another 35% extended to the distal or middle thoracic aorta, and 4% involved the entire remaining visceral and thoracic aorta. The 30-day operative mortality rate was 4.1% in patients with nonruptured aneurysms and 50% in patients with ruptured aneurysms, for an overall mortality rate of 8.2%. Fifteen patients (30.6%) had major morbidity, including paresis in two patients and dialysis-dependent renal failure in five patients. At late follow-up, three patients required further aortic operations to treat additional aneurysms, and four patients had fatal aortic ruptures. Two-year and 5-year cumulative survival rates were 61% (+/-7.5%) and 37% (+/-7.8%), respectively. At univariate analysis, operative blood loss was the sole significant predictor of major morbidity (P <.023), and rupture (P <.030, P <.0001) and aneurysm extent (P <.0007, P <.0001) correlated with both operative death and long-term survival. Only aneurysm extent (P <.010, relative risk 37.3) remained a significant predictor of long-term survival at multivariate analysis. CONCLUSION: Elective repair of TVAAs after previous AAA repair can be performed with an acceptable level of operative mortality, though with considerable operative morbidity. Limited long-term survival mandates careful patient selection, and the high mortality associated with ruptured TVAA underscores the need for post-AAA surveillance.     

解剖条件复杂的肾下型腹主动脉瘤的腔内治疗

目的 探讨腔内修复术治疗复杂解剖条件肾下型腹主动脉瘤的安全性和有效性.方法 对2003年1月至2011年3月接受经股动脉植入分体式覆膜支架治疗解剖条件复杂的48例腹主动脉瘤患者的临床资料进行回顾性分析.男性37例,女性11例;年龄50～81岁,平均71.4岁.其中近端短瘤颈(＜15 mm) 14例,近端瘤颈成角大(＞60°)13例,复杂髂动脉解剖者21例,其中髂动脉严重扭曲者15例,髂动脉狭窄(直径＜7 mm)者6例.结果 所有病例治疗均获成功,术中无中转开腹手术者,围手术期生存率100％.40例患者获得随访,随访时间4-122个月,平均63个月,死亡2例,均为心脑血管意外,其余生存良好,累积生存率95.8％.Ⅰ型内漏2例,其中1例2周后消失,1例长期存在,随访过程中未发现新发内漏、支架移位或堵塞、瘤体扩大或瘤体破裂等并发症;2例封堵一侧大部分肾动脉的患者恢复良好,术后未出现肾功能不全.结论 腔内修复术治疗复杂解剖条件肾下型腹主动脉瘤安全、有效.随着经验的不断积累,腔内修复术在治疗解剖条件复杂的肾下型腹主动脉瘤中将发挥更重要的作用.     

Midterm results of endovascular infrarenal abdominal aortic aneurysm repair in high-risk patients

Short-term and midterm clinical outcomes after endovascular repair of abdominal aortic aneurysms (AAAs) have been well documented. Evaluation of longer term outcomes is now possible. Here we describe our initial 100 high-risk patients treated with endovascular aneurysm repair (EVAR), all with a minimum of 5 years of follow-up. A retrospective review of prospectively recorded data in a departmental database was undertaken for the first 100 consecutive EVAR patients with a minimum of 5 years (range, 60-105 months) of follow-up performed between December 1997 and June 2001. Information was obtained from surgical follow-up visits and family doctors' offices. Endovascular repair of AAA in high-risk patients can be achieved with acceptably low postoperative mortality and morbidity. Longer term results in this high-risk cohort suggest that EVAR is effective in preventing aneurysm-related deaths at 5 years and beyond. All late mortalities were due to patients' comorbid diseases.     

Evaluation of the effect of endovascular options on infrarenal abdominal aortic aneurysm repair

Endovascular devices designed to exclude flow to infrarenal abdominal aortic aneurysms (AAA) were approved by the Food and Drug Administration in the United States in 1999. This action allowed widespread use of this technology for AAA exclusion. The purpose of this report is to examine trends for use of these modalities, rates of rupture of AAA, and to compare results of open AAA repair with endovascular repair. Results were collected for all hospitals, except for Veterans Administration hospitals, by a state-wide repository. Data for the years 1996 through 1998 and 2001 through 2002 were evaluated, and data from 1999 through 2000 were excluded because no separate codes were available to distinguish between open and endovascular repair. The information gathered is based on the All Patient Refined Diagnostic Related Group (APRDRG; 3M, St. Paul, MN). An average of 718 open, elective AAA was performed between 1996 and 1998. This dropped to 503 open repairs from 2001 to 2002 (P < 0.005). During that same interval, 308 endovascular elective AAA repairs were performed, therefore the total rate of elective repair increased by 100. The average rate of ruptured AAA repairs from 1996 to 1998 was 121 per year, and this dropped to 89 from 2001 to 2002 (P < 0.005). The mortality of open AAA repair during the 1996 to 1998 and 2001 to 2002 intervals was unchanged (4.7%). Mortality from endovascular AAA repair between 2001 and 2002 was 1.9 per cent (P = 0.003). Major morbidity was 14.5 per cent for open, elective AAA repair and 6.3 per cent for endovascular elective repair from 2001 to 2002 (P < 0.001). These data suggest that the advent of endovascular AAA repair has contributed to a reduction in the rate of ruptured AAA repairs, an increase in total procedures performed, and a significant decrease in perioperative deaths and major complications when compared with open AAA repair.     

Endovascular abdominal aortic aneurysm repair: a community hospital's experience

Endovascular abdominal aortic aneurysm repair (EVAR) has become the first-line approach for the treatment of abdominal aortic aneurysms. Outcomes outside of tertiary care settings remain unknown. The purpose of this study is to report the midterm outcomes of EVAR in a community hospital. A retrospective review of 75 elective, consecutive EVARs performed at a single nonacademic community hospital was performed. There were no conversions to open repair during or after endovascular repair. The mean follow-up was 18 months. There were no postoperative ruptures or aneurysm-related deaths. At 24 months, freedom from aneurysm-related death was 100%, freedom from secondary interventions was 91%, and freedom from endoleak was 69%. EVAR in the community setting is a safe and durable procedure, even in a medically high-risk population. Comparable outcomes can be achieved to tertiary care centers, in carefully selected patients with favorable anatomy.     

Total laparoscopic infrarenal aortic aneurysm repair: preliminary results

OBJECTIVES: We describe our initial experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. MATERIAL AND METHODS: Between February 2002 and September 2003, we performed 30 total laparoscopic AAA repairs in 27 men and 3 women. Median age was 71.5 years (range, 46-85 years). Median aneurysm size was 51.5 mm (range, 30-79 mm). American Society of Anesthesiologists class of patients was II, III and IV in 10, 19, and 1 cases, respectively. We performed total laparoscopic endoaneurysmorrhaphy and aneurysm exclusion in 27 and 3 patients, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 27 patients. We operated on 2 patients via a tranperitoneal left retrorenal approach and 1 patient via a retroperitoneoscopic approach. RESULTS: We implanted tube grafts and bifurcated grafts in 11 and 19 patients, respectively. Two minilaparotomies were performed. In 1 case, exposure via a retroperitoneal approach was difficult and, in another case, distal aorta was extremely calcified. Median operative time was 290 minutes (range, 160-420 minutes). Median aortic clamping time was 78 minutes (range, 35-230 minutes). Median blood loss was 1680 cc (range, 300-6900 cc). In our early experience, 2 patients died of myocardial infarction. Ten major nonlethal postoperative complications were observed in 8 patients: 4 transcient renal insufficiencies, 2 cases of lung atelectasis, 1 bowel obstruction, 1 spleen rupture, 1 external iliac artery dissection, and 1 iliac hematoma. Others patients had an excellent recovery with rapid return to general diet and ambulation. Median hospital stay was 9 days (range, 8-37 days). With a median follow-up of 12 months (range, 0.5-20 months), patients had a complete recovery and all grafts were patent. CONCLUSION: These preliminary results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. However, prior training and experience in laparoscopic aortic surgery are needed to perform total laparoscopic AAA repair. Despite these encouraging results, a greater experience and further evaluation are required to ensure the real benefit of this technique compared with open AAA repair.     

Predictors of acute kidney injury after infrarenal abdominal aortic aneurysm repair in octogenarians

Objective

Acute kidney injury (AKI) is a common postoperative complication after abdominal aortic aneurysm (AAA) repair and is associated with significant morbidity and mortality. However, limited studies have investigated this complication in elderly patients. This study aims to evaluate AKI in octogenarians after open endovascular AAA repair (OAR) and endovascular AAA repair (EVAR).