小腹主动脉瘤研究进展

直径3.0~5.5 cm的腹主动脉瘤称为小腹主动脉瘤,这部分病人目前尚未纳入手术指征,但其也存在破裂可能性。小腹主动脉瘤会逐渐增大,且其直径越大,增长越快,故需严密监测。血管壁的应力、弹性及硬度、管壁钙化程度及瘤体直径被认为动脉瘤增长的预测因素。降低动脉瘤扩张的药物治疗可作为一种选择,目前尚无足够证据支持手术或腔内修复优于随访观察。     

腹主动脉瘤手术适应证及形态学破裂风险评估的进展

目的总结腹主动脉瘤(abdominal aortic aneurysm,AAA)的干预阈值的最新循证医学证据以及AAA形态学破裂风险评估方面的新进展及其临床应用价值。方法收集关于特定人群的AAA患者以及特殊形态学特征AAA的破裂风险的国内外文献并进行综述。结果进一步降低干预阈值后,特定亚组的无症状患者同样可能从AAA手术中获益。同时,除了瘤体最大径外,瘤体真实几何形态、瘤壁厚度、附壁血栓等形态学因素对于AAA的破裂风险同样有着重要的预测价值。结论制定基于AAA患者实际情况的个体化破裂风险评估方案,能更准确地服务于临床的诊断和治疗。     

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     

腹主动脉瘤的无创检查

腹主动脉瘤是血管外科比较常见的动脉扩张性疾病,是由于腹主动脉局限性退化扩张,最终无法承受血流冲击导致瘤壁破裂的一种高危性疾病,90%以上的动脉瘤破裂者发生猝死.在得到诊断的症状性腹主动脉瘤中,2年内自然破裂率达到50%.而随着人类的寿命的不断延长,它已经逐渐成为危害老年人生命健康的重要疾病.据报道,在澳洲大于65岁的老年男性腹主动脉瘤患者中,最大直径大于3 cm的患者超过了7.2%.如何在早期发现并正确诊断的同时避免不必要的检查创伤,也是摆在临床医生面前的一大课题.腹部X平片,曾经是诊断腹主动脉瘤的常用诊断方法 ,但由于其只能发现腹主动脉瘤瘤体巨大或瘤壁钙化较明显的患者,并且无法显示血流动力学的改变和进行参数的测量,故诊断率低,临床应用有限.目前在诊断和动态监测腹主动脉瘤方面已很少使用.随着影像学技术的发展,腹主动脉瘤的诊断方法 有了长足的进步.在非侵入性诊断中,超声、CT、MRI成为当前常用的三种主要诊断方法 .     

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自 195 1年ＤｕＢｏｓｔ[1 ] 首次成功施行腹主动脉瘤切除术以来 ,由于手术技巧的不断改进和更为妥善的术前术后处理 ,目前在世界范围内择期腹主动脉瘤围手术期病死率已被控制在 5 % [2 ] 以内。我院 1998年报道的 2 6 1例肾动脉下腹主动脉瘤的围手术期病死率为 3 8% [3] 。虽然腹主动脉瘤的手术死亡率自 2 0世纪 70年代后已降至很低 ,但这并不意味所有的腹主动脉瘤病人都需立即行手术治疗。只有当瘤体破裂的风险大于手术风险时 ,手术才是正确的选择。1　传统手术治疗1.1　手术指征对腹主动脉瘤手术指征的掌握涉及瘤体破裂风险、手术风险和…     

腹主动脉瘤破裂的外科治疗

报道４例腹主动脉瘤破裂的外科治疗。其中２例死于开腹手术中腹腔内大量出血，另２例瘤体向腹膜后间隙破裂者手术后在活。认为腹主动脉瘤患者若没有手术禁忌症，应争取择期外科手术治疗，一旦瘤体破裂，迅速补充血容量，紧急手术，缩短从破裂到外科手术治疗的时间，对挽救患者的生命具有重要意义。     

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.     

主动脉扩张病腔内治疗——腹主动脉瘤的无创检查

腹主动脉瘤是血管外科比较常见的动脉扩张性疾病，是由于腹主动脉局限性退化扩张，最终无法承受血流冲击导致瘤壁破裂的一种高危性疾病，90％以上的动脉瘤破裂者发生猝死。在得到诊断的症状性腹主动脉瘤中，2年内自然破裂率达到50％。而随着人类的寿命的不断延长，它已经逐渐成为危害老年人生命健康的重要疾病。据报道，在澳洲大于65岁的老年男性腹主动脉瘤患者中，最大直径大于3cm的患者超过了7．2％。如何在早期发现并正确诊断的同时避免不必要的检查创伤，也是摆在临床医生面前的一大课题。腹部X平片，曾经是诊断腹主动脉瘤的常用诊断方法，但由于其只能发现腹主动脉瘤瘤体巨大或瘤壁钙化较明显的患者，并且无法显示血流动力学的改变和进行参数的测量，故诊断率低，临床应用有限。     

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。     

小腹主动脉瘤快速扩张的危险因素

虽然破裂是扩张中腹主动脉瘤的最终结局,但尚不知有些腹主动脉瘤为何突然破裂。小腹主动脉瘤(<5cm)的最佳手术修复时机尚不清楚。如能认识腹主动脉瘤快速扩张的危险因素,并以此密切监测病人,可有助于明确手术时机。本研究拟就腹主动脉瘤快速扩张的危险因素作一些探讨。 方法:1982～1994年,本研究检测了514例患者(男性376例,女性138例),年龄36～92岁。腹主动脉直径经B型超声重复测量结果定为±0.3cm。测量位置为肾脏上和肾脏下,主动脉分叉上方。如果腹主动脉直径大于正常值50％以上(年青人2.5cm,老年人3cm)即认为存在动脉瘤性扩张。>4cm的腹主动脉瘤随访间期为6～12月,<4cm的随访间期为12个月。腹主动脉瘤扩张在3个月增大0.25cm或一年大于1cm为迅速扩张。分析年龄、严重心脏疾患、吸烟、糖尿病、高血压、高胆固醇血症、脑卒中病史、心绞痛、饮酒与动脉瘤体快速扩张的关系。     

“ENGAGE”治疗腹主动脉瘤8年随访数据解读及展望

腹主动脉瘤（AAA）是一种永久且不可逆的腹主动脉局部扩张性病变，其破裂病死率高达60%~70%。AAA腔内修复术凭借其临床安全性和有效性已经成为AAA的一线治疗方法，但其长期随访中的支架移位、内漏等并发症仍值得关注。“ENGAGE”是迄今最大的AAA腔内治疗的长期注册研究，笔者基于“ENGAGE”研究8年随访结果和相应的文献分析，系统介绍AAA腔内治疗现状及前景。     

对感染性腹主动脉瘤治疗的再认识

感染性腹主动脉瘤（IAAA）是临床灾难性疾病,治疗困难,病死率高。手术治疗的目标是清除病灶、防止瘤体的破裂以及保持血流通道。尽早足疗程抗生素的使用是治疗的基础,包括原位重建及腋股旁路术的传统外科手术符合外科治疗原则,但清除感染病灶后的原位重建术后移植物感染率较高,腋股旁路术后有可能出现移植物阻塞及主动脉残端破裂等严重并发症。腔内治疗与外科处理原则不尽相符,但临床现有的资料证实高龄不能耐受开放手术的病例仍然适用。后腹膜旁路术能有效减少移植物感染并保持移植物通畅,是较合理的IAAA的手术方式。     

感染性腹主动脉瘤的诊断和治疗进展

感染性腹主动脉瘤(IAAA)是血管外科极具挑战性的一种疾病,是由致病微生物直接或者间接感染腹主动脉所引起的,具有进展快、破裂风险高、病死率高以及预后差的特点。目前对于IAAA的治疗是以抗感染作为基础,应用腔内腹主动脉覆膜修复术或外科手术来进行干预。笔者将就国内外对于IAAA的诊断和治疗经验与进展进行一综述,从而为患者更好的个体化治疗提供参考。     

感染性腹主动脉瘤的诊疗进展

感染性腹主动脉瘤(IAAA)是由于各种致病菌感染所致的一类特殊类型的动脉瘤。IAAA发病急、病情进展迅速、瘤体易于破裂、临床预后差,因此对其早诊早治十分关键。依据典型病史、实验室检查、CTA影像、术中所见、血培养或组织培养阳性结果可做出诊断。诊断明确后,应在足量应用抗生素的基础上尽早手术治疗。但有关抗生素具体使用方案、手术方案等治疗选择上尚未达成一致。目前推荐术后用抗生素至少6个月以上。伴随微创技术的发展,腔内修复术治疗IAAA的比例越来越高,且短期效果良好,未来有望成为首选的手术方式。     

Ten-year outcome of patients with very small abdominal aortic aneurysm

BACKGROUND: The long-term fate of very small abdominal aortic aneurysms (AAA) is not well known. METHODS: Forty-one patients with asymptomatic small AAA (range 25 to 40 mm) underwent ultrasonographic surveillance. RESULTS: The median follow-up period was 7.3 years. The median linear aneurysm expansion rate was 2.0 mm/year (range 0 to 8.4). Three patients experienced aneurysm rupture (7.3%) which resulted in 1 patient'death. Thirteen patients underwent aneurysm repair (31.7%) and 1 patient died postoperatively (7.7%). The survival rate at 10-year follow-up was 59.0%. The survival rate free from aneurysm rupture and repair at 10-year follow-up was 69.9%. The median time for occurrence of aneurysm rupture was 4.9 years (range 1.8 to 10.5) and the need for aneurysm repair was 4.5 years (range 1.4 to 10.4). CONCLUSIONS: The fate of very small AAA is to slowly enlarge in size, sometimes threatening the patient's life. These observations underline the importance of continuous surveillance and the potential benefits of any medical treatment in this patient population.     

Axillobifemoral bypass and aortic embolization for the treatment of two patients with ruptured infrarenal aortic aneurysms

We report two cases of hemodynamically stable patients with contained, ruptured, juxtarenal abdominal aortic aneurysm that were both successfully treated by nonresectional therapy including axillobifemoral bypass with externally supported polytetrafluoroethylene graft, followed by coil embolization of the aneurysm sac and bilateral common iliac arteries. The patients were elderly with multiple comorbidities and complex aneurysm morphology not amenable to endovascular repair. In both cases complete thrombosis of the aneurysm was verified by computed tomography. Both patients are alive at follow-up without evidence of an increase in aneurysm size, postoperative leak, or rupture or impairment of renal function. To our knowledge these are the first reported cases in which this modality has been successfully used in patients presenting with ruptured abdominal aortic aneurysms. Earlier results of nonresectional therapy for abdominal aortic aneurysm have reported a significant incidence of postoperative aneurysm rupture and renal failure. Growing experience at our institution with nonresectional therapy for high risk patients with abdominal aortic aneurysms suggests that nonresectional therapy can be a valuable treatment modality for high risk patients including those with contained rupture of the aneurysm who are hemodynamically stable.     

肠系膜动脉瘤破裂出血的诊治分析：附8例报告

背景与目的 肠系膜动脉瘤是一种罕见的疾病,大部分患者确诊时动脉瘤已出现破裂大出血,病情危重,治疗风险大。本文回顾性分析肠系膜动脉瘤破裂患者的病例特点,探讨该疾病诊断和治疗方式的选择。方法 回顾性分析于2016年1月—2020年12月在湖南省郴州市第一人民医院血管外科收治的8例肠系膜动脉瘤破裂出血患者的临床资料和随访情况。结果 8例患者行腹部CTA或腹部增强CT明确诊断为肠系膜动脉瘤破裂出血。患者均行急诊手术治疗,其中6例行腹腔动脉造影+栓塞术;1例因腔内治疗失败后选择行开放手术;1例首选开放手术。8例患者均抢救成功,3例患者腔内治疗术后出现腹痛腹胀,药物保守治疗好转;1例患者开放手术术后出现创伤性胰腺炎,予以药物治疗治愈。所有患者住院期间均无再出血、肠缺血、肠坏死等并发症与再次手术。8例患者均随访12个月,患者正常饮食后无腹痛腹胀不适,无再次出血;复查腹部增强CT或CTA提示动脉瘤栓塞良好,血肿明显吸收。结论 临床医生要提高对肠系膜动脉瘤破裂出血疾病的认识和警惕,及时做出正确诊断。手术治疗方案可分为开放手术和腔内治疗,均安全和有效,术前应根据患者病情、瘤体位置和形态决定具体手术方案。     

Surgery for aortic aneurysms

Aortic aneurysms, the majority of which affect the infrarenal abdominal portion of the aorta, are responsible for 1–2% of all deaths in men aged over 65 years in the Western world. The disease most commonly represents a multifactorial degenerative process involving both genetic and environmental risk factors and is characterized pathologically by a reduction in elastic lamellae within the aortic wall. The natural history of the condition is one of progressive enlargement with an associated increase risk of aneurysm rupture. Although aneurysm rupture remains a catastrophic event, with an overall mortality of approximately 80%, the majority of patients are asymptomatic. Asymptomatic aneurysms are usually diagnosed as an incidental finding and management relies on an assessment of the risks of future aneurysm rupture weighed against the risks associated with elective surgical repair. Aneurysm repair may be accomplished by traditional open surgery or minimally invasive endovascular repair. Although the latter confers a short-and medium-term survival advantage in selected patients, long-term follow-up data suggest this benefit may not persist. Thoracoabdominal aortic aneurysm disease is considerably more complex, with intervention, even in specialist centres, associated with significant morbidity and mortality. Best medical management of aortic aneurysm disease requires control of blood pressure, smoking cessation together with aspirin and statin therapy. Screening has been introduced in an effort to identify a largely silent killer although with better medical management the overall prevalence may be in decline.     

The natural history of abdominal aortic aneurysms and their risk of rupture

The UK Small Aneurysm Trial has shown that ultrasound surveillance is a safe management option for patients with small abdominal aortic aneurysms (4.0 to 5.5 cm in diameter), with an annual rupture rate of only 1%. We investigated baseline risk factors associated with aneurysm rupture in the 1090 trial patients and an additional 1167 patients enrolled in the UK Small Aneurysm Study. In this cohort of 2257 patients there were 103 cases of aneurysm rupture. After 3 years the annual rate of rupture was 2.2% (95% CI 1.7 to 2.8). The risk of rupture was independently and significantly associated with female sex (p < 0.001), larger initial aneurysm diameter (p < 0.001), current smoking (p = 0.01) and higher mean blood pressure (p = 0.01). Age, body mass index, serum cholesterol concentration and ankle/brachial pressure index were not associated with an increased risk of aneurysm rupture. The most surprising finding was that women had a 3-fold higher risk of aneurysm rupture than men. Effective control of blood pressure and cessation of smoking are two simple measures that are likely to diminish the risk of aneurysm rupture and improve the cardiovascular health of patients with abdominal aortic aneurysm.     

一体式覆膜支架在腹主动脉腔内修复中的应用

目的:总结一体式覆膜支架在腹主动脉以及髂动脉病变中的应用效果。方法:回顾性分析应用一体式腹主动脉覆膜支架腔内修复腹主动脉瘤15例、髂动脉瘤5例及腹主动脉或髂动脉夹层5例的临床资料。结果:平均时间42.4 min,手术成功率100%(25/25)。术后无I、III型内漏,发生髂动脉血栓形成1例,围术期无死亡病例。随访3~16个月复查无动脉瘤复发和II型内漏。结论:一体式覆膜支架是腹主动脉瘤和夹层动脉瘤腔内治疗方法的一种较好选择,具有快速、简单、有效的优点;其远期疗效需进一步观察。