感染性腹主动脉瘤的治疗探讨

<正>感染性腹主动脉瘤(infected abdominal aortic aneurysm,IAAA)发病率约占所有腹主动脉瘤的0.7%~3.0%[1],临床误诊率高、并发症多、预后差、治疗困难,主要致死原因为感染所致的动脉瘤破裂出血(包括动脉瘤-消化道瘘)及全身性感染并发症。目前IAAA的主要治疗方法包括抗生素治疗、清创并原位血管重建手术、腋股动脉旁路术并清创术、腹主动脉腔内隔绝术等。但由于IAAA的病因和     

解剖外旁路手术在下肢缺血性病变治疗中的应用

解剖外旁路手术(extra anatomicbypass)是指经非自然血管途径的旁路手术,主要指腋股旁路手术,股股旁路手术,及颈动脉锁骨下动脉旁路手术、腋腋旁路手术、脾肾动脉旁路手术等。1　腋股动脉旁路手术腋股动脉旁路手术又可分为腋单股动脉旁路手术(ax illounifemoral,AxUF)及腋双股动脉旁路手术(axillob ifemoral,AxBF)。Blaisdele(196 3)首先报道腋股动脉旁路移植手术的临床应用。最初该术式主要用于解决下肢严重缺血病变。后来逐渐用于腹主动脉人工血管感染,主髂动脉闭塞性病变。其主要适应证是:患有腹主动脉末端及两则髂动脉闭塞(Leriche…     

人造血管旁路术后移植物感染的外科治疗

为评价人造血管旁路术后移植物感染外科治疗的临床疗效,作者对１９８５年～１９９５年上海中山医院收诊的２５０例人造血管旁路术后发生移植物感染的８例进行分析。临床表现为移植物外露伴创口溢脓、大出血、移植物和／或远端肢体动脉搏动消失、远端肢体坏疽。移植物感染率３．２％。外科治疗包括：（１）移植物去除、清创引流术;（２）移植物去除、清创引流加截肢术;（３）移植物去除、清创引流加近远端动脉人造血管重建术;（４）单纯清创引流术。结果显示,８例中６例痊愈,２例因吻合口破裂出血死亡。作者认为移植物感染的危险因素有：（１）糖尿病;（２）继发血肿;（３）同一部位多次手术。外科积极处理较保守治疗愈后更好。     

感染性腹主动脉瘤的诊治经验

目的总结感染性腹主动脉瘤(infected abdominal aortic aneurysm,IAAA)的诊治经验。方法回顾性分析2010年7月至2018年12月哈尔滨医科大学附属第一医院血管外科收治的10例IAAA患者的临床资料。结果 5例动脉瘤破裂行急诊手术(4例腔内手术、1例开放手术),5例择期手术。6例细菌培养阳性,4例阴性。3例开放手术患者均为原位血管重建,其中1例术后26 d死于腹主动脉消化道瘘,术后1年生存率为66.7%(2/3)。5例腔内修复患者围术期无死亡。随访期内死亡2例,术后1年生存率为60.0%(3/5)。2例复合手术患者围术期和随访期均无死亡和严重并发症发生,术后1年生存率为100.0%(2/2)。结论 IAAA治疗的关键在于控制感染、手术时机把握以及动脉重建方式的选择,临床工作中应根据患者的具体情况选择最佳的治疗方案。     

13例腹主动脉腔内移植物感染的诊断及外科治疗

目的:探讨腹主动脉腔内移植物感染（vascular endograft infections,VEGI）的诊断及外科治疗方式。方法:回顾性分析2015年1月至2021年1月北京大学人民医院血管外科行外科手术治疗的13例腹主动脉腔内移植物感染患者的临床资料。结果:13例患者均行腋-双股动脉人工血管转流术+腹主动脉移植物切...     

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。     

皮瓣重建修复下肢动脉旁路移植术后人工血管外露

目的 探讨皮瓣重建技术修复因重症下肢缺血行人工血管旁路移植术后人工血管外露的可行性.方法 回顾性分析2007年8月至201 1年12月诊治的192例下肢人工血管旁路移植术后患者,其中5例(2.6％)在前次术后6～13d发生人工血管外露,包括男性4例,女性1例,年龄52～81岁,中位年龄68岁.外科处理主要包括局部清创及保留移植物的任意皮瓣或肌皮瓣转移修复术,3例应用“Z”形任意皮瓣改形修复,2例采用腹直肌或股直肌皮瓣转移修复.结果 4例成功保留了人工血管,切口一期愈合;随访5～ 57个月,中位随访时间38个月,均未再出现人工血管外露及感染症状,旁路血管通畅;1例术后2周人工血管破裂出血,切除人工血管后因患肢缺血严重行膝上截肢术.结论 人工血管外露后果严重,保留血管移植物的任意皮瓣或肌皮瓣修复术是有效的外科处理手段.     

胸主动脉腔内修复术后移植物感染药物保守治疗的临床效果

回顾性分析中南大学湘雅二医院血管外科确诊胸主动脉腔内修复(thoracic endovascular aortic repair, TEVAR)术后移植物感染且首次治疗方案选择药物保守治疗的8例患者的临床资料。患者确诊移植物感染与TEVAR手术间隔3～96个月, 住院期间均进行个体化抗感染治疗, 出院后长期口服抗生素。随访时间6～44个月, 2例患者分别因脓毒症复发和继发主动脉食管瘘进行手术治疗, 前者术后恢复良好, 后者因术后主动脉残端破裂死亡;6例继续药物保守治疗, 其中3例因主动脉食管瘘发生致命性大出血死亡;2例因脓毒症复发入院再次行抗感染治疗;1例无感染症状, 仍在追踪观察。本研究显示移植物感染是TEVAR术后罕见但致命的并发症, 常并发主动脉-食管瘘, 死亡率较高, 外科手术清除感染的移植物是有效的方法。对拒绝行手术治疗的患者采取个体化的抗感染治疗短期内可能有效, 但部分患者最终的结局是开放手术或死亡, 选择药物保守治疗的患者需时刻警惕脓毒症的复发且终生服用抗生素。     

单节段腰椎结核前路病灶清除植骨内固定治疗探讨

目的 探讨前路病灶清除椎间植骨原位内固定治疗单节段腰椎结核临床疗效.方法 1999年2月-2005年2月,采用前路病灶清除、椎间植骨原位内固定手术治疗单节段腰椎结核26例,平均随访2年半(30个月).观察术前、术后、随访时的背痛、腿痛、发热、盗汗、病灶情况、窦道愈合、有无相关并发症发生等.影像学观察包括:病变节段的后凸、椎间高度、植骨融合及内固定系统姿态保持等.结果 术后1年临床症状消失,融合节段前柱高度恢复、保持并全部骨性愈合.结论 前路病灶清除椎间植骨原位内固定治疗单节段腰椎结核能达到彻底清除病灶、恢复并保持腰椎前中柱高度、早期下地活动等,方法简便安全、疗效满意.     

解剖外腋-股、股-股动脉旁路移植术治疗主髂动脉闭塞症

目的探讨解剖外腋股、股股动脉旁路移植术治疗主髂动脉闭塞症的疗效。方法采用解剖外旁路移植术治疗主髂动脉闭塞症患者３２例。１８例腹主动脉或两侧髂动脉闭塞者采用腋股动脉旁路术，其中２例为腋两股动脉旁路术；１４例单侧髂动脉闭塞者采用股对侧股动脉旁路术。采用腋股动脉旁路的患者，术中８例用真丝人造血管移植，１０例用聚四氟乙烯（ＧｏｒｅＴｅｘ）人造血管；股股动脉旁路术中６例用真丝人造血管移植，１例用自体大隐静脉，７例用ＧｏｒｅＴｅｘ人造血管。结果术后５年随访时，股股动脉旁路术通畅率为７８％，其中真丝人造血管与ＧｏｒｅＴｅｘ人造血管通畅率无明显差异；腋股动脉旁路术中，８例真丝人造血管均已闭塞，１０例ＧｏｒｅＴｅｘ人造血管中１例闭塞，１例发生腹股沟部假性动脉瘤。结论解剖外动脉旁路移植术操作简单，创伤小，无腹部手术并发症，手术安全，术后恢复快。真丝人造血管的使用应限于短段的股股动脉旁路术     

小腹主动脉瘤临床随访现状与展望

小腹主动脉瘤是指瘤体最大直径30～54 mm的腹主动脉瘤。虽然多数患者无症状且破裂风险较低,但临床工作中仍会遇到小瘤体破裂的患者。瘤体一旦破裂其病死率极高。同时,随访过程中给予手术干预的比例也非常高。目前尚缺乏成熟的针对发病机制层面的治疗策略。如何做好临床随访工作、预测破裂风险及时行外科人工血管置换术或腔内隔绝术显得尤为重要。笔者就目前小腹主动脉瘤的临床随访现状以及如何精准预测破裂风险予以阐述。     

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。     

Novel extra-anatomic intra-abdominal reconstruction for treatment of paravisceral aortic infection

Adequate treatment of native or prosthetic aortic infection requires extensive surgical debridement and establishing flow to the extremities using extra-anatomic or in situ reconstruction, each with its inherent limitations. Infection of the paravisceral aortic segment precludes an axillofemoral bypass as the sole treatment because of inability to provide visceral perfusion. In situ autograft or allograft reconstructions could be limited by conduit availability or significantly prolonged operative time, or both. Placement of an antibiotic-soaked prosthetic in a field with gross purulence carries a high risk of reinfection. We describe a technique for extra-anatomic, intra-abdominal reconstruction using an antibiotic-soaked prosthetic graft to avoid the infected paravisceral aortic bed and achieve antegrade lower extremity and visceral vessel perfusion.     

Use of rifampin-soaked gelatin-sealed polyester grafts for in situ treatment of primary aortic and vascular prosthetic infections

BACKGROUND: In situ treatment of artery/graft infection has distinct advantages compared to vessel excision and extra-anatomic bypass procedures. Based on animal studies of a rifampin-soaked, gelatin-impregnated polyester graft that demonstrated prolonged in vivo antibacterial activity, this antibiotic-bonded graft was used selectively in patients for in situ treatment of low-grade Gram-positive prosthetic graft infections or primary aortic infections not amenable to excision and ex situ bypass. METHODS: In a 5-year period (1995-1999), 27 patients with prosthetic graft infection (aortofemoral, n = 18, femorofemoral, n = 3; axillofemoral, n = 1) or primary aortic infection (mycotic aneurysm, n = 3; infected AAA, n = 2) underwent excision of the infected vessel and in situ replacement with a rifampin soaked (45-60 mg/ml for 15 min) gelatin-impregnated polyester graft. All prosthetic graft infections were low grade in nature, caused Gram-positive bacteria (Staphylococcus epidermidis, 16; Staphylococcus aureus, 5; Streptococcus, 1), and were treated electively. Patients with mycotic aortic aneurysm presented with sepsis and underwent urgent or emergent surgery. RESULTS: Two (8%) patients died-1 as a result of a ruptured Salmonella mycotic aortic aneurysm and the other from methicillin-resistant S. aureus infection following deep vein replacement of an in situ replaced femorofemoral graft. No amputations or late deaths as the result of vascular infection occurred in the 25 surviving patients. Two patients developed recurrent infection caused by a rifampin-resistant S. epidermidis in a replaced aortofemoral graft limb and were successfully treated with graft excision and in situ autogenous vein replacement. Eighteen patients remain alive and clinically free of infection after a mean follow-up interval of 17 months. CONCLUSIONS: In situ replacement treatment using a rifampin-bonded prosthetic graft for low-grade staphylococcal arterial infection was safe, durable, and associated with eradication of clinical signs of infection. Failure of this therapy was the result of virulent and antibiotic-resistant bacterial strains.     

Repair of a saccular aortic aneurysm with superficial femoral-popliteal vein in the presence of a pancreatic abscess

When one is faced with impending rupture, repair of an aortic aneurysm cannot be delayed. In the presence of coexisting intra-abdominal sepsis, traditional therapy would call for aneurysm exclusion and axillofemoral bypass grafting. Consequences of this choice of treatment include limited long-term graft patency and recurrent prosthetic infection. Autogenous deep veins from the lower extremities have demonstrated exceptional patency and resilience to infection when used to replace infected aortic grafts. We now report a case of concomitant open drainage of a pancreatic abscess and repair of a saccular abdominal aortic aneurysm using the superficial femoral-popliteal vein as a conduit.     

Ruptured Abdominal Aortic Aneurysms due to <Emphasis Type="Italic">Salmonella</Emphasis>, not of <Emphasis Type="Italic">typhi</Emphasis> Species

Ruptured aortic aneurysms due to Salmonella not of typhi species are rare and associated with high morbidity and mortality. We present three patients with Salmonella-infected ruptured aortic aneurysms successfully treated with an in situ prosthetic bypass graft. One patient had a saccular aneurysm at the infrarenal aorta and two patients had fusiform aneurysms at the aortic bifurcation. All the patients were treated with wide debridement of the infected aortic tissue followed by in situ graft replacement and long-term systemic antibiotic therapy. The method of revascularization, in situ bypass or extraanatomic bypass, remains controversial. On the basis of our clinical experience and recent literature focusing on more than 10 cases, in situ bypass reconstruction may be a feasible surgical technique for Salmonella-infected ruptured aortic aneurysm.     

Supraceliac aortofemoral bypass

Increasing numbers of patients with aortoiliac disease are seen with contraindications to standard infrarenal aortofemoral reconstruction. Although axillofemoral bypass is possible in these patients, the decreased patency rate associated with this operation makes alternate procedures desirable. This report details our experience with prosthetic bypass from the supraceliac aorta to the femoral arteries in seven patients with limb-threatening ischemia of the lower extremity, all of whom had undergone multiple previous aortic operations. The operations were performed through thoracoabdominal or flank incision, and the preferred graft configuration consisted of a single Dacron tube from the aorta to the left groin with a standard subcutaneous femorofemoral graft to the right groin. No surgical deaths occurred. At 3 1/2 years' mean follow-up, there has been one graft limb occlusion that resulted in amputation for an overall life table patency and limb salvage rate of 93%. We conclude that supraceliac to femoral artery bypass is a useful procedure for the treatment of patients who have had multiple previous aortic reconstructions fail.     

Mycotic aneurysms of the suprarenal abdominal aorta: prolonged survival after in situ aortic and visceral reconstruction

Necrotizing infection of the arterial wall causes rupture and false ("mycotic") aneurysm formation, with a very poor prognosis if untreated. Cure can be achieved by surgical drainage and debridement, with restoration of arterial continuity through uncontaminated tissues. The dilemma of applying these principles to the treatment of mycotic aneurysms of the suprarenal aorta is that no remote or extraanatomic routes are available to maintain perfusion to the viscera. We report the first case of Klebsiella suprarenal mycotic aortic aneurysm successfully treated with in situ prosthetic reconstruction of the aorta and visceral arteries, and we have reviewed the 21 other suprarenal mycotic aortic aneurysms reported in the English-language literature. Repair was performed in 20 of the 22 cases, with in situ prosthetic reconstruction performed in 18. Prolonged survival has been achieved in 16 patients after in situ repair. No long-term survival has been reported after extraanatomic reconstruction of the aorta and visceral arteries in patients with such aneurysms. We conclude that in situ prosthetic reconstruction, accompanied by thorough drainage and debridement, prolonged parenteral antibiotic therapy, and permanent suppressive oral antibiotics, offers the best chance for survival in these patients.     

Abdominal aortic aneurysms infected with salmonella: problems of treatment

Seven patients with abdominal aortic aneurysms infected with salmonella organisms were surgically treated between 1985 and 1988. Salmonella culture was obtained from the wall of the aneurysm in every patient, and in five patients it was identified as Salmonella typhimurium. S. choleraesuis and salmonella group D (isolated from this patient but not speciated) were found in the other two remaining patients. Three patients underwent aneurysmal resection with axillofemoral bypass grafting, and three patients were treated by aneurysmal resection with in situ graft; two of this group had the wall and infective periaortic tissue excised. One patient died during the operation as a result of rupture of the aneurysm. Therapeutic doses of antibiotic drugs were given to all of the patients. Although two of the patients in the first group (with the axillofemoral bypass graft) died and the remaining patient had very complicated postoperative course, all the patients in the second group (with in situ graft) survived. We think that in situ graft placement after an extensive debridement of the aneurysmal wall and infected periaortic tissue together with more effective and adequate antibiotic therapy for at least 6 weeks after the operation is a satisfactory method of surgical treatment of this condition. However, graft infection is still a possibility, therefore regular follow-up is needed.