带蒂大网膜在心胸外科应用的研究

目的通过动物实验或临床应用，对带蒂大网膜在心胸外科的应用进行了系列研究。方法动物实验：（１）大网膜覆盖主动脉感染裂口或已感染的主动脉裂口移植物；（２）大网膜覆盖缺血心肌表面，促进侧支循环建立。临床：充填各种脓胸脓腔，包绕植入的人工气管，包绕食管胃吻合口防瘘，治疗食管裂口感染破溃，充填纵隔、胸骨感染缺损和将主动脉移植物与消化道隔开防瘘。结果动物实验：（１）主动脉感染裂口出血死亡率由１００％分别降至３３％和２７．３％；（２）缺血心肌明显增加血液供应。临床：８９例患者全部康复痊愈。结论带蒂大网膜在心胸外科的应用，使一些难治顽症变成了可治之症，提高了某些疾病的治愈率或明显减少了并发症。     

血管移植物感染的外科诊治15例体会

目的评价人工血管移植物和支架型血管移植物感染的诊断方法和外科治疗。方法对1985-2005年复旦大学附属中山医院血管外科诊治的15例血管移植物感染进行回顾性分析。结果本组同期共施行血管重建手术1316例，其中发生血管移植物感染15例，发生率为1．14％。13例发生在手术后4个月以内（86．7％）；2例发生在手术后4个月以后（13．3％）。血管移植物感染的临床表现为移植物外露伴伤口溢脓、发热或败血症、腹股沟区肿胀或窦道形成、吻合口大出血、移植物和／或远端肢体动脉搏动消失、远端肢体坏疽。外科治疗包括：（1）完整取出感染的血管移植物、清创引流术加局部抗生素溶液灌洗；（2）完整取出感染的血管移植物、清创引流加截肢术；（3）完整取出感染的血管移植物、清创引流加近远端动脉自体大隐静脉或人工血管重建术；（4）单纯清创引流术加局部抗生素溶液灌洗。15例中11例痊愈，4例死亡。结论血管移植物感染一旦发生，后果严重，死亡率和截肢率高，早期诊断、外科积极处理可改善预后。     

带蒂大网膜对严重损伤输尿管的修复作用

目的 探讨带蒂大网膜对严重输尿管损伤的修复作用及其机制.方法 随机将20条犬均分为实验组及对照组,建立严重输尿管损伤动物模型,实验组采用带蒂大网膜包裹损伤输尿管,对照组未采用大网膜包裹.术后观察尿瘘及输尿管坏死情况,术后12周再手术观察输尿管损伤愈合及吻合口血管再生情况,免疫组织化学染色检测血管内皮生长因子(VEGF)及其受体KDR的表达.结果 实验组均无尿瘘,对照组2例因尿瘘反复腹腔感染而死亡.术后12周实验组输尿管吻合口处黏膜及平滑肌层再生,血管再生现象明显,VEGF及KDR表达升高.对照组吻合口处愈合不良或瘢痕愈合,血管再生不明显,VEGF及KDR阴性或弱表达.结论 带蒂大网膜有促进严重输尿管损伤修复的作用,可能通过VEGF及KDR的表达升高促进血管再生而实现.     

带蒂大网膜吻合在老年食管癌术中应用价值

目的分析带蒂大网膜在老年食管癌术中应用的价值。方法老年食管癌患者214例随机分成带蒂大网膜吻合组(130例)和常规吻合组(84例),带蒂网膜吻合组患者术中游离胃时,保留胃右动脉处网膜宽约4.0~6.0 cm,将带蒂网膜垂帘式包绕食管胃吻合口1周,间断缝合固定,剩余网膜和胃网膜右动脉平铺在食管床,呈半包围状覆盖管胃,防止吻合口及胃小弯侧胃漏。观测两组患者术后胸腔引流量、拔胸管时间、出院时间、吻合口漏、胸胃综合征、心律失常(包括房颤、室上速等)、肺部感染、术后1个月肺功能等指标。结果两组患者均治愈出院,无死亡病例,带蒂网膜吻合组术后吻合口漏与常规组相比,差异有统计学意义(P0.05),两组患者术后胸腔引流量、拔胸管时间、出院时间、胸胃综合征、心律失常、肺部感染、术后1个月肺功能等指标相比差异无统计学意义(P0.05)。结论带蒂大网膜垂帘式包绕吻合口、网膜平铺食管床半包匪管胃,可有效降低吻合口漏的发生,有利于老年患者快速康复。     

TEVAR保留左锁骨下动脉治疗主动脉夹层

<正>Stanford B型主动脉夹层(aortic dissection,AD)指夹层裂口及假腔只侵及降主动脉的AD。胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)已成为Stanford B型AD的首选治疗方法。本文所讨论的内容为TEVAR术中支架移植物需覆盖左锁骨下动脉的这部分Stanford B型AD。常见有:(1)夹层近端裂口距离左锁骨下动脉15 mm,约占B型AD 24.5%~([1]);(2)夹层近端裂口距离左锁骨下动脉≥15 mm,但夹层假腔逆撕,使健     

腔内修复联合旁路手术治疗DeBakeyⅠ型升主动脉夹层

目的探讨腔内修复联合人造血管旁路手术治疗DeBakeyⅠ型升主动脉夹层的临床应用价值。方法分析2005年中山大学附属第一医院血管外科运用腔内修复联合人造血管旁路手术治愈的2例DeBakeyⅠ型升主动脉夹层临床资料。结果腔内修复前先行左锁骨下动脉-左颈总动脉-右颈总动脉人造血管旁路手术,然后从右股总动脉将带膜支架植入升主动脉封闭内膜撕裂口,并同时封闭无名动脉和左颈总动脉,1例术后即时造影和术后2个月随访造影均显示升主动脉夹层消失,无内漏,颈部人造血管旁路血流通畅,病人健康生存;另1例术后2个月随访,一般情况良好。结论对于内膜撕裂口靠近无名动脉和左颈总动脉的DeBakeyⅠ型升主动脉夹层,腔内修复联合人造血管旁路手术是一种安全而有效的治疗方法。     

脊髓切开带蒂大网膜脊髓内移位术治疗截瘫的实验研究

在乌拉坦静脉麻醉下，对５８只家兔采用导管胶囊法压迫脊髓２４小时，造成压迫性截瘫。随机分为５组用不同方法治疗。（１）带蒂大网膜脊髓内移位，（２）带蒂大网膜脊髓表面覆盖，（３）脊髓切开，（４）椎板减压，（５）对照组。带蒂大网膜脊髓内移位是先做脊髓切开，清除髓内坏死组织及积血，再将带蒂大网膜植入脊髓内。该治疗组截瘫兔跳跃功能恢复率５０％，ＳＥＰ恢复率９２．５％，明显高于其它治疗组。光镜、电镜检查及血管造     

微创腔内隔绝术治疗降主动脉夹层动脉瘤

目的：探讨腔内隔绝术（ＥＶＧＥ）治疗降主动脉夹层动脉瘤（ＤＡＡ）的临床应用价值。方法：２３例ＤｅｂａｋｅｙⅢ型ＤＡＡ患者,经股动脉将直形人造血管－支架复合体（移植物）导入夹层动脉瘤裂口处,支架张开使人造血管固定于裂口附近的动脉壁上,将裂口封闭,消除动脉瘤破裂的危险。结果：３例术中出现内漏的病人,经即时附加导入移植物而将漏门封闭。全部获得成功。结论：ＥＶＧＥ治疗ＤＡＡ,创伤小、并发症少、术后恢复快,有广阔的临床应用前景。     

犬涤纶人造血管移植后不同时期的组织形态学研究

我们通过１０条犬的涤纶血管移植实验研究，连续观察分析了中口径国产涤纶人造血管移植于犬腹主动脉，术后１２周以内不同时期移植血管的组织形态学改变。结果表明２ｃｍ长国产中口径涤纶人造血管移植于腹主动脉后其新生内膜覆盖管腔内壁大约需要４周。新生内膜主要来自邻接动脉内膜的平滑肌增生爬行；内皮细胞覆盖人造血管内膜的时间较自体静脉晚得多，术后７周涤纶血管内膜尚无完整稳定的内皮细胞层；经高压蒸汽灭菌法消毒过的中口径国产涤纶人造血管不宜再次使用。     

腔内隔绝术治疗Stanford B型主动脉夹层--116例临床分析

目的　探讨腔内隔绝术 (EVGE)治疗 Stanford B型主动脉夹层动脉瘤的手术指征、术前评估方法、手术操作技巧、并发症防治原则及临床应用前景。　方法　对自 1998年 9月至 2 0 0 1年 12月间施行的 116例 Stanford B型胸主动脉夹层动脉瘤 EVGE进行了回顾性研究。术前 CT血管造影 (CTA)或磁共振血管造影 (MRA)显示 :夹层动脉瘤最大直径平均 6 6 .2± 18.1mm,72例患者表现为单一夹层裂口 ,4 4例表现为多裂口。经股动脉或髂动脉将移植物导入胸主动脉封闭夹层裂口 ,手术在数字剪影血管造影 (DSA)监视下完成。　结果　术中移植物成功释放 115例 ,72例单一夹层裂口患者中 6 2例使用单一移植物 ,8例使用 2个移植物 ,2例使用 3个移植物 ,6例手术结束时残存 I型内漏 ;4 4例多夹层裂口者 ,18例使用 2个移植物同时封闭不同部位夹层裂口 ,2 6例远端夹层裂口旷置 ,1例中转开胸手术。平均随访时间 15 .4± 11.2个月 ,围手术期死亡 6例 ,其余病例术后无心、肺、肾功能衰竭及截瘫等严重并发症 ;术后 11个月猝死 1例 ,2例分别于术后 14个月和 2 4个月再发 Stanford A型胸主动脉夹层而行 Bentall手术 ,其余患者未出现与夹层及手术相关的并发症。　结论　 EVGE治疗 Stanford B型主动脉夹层动脉瘤是一种创伤小、恢复快的新方法     

In situ autogenous reconstruction of the thoracoabdominal aorta and branches for treatment of an infected thoracoabdominal aortobifemoral bypass graft

Graft infection is an uncommon but potentially lethal complication of prosthetic aortic repair. We describe a novel technique for upper abdominal aortic and visceral revascularization after percutaneous drainage and antibiotics failed to cure a thoracofemoral prosthetic graft infection. One week after axillofemoral and femorofemoral bypass grafting, the infected thoracoabdominal graft was removed and a bifurcated iliac artery autograft was used to replace the upper abdominal aorta and revascularize the abdominal viscera. The infected graft was removed from the thorax and retroperitoneum, the infection resolved, and the patient remained well until his death of lung cancer 9 years later. (J Vasc Surg 1998;27:977-80.)     

The management of aortoduodenal fistula by in situ replacement of the infected abdominal aortic graft.

Conventional surgical wisdom dictates the complete removal of infected abdominal aortic graft, oversewing of the aorta, and restoration of lower limb bloodflow by extra-anatomic bypass grafting. Dissatisfied with this approach because of the high incidence of local complications, mortality, and loss of limb, 20 patients with secondary aortoduodenal fistula had duodenal repair, excision of the old graft, and placement of a new graft in the same location. A similar technique was used in three patients with erosion of an aortic graft into the jejunum. Length of follow-up averaged 5.2 years, and was more than 1 year in each instance. Of the eighteen patients who survived the repair, three have had early recurrent rupture or false aneurysm of the proximal aortic anastomosis, with consequent death in two, but fifteen patients (83%) have had no further related problem. There was no loss of limb. Use of greater omentum as a protective barrier seemed helpful. Optimal antibiotic usage, and the idea that varying degrees of graft infection require different approaches, require further definition. In conclusion, in situ graft replacement is the correct operative strategy in this challenging group of patients.     

Primary aortoesophageal fistula from aortic aneurysm: successful surgical treatment by use of omental pedicle graft

A 65-year-old woman sought treatment for sentinel upper gastrointestinal hemorrhage. Three years previously she had undergone graft replacement of her ascending aorta for aneurysm. In the interim she was followed for chronic dissection of her remaining aorta, and 6 months before this admission she had undergone graft replacement of a large abdominal aortic aneurysm. Arteriography and CT scanning of the thorax revealed an 8 cm aneurysm of the descending thoracic aorta. Operation was undertaken at which time an aortoesophageal fistula, as a result of erosion of the aneurysm into the esophagus, was identified. The descending thoracic aortic aneurysm was replaced with a Dacron tube graft, the esophageal defect was repaired primarily, and a viable pedicle flap of omentum was used to reinforce the esophageal repair and cover the aortic graft. Her postoperative recovery was free of infection but complicated by rapid expansion of the upper abdominal aorta at the visceral arterial level. Eight weeks after initial operation she underwent graft replacement of her remaining thoracoabdominal aorta with direct reattachment of her celiac axis, superior mesenteric artery, and both renal arteries. Recovery after her second procedure was uneventful, and she continues to do well at 13 months after operation. Development of a primary aortoesophageal fistula caused by aneurysms of the aorta is a rare but lethal complication. We present a technique for treatment of primary aortoesophageal fistula using omentum and preservation of gastrointestinal continuity as a one-stage operation. It is possible in selected cases to manage the esophageal perforation with primary closure and omental coverage to achieve healing free of infection without temporary or permanent discontinuity of the gastrointestinal tract.     

主动脉夹层的细化分型及其应用

目的探讨在Stanford分型的基础上根据主动脉夹层的部位和病变程度再进行细化分型,对指导临床选择手术时机、确定治疗方案和手术方式,以及判断预后的价值。方法1994年1月至2004年12月我院治疗主动脉夹层708例。其中Stanford A型夹层477例：（1）根据主动脉根部病变程度分为3型。A1型（主动脉窦部正常型）212例,行保留主动脉窦部的主动脉替换;A2型（主动脉窦部轻度受累型）72例,行主动脉窦部成形63例、David手术9例;A3型（主动脉窦部重度受累型）193例,行主动脉根部替换术（Bentall手术）。（2）根据主动脉弓部病变分为2型。C型（复杂型）78例,行主动脉弓部替换＋象鼻术;S型（单纯型）399例,行部分主动脉弓部替换。Stanford B型夹层231例,（1）根据主动脉扩张的范围分为3型：B1型：降主动脉无扩张或仅有近端扩张,147例,行腔内带膜支架主动脉腔内修复术103例（B1S型）、部分胸降主动脉替换术32例、部分胸降主动脉替换术＋远端支架象鼻术12例;B2型：全部胸降主动脉扩张,53例,行部分胸降主动脉替换术＋主动脉成形32例、全部胸降主动脉替换术21例;B3型：全部胸降主动脉及腹主动脉扩张,31例行胸腹主动脉替换术。（2）根据左锁骨下动脉和远端主动脉弓部是否受夹层累及分为2型：C型（复杂型）：夹层累及左锁骨下动脉或远端的主动脉弓部,44例,在深低温停循环下手术治疗;S型（单纯型）：远端主动脉弓部和左锁骨下动脉未受夹层累及,187例,介入治疗103例、手术治疗84例（常温阻断下手术60例,股动脉-股静脉转流下手术24例）。结果Stanford A型夹层住院病死率为4．6％（22／477）,并发症发生率为14．5％（69／477）。Stanford B型夹层：介入治疗组病死率1．9％（2／103）,并发症发生率为2．9％（3／103）,轻度内漏发生率为9．7％（10／103）;手术治疗组住院病死率为3．1％（4／128）,并发症发生率为18．8％（24／128）。结论细化主动脉夹层的分型对于术前判断手术时机、制定手术方案和初步判断预后,具有重要的指导作用。     

Delayed rupture of an internal iliac artery aneurysm following proximal ligation for abdominal aortic aneurysm repair

This is a report of a patient presenting with a contained rupture of an internal iliac aneurysm following proximal ligation after abdominal aortic aneurysm repair three years earlier. The patient presented with a large pelvic mass with symptoms of urgency, frequency, dysuria, tenesmus and fevers associated with anemia. Following evacuation of the aneurysm and direct suture ligation of the distal branches of the internal iliac artery, the patient's aortic graft was covered with omentum which also filled the pelvic cavity. The importance of proximal and distal control of aneurysms and/or the importance of complete luminal control of internal iliac artery aneurysms is emphasized by this case.     

Management of infected grafts and mycotic aneurysms of the aorta using cryopreserved homografts

OBJECTIVE: To evaluate the efficacy of the treatment of infected prosthetic grafts and mycotic aneurysms of the aorta with cryopreserved homografts. MATERIALS AND METHODS: Between April 1994 and May 2002, 15 cryopreserved aortic homografts were used in 13 patients in the thoracic and abdominal aortic position with supplementary omental or pectoral muscle wrapping for infected grafts (n=11), and mycotic aneurysms (n=2) (mean age: 57.5). RESULTS: One patient died due to multiorgan failure and the other due to postoperative cerebral hemorrhage (15.38%). Another patient died four months after the operation due to septic arthritis, and coronary heart disease. Ten patients are still alive without evidence of infection (76.92%) during a follow up of 44+/-23.03 (range 4-71) months. CONCLUSION: The use of cryopreserved homografts with supplementary omentum and/or muscle flap coverage, assures an anatomical reconstruction with good results in this difficult group of patients.     

Simultaneous repair of arch and abdominal aortic aneurysms

Objective: Atherosclerotic aneurysms in the aortic arch are associated with abdominal aortic aneurysms in up to 37% of cases. We have developed a single-stage approach to the repair of both aneurysms using a temporary bypass. Subjects: Since November 1996, 5 patients underwent simultaneous repair of aneurysms in the aortic arch and in the infrarenal abdominal aorta, using a new temporary bypass graft technique. Entire arch replacement with simultaneous abdominal aortic aneurysmectomy was performed in one patient. The other 4 patients underwent distal hemiarch replacement distal from the orifice of the brachiocephalic artery with simultaneous repair of the abdominal aortic aneurysm. Method: For the entire arch replacement procedure, blood flow to all major branches of the aortic arch was established using a bifurcated graft. This graft anastomosed to the ascending aorta was used as the proximal inflow of the temporary bypass graft. For the hemiarch replacement procedure, the proximal inflow segment of the temporary bypass graft was anastomosed to the brachiocephalic artery. In both cases, the distal outflow segment of the temporary bypass graft was the graft used for repair of the abdominal aortic aneurysm. In order to prevent any clamp injury, Teflon felt was tightly wrapped around the aorta before the clamp was applied. Results: Evaluation of the hemodynamic parameters measured during cross-clamping of the aortic arch revealed stable distal perfusion to the visceral organs and no excessive increase in cardiac afterload. All patients had an uneventful postoperative course and were discharged within 1 month of surgery. Conclusion: Our temporary bypass method is recommended for simultaneous replacement of aneurysms in the aortic arch and the abdominal aorta.     

Simultaneous repair of arch and abdominal aortic aneurysms. A simple new technique using a temporary bypass graft.

OBJECTIVE: Atherosclerotic aneurysms in the aortic arch are associated with abdominal aortic aneurysms in up to 37% of cases. We have developed a single-stage approach to the repair of both aneurysms using a temporary bypass. SUBJECTS: Since November 1996, 5 patients underwent simultaneous repair of aneurysms in the aortic arch and in the infrarenal abdominal aorta, using a new temporary bypass graft technique. Entire arch replacement with simultaneous abdominal aortic aneurysmectomy was performed in one patient. The other 4 patients underwent distal hemi-arch replacement distal from the orifice of the brachiocephalic artery with simultaneous repair of the abdominal aortic aneurysm. METHOD: For the entire arch replacement procedure, blood flow to all major branches of the aortic arch was established using a bifurcated graft. This graft anastomosed to the ascending aorta was used as the proximal inflow of the temporary bypass graft. For the hemi-arch replacement procedure, the proximal inflow segment of the temporary bypass graft was anastomosed to the brachiocephalic artery. In both cases, the distal outflow segment of the temporary bypass graft was the graft used for repair of the abdominal aortic aneurysm. In order to prevent any clamp injury, Teflon felt was tightly wrapped around the aorta before the clamp was applied. RESULTS: Evaluation of the hemodynamic parameters measured during cross-clamping of the aortic arch revealed stable distal perfusion to the visceral organs and no excessive increase in cardiac afterload. All patients had an uneventful postoperative course and were discharged within 1 month of surgery. CONCLUSION: Our temporary bypass method is recommended for simultaneous replacement of aneurysms in the aortic arch and the abdominal aorta.     

Transcarotid artery endovascular reconstruction of the aortic arch by modified bifurcated stent graft for Stanford type A dissection

A 40-year-old man with Stanford type B dissection underwent his first endovascular repair (EVAR) in April 2004 by Talent thoracic stent graft. He had an uncomplicated recovery and maintained good blood pressure control. However, a new retrograde dissection appeared in September 2004. The new dissection involved his aortic arch and ascending thoracic aorta to the opening of the coronary arteries. To reconstruct the aortic arch, bypasses between the right common carotid artery (RCCA), left common carotid artery and left subclavian artery were performed before endovascular repair. A modified bifurcated Talent stent graft was deployed from the RCCA to the ascending thoracic aorta with a long limb in the innominate artery and a short limb in the aortic arch. A further two pieces of graft were deployed via the common femoral artery. The ascending thoracic aorta and aortic arch were reconstructed completely by the bifurcated stent graft. The final angiography confirmed that there was good stent graft configuration, normal blood flow, and stable haemodynamics. No endoleak or other major complications were encountered. This result indicated that it is possible to reconstruct the aortic arch with a bifurcated stent graft and could be a new endovascular repair model for complex thoracic aortic aneurysm and dissection.