胸,腹主动脉瘤腔内隔绝术的临床应用

目的:总结腔内隔绝术治疗胸、腹主动脉瘤的初步临床经验,探讨其指征、方法、操作要点及临床应用前景.方法:本组15例患者在DSA监视下经股总动脉小切口将人造血管内支撑复合体(移植物)导人腹主动脉瘤,从腔内将瘤体与血流隔绝.15例中置入直管型移植物4例,分叉型移植物11例.结果:13例患者于手术当日进食,次日下床活动;1例出现急性酸中毒;1例因髂动脉扭曲导致移植物将髂动脉阻塞,而加作股.股交叉转流术,恢复较慢.4例出现内漏,其中1例3月后自行愈合;1例术后第4天动脉瘤破裂,经传统开腹手术治愈;另2例随访中.2周及3月后分别复查彩超、螺旋CT.结果显示全部病例移植物中血流通畅,无移位.结论:腔内隔绝术简捷、方便,避免了常规开腹手术所见腹部及重要脏器并发症,创伤小、恢复快,适用于所有尤其是高龄高危肾下腹主动脉瘤及胸降主动脉瘤患者.全程内支架-人造血管复合体应用于EVGE效果良好.熟练的导管操作技巧及精确的术前评估有利于提高操作成功率及减少术后并发症.并发内漏的问题有待于继续观察探讨.     

Endovascular Repair of Abdominal Aortic Aneurysms with Aortocaval Fistula

OBJECTIVES: To examine the risk of high-flow type II endoleak following endovascular repair of abdominal aortic aneurysm with aortocaval fistula. DESIGN: Case reports. SUBJECTS: Two patients with abdominal aortic aneurysms with aortocaval fistula. METHODS: Both patients had an endovascular repair of their aortic aneurysms. RESULTS: The aneurysms were successfully treated in both patients, without any endoleak on completion angiography. Apart from a transient type II lumbar endoleak in one of the patients, no endoleak was found after 3 and 12 month follow-up. Seven other cases have been published, reporting one type II and one type Ic endoleak. CONCLUSION: We found no evidence that endovascular repair of abdominal aortic aneurysm with aortocaval fistula is associated with a higher incidence of persistent endoleak.     

Appraisal Era for Endovascular Repair of Abdominal Aortic Aneurysms

Aims: To determine the impact of preoperative use of breast magnetic resonance imaging (MRI) in therapeutic surgical approach in women with breast cancer.

Materials and Methods: Preoperative contrast-enhanced MRI of the breast was performed in 105 patients with suspected breast carcinomas. MRI findings were correlated with mammography (MMG) and ultrasonography (US). Results: Histopathologic analysis revealed 144 breast carcinomas. The results of the MRI lead to a change in 17.1% of the planned surgical procedure. MRI imaging alone revealed 16 multifocal or multicentric tumors and four contralateral carcinomas.

Conclusion: Breast MRI could be recommended as a pre-surgical diagnostic procedure in patients allocated to breast conservation surgery. Nevertheless, further studies are needed to determine if preoperative breast MRI leads to a decrease in tumor recurrence and in overall survival.     

Emergency Endovascular Repair for Ruptured Abdominal Aortic Aneurysms: Feasibility and Comparison of Early Results with Conventional Open Repair

PURPOSE: To assess the feasibility of endovascular aortic repair (EVAR) on patients presenting with a ruptured abdominal aortic aneurysm (AAA) in a teaching hospital, and to compare there post-operative outcomes with contemporaneous patients treated with open repair (OR). METHODS: A series of consecutive of patients presenting ruptured AAA with retro/intraperitoneal haematoma were included in the study. EVAR was attempted whenever possible. In all other cases (severe haemodynamic instability, adverse anatomy, device unavailability), ruptured AAA were treated by OR. RESULTS: Thirty-seven patients were enrolled between January 2001 and July 2004. Seventeen (46%) patients were treated using adapted designed aortoiliac endografts (eight bifurcated, eight aorto-uniiliac, one iliac extension). Twenty (54%) patients unfit for EVAR because of severe haemodynamic instability (n=8), adverse anatomical configuration (n=7), or unavailability of an appropriate endograft (n=5) were treated by OR. Twenty-seven (73%) had a retrospective suitable anatomy for EVAR. Three early conversions from EVAR to OR were performed. Blood loss, operating time, and intensive care stay were significantly decreased in EVAR patients (respectively: 156 min+/-60, 1520 ml+/-1175, 3 days for EVAR; vs. 222 min+/-82, 3075 ml+/-1750, 13 days for OS; P<.01). The 30-day mortality rate was 23.5% for EVAR vs. 50% for OR (P=0.09). CONCLUSION: EVAR of ruptured AAA is feasible for selected patients based on haemodynamic and morphologic criteria, and should be associated with improved immediate outcomes as compared with OR. These results should be tempered by the fact that these patients have heavy comorbidities which explains the absence of difference in mid-term mortality rates between the two groups, but should also encourage surgical institutions that are managing such life-threatening emergencies to introduce EVAR as part of their therapeutic arsenal for ruptured AAA.     

Final Results of the Prospective European Trial of the Endurant Stent Graft for Endovascular Abdominal Aortic Aneurysm Repair

Objectives

The Endurant Stent Graft System (Medtronic Vascular, Santa Rosa, CA) is specifically designed to treat patients with abdominal aortic aneurysm, including those with difficult anatomies. This is the 1-year report of a prospective, non-randomised, open-label trial at 10 European centres.

Methods

Between November 2007 and August 2008, 80 patients were enrolled for elective endovascular aneurysm repair (EVAR) with the Endurant; 71 with moderate (≤60°) and nine with high (60–75°) infrarenal aortic neck angulation. Safety and stent-graft performance were assessed throughout a 1-year follow-up period.

Results

The device was successfully delivered and deployed in all cases. All-cause mortality was 5% (4/80), with one possibly device-related death. Serious adverse events were comparable between the high and moderate angulation groups. There were no device migrations, stent fractures, aortic ruptures or conversions to open repair. Maximal aneurysm diameter decreased >5 mm in 42.7% of cases. A total of 28 endoleaks were observed (26 type II, two undetermined). Three secondary endovascular procedures were performed for outflow vessel stenosis, graft limb occlusion and iliac extension, resulting in a secondary patency rate of 100%. No re-interventions were required in the high angulation group.

Conclusions

The Endurant Stent Graft was successfully delivered and deployed in all cases and performed safely and effectively in all patients, including those with unfavourable proximal neck anatomy.     

Life-table Analysis of Primary and Assisted Success Following Endoluminal Repair of Abdominal Aortic Aneurysms: the Role of Supplementary Endovascular Intervention in Improving Outcome

AIM: the aim of this study was to analyse the effect of supplementary endovascular intervention on the outcome of primary endoluminal repair of abdominal aortic aneurysm (AAA). METHODS: between May 1992 and December 1998, 266 patients underwent endoluminal repair of AAA. Minimum period of follow-up was 6 months. Those patients in whom the endoprosthesis could not be deployed were converted to open repair at the primary operation. Patients developing an early endoleak, within 31 days, were treated by a period of observation and secondary endovascular intervention in persistent cases. Patients developing a late endoleak were treated similarly, without a period of observation. Outcome was analysed by the life-table method. Primary success was defined as exclusion of the aneurysm from the circulation resulting from the original operation. Assisted success occurred when aneurysms with endoleaks became excluded from the circulation as a result of supplementary endovascular intervention. RESULTS: endoluminal repair failed in 17 patients requiring conversion to open repair at the original operation. Supplementary endovascular intervention was undertaken in 26 patients, with early endoleaks (n=6) and late endoleaks (n=20). Interventions involved deployment of secondary endoluminal grafts within the primary grafts (n=22), and coil embolisation (n=4). Successful exclusion of the aneurysm sac was achieved in 22 of 26 (85%) patients undergoing supplementary endovascular procedures. Conditional cumulative incidence of primary graft failure and secondary graft failure in the presence of all-cause mortality at 6 years was 47% and 25% respectively. CONCLUSIONS: supplementary endovascular intervention is an important adjunct to endoluminal AAA repair with the potential to improve outcome and avoid conversion to open repair. Successful supplementary endovascular intervention was achieved in 85% of patients in whom it was attempted. Life-table analysis showed these supplementary procedures to be durable in the long term.     

Endovascular Treatment of Thoracic Aortic Pathology: Feasibility and Mid-term Results

OBJECTIVE: to report our experience with 21 consecutive patients treated with a thoracic stent-graft.DESIGN: retrospective analysis. MATERIALS AND METHODS: Between October 1998 and February 2002, 21 patients (12 male), mean age 55.6 years (range 19-86 years), were treated for aorticortic pathology localized to the descending aorta (18 patients), the aortic arch (2 patients) and the ascending aorta (1 patient) and comprising true aneurysms (8 patients), false aneurysms (6 patients), traumatic rupture (4 patients), mycotic aneurysms (2 patients), and ruptured aneurysm (1 patient). Plain chest X-rays and computed tomography was performed at 3, 6 and 12 months postoperatively and then annually. RESULTS: the median (range) operation time was 85min (50-305min), hospital stay 6 days (3-63 days) and follow-up 24 months (5-44 months). Complications occurred in 5 patients and comprised intraoperative migration (1), type I endoleak (1), type II endoleak (1), ischemic myelopathy (1), pneumonia (2), suture granuloma (1) and common femoral artery dissection (1). CONCLUSIONS: stent-grafting can be successfully employed to treat a wide range of thoracic aortic pathologies with a mortality, morbidity and resource utilization that is considerably less than that associated with conventional surgery. However, long term follow-up on safety and efficacy is needed.     

覆膜支架主动脉腔内修复术在Stanford B型主动脉夹层中的应用

目的观察覆膜支架主动脉腔内修复术（TEVAR）对Stanford B型主动脉夹层和降主动脉瘤的治疗效果。方法回顾性分析华西医院2013年3～6月采用TEVAR治疗Stanford B型主动脉夹层和降主动脉瘤患者20例的临床资料,其中男19例,女1例;年龄41～76（58．3±10．2）岁,分析其疗效。结果20例患者中,治愈18例,自动出院1例,术后死亡1例。随访满3个月者16例,随访率88．9％。全部随访患者支架范同内真腔管径有所恢复,假腔或瘤腔内血栓形成。结论TEVAR为Stanford B型主动脉瘤提供了一个新的选择,特别是为高龄和合并严重疾病的患者提供了新的治疗手段,优势明显,值得临床应用。     

复杂瘤颈的近肾腹主动脉瘤腔内修复中烟囱技术的应用

目的探讨瘤颈解剖复杂的近肾腹主动脉瘤(juxtarenal aortic aneurysms,JAA)腔内修复(endovascular aneurysmrepair,EVAR)中应用烟囱技术的价值。方法 2007年1月～2011年10月,对7例瘤颈复杂的JAA采用EVAR治疗。由于瘤颈解剖结构不适于标准的腔内修复方案,术中自肱动脉穿刺预先于可能被覆膜支架主体覆盖的肾动脉置入导丝,置入修复腹主动脉瘤的覆膜支架主体后造影明确肾动脉覆盖情况,于相应肾动脉置入自膨支架或球囊扩张支架,以延长瘤颈长度使之符合EVAR要求,并有效保护肾动脉(即烟囱技术),然后再完成标准EVAR操作。结果 7例手术全部获成功。7例使用9枚肾动脉支架,其中5枚球扩支架,4枚自膨支架。腔内治疗最后的造影显示:腹主动脉瘤(abdominal aortic aneurysm,AAA)瘤腔隔绝良好,肾动脉血流良好。术中1例近端Ⅰ型内漏,近端增加Cuff后内漏消失;1例造影显示少量的Ⅱ型内漏,无须处理。7例随访1～52个月,平均11.6月:1例术后2个月因心功能衰竭死亡;1例Ⅱ型内漏术后3个月随访内漏消失;肾动脉烟囱支架均保持通畅。结论对于不适宜行开腹手术治疗的瘤颈解剖不佳的JAA,烟囱技术是传统EVAR技术的有效补充,远期效果及肾动脉支架长期通畅性尚需要进一步观察。