腹主动脉瘤腔内修复术中髂内动脉的疏与堵

腹主动脉瘤腔内修复术(EVAR)中髂内动脉的疏与堵的问题,是长期伴随EVAR发展过程的焦点问题。笔者复习了数十篇国外文献,总结和分析了从百年前至今对髂内动脉的系统的解剖学研究、非血管外科手术过程中髂内动脉结扎或栓塞、腹主动脉与髂动脉开放手术中对髂内动脉实施结扎或栓塞、EVAR术中各种栓塞髂内动脉方式的临床后果、导致盆腔缺血各种并发症的危险因素,最终认为,EVAR术中,维持髂内动脉通畅是必要的,并对没有维持通畅的条件而必须栓塞髂内动脉,操作时如何防止或减少盆腔脏器缺血、具体实施技巧、术中术后注意事项等进行了归纳。     

Use of an aortic bifurcation-sparing endograft facilitates hypogastric preservation during aortoiliac aneurysm repair

A significant percent of patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) have concomitant common iliac artery aneurysms. While most of these patients will tolerate sacrifice of the hypogastric artery during repair, a subset will develop sequelae of hypogastric occlusion. EVAR was performed in two patients using a bifurcation-sparing unibody endograft (Powerlink, Endologix, Irvine, CA, USA). To avoid simultaneous bilateral hypogastric occlusion, one side was treated with coil embolization while the other was treated with a hypogastric graft (Viabahn, W L Gore and Associates, Flagstaff, AZ, USA). Access to the preserved hypogastric artery was obtained from a sheath inserted from the contralateral femoral artery and brought over the aortic bifurcation with the assistance of a 'rail-wire' traversing from the contralateral to ipsilateral femoral sheaths. The hypogastric limb was deployed simultaneously with the ipsilateral external iliac limb extension, creating a double-barrel flow lumen preserving both hypogastric and external iliac flow. At a mean follow-up of 5.1 months, both hypogastric limbs are patent and no endoleaks were observed. In conclusion, until commercially-produced branched hypogastric endografts are widely available, techniques such as those described above can allow for hypogastric preservation during aortoiliac aneurysm repair without the need for device modification or brachial access for hypogastric limb delivery.     

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.     

Kissing iliac artery stent technique for salvage of hypogastric artery occlusion secondary to iliac artery dissection during endovascular aneurysm repair

While undergoing endovascular aneurysm repair (EVAR), dissection occurred in bilateral common and external iliac arteries resulting in acute bilateral hypogastric artery occlusion. Attempts were made to reestablish flow to the left internal iliac artery via retrograde ipsilateral approach without success. A left brachial approach was used to gain access to the left internal iliac artery and kissing angioplasty and subsequent stent placement with 2 self-expanding stents was performed raising the iliac bifurcation to the level of the stent graft to salvage the internal iliac artery.     

Bilateral gluteal compartment syndrome after elective unilateral hypogastric artery ligation and revascularization of the contralateral hypogastric artery during open abdominal aortic aneurysm repair

Gluteal compartment syndrome is an uncommon entity that has been described in the literature after drug overdose and orthopedic procedures. We describe the first case of bilateral gluteal compartment syndrome that followed pelvic revascularization after the repair of an abdominal aortic aneurysm with bilateral common and internal iliac aneurysms. The patient was treated with aggressive fluid hydration and bilateral gluteal fasciotomies with resolution. The bilateral gluteal compartment syndrome was likely caused by increased pressure on the gluteal muscles, secondary to increased patient weight combined with a period of local ischemia to the watershed areas during iliac cross-clamp.     

Hypogastric artery bypass to preserve pelvic circulation: improved outcome after endovascular abdominal aortic aneurysm repair

OBJECTIVE: This study was carried out to compare the functional outcomes after hypogastric artery bypass and coil embolization for management of common iliac artery aneurysms in the endovascular repair of aortoiliac aneurysms (EVAR). METHODS: Between 1996 and 2002, 265 patients underwent elective or emergent EVAR. Data were retrospectively reviewed for 21 (8%) patients with iliac artery aneurysms 25 mm or larger that involved the iliac bifurcation. Patients underwent hypogastric artery bypass (n = 9) or coil embolization (n = 12). Interviews about past and current levels of activity were conducted. A disability score (DS) was quantitatively graded on a discrete scale ranging from 0 to 10, corresponding to "virtually bed-bound" to exercise tolerance "greater than a mile." Worsening or improvement of symptoms was expressed as a difference in DS between two time points (-, worsening; +, improvement). RESULTS: There was no difference in age (72.6 +/- 7.3 years vs 73.1 +/- 6.4 years), sex (male-female ratio, 8:1 vs 11:1), abdominal aortic aneurysm size (60.1 +/- 5.9 mm vs 59.3 +/- 7.0 mm), or number of preoperative comorbid conditions (1.9 +/- 0.8 vs 2.1 +/- 0.8) between hypogastric bypass and coil embolization groups, respectively. Mean follow-up was shorter after hypogastric bypass (14.8 vs 20.5 months; P <.05). There was no difference in the mean overall baseline DS between the bypass and the embolization groups (8.0 vs 7.8). Six (50%) of the 12 patients with coil embolization reported symptoms of buttock claudication ipsilateral to the occluded hypogastric artery. No symptoms of buttock claudication were reported after hypogastric bypass (P <.05). There was a decrease in the DS after both procedures; however, coil embolization was associated with a significantly worse DS compared with hypogastric artery bypass (4.5 vs 7.3; P <.001). In 4 (67%) of 6 patients with claudication after coil embolization symptoms improved, with a DS of 5.4 at last follow-up. This was significantly worse than in patients undergoing hypogastric artery bypass, with a DS of 7.8 at last follow-up (P <.001). There was no difference between the groups in duration of procedure, blood loss, length of hospital stay, morbidity, or mortality (0%). CONCLUSIONS: Hypogastric artery bypass to preserve pelvic circulation is safe, and significantly decreases the risk for buttock claudication. Preservation of pelvic circulation results in significant improvement in the ambulatory status of patients with common iliac artery aneurysms, compared with coil embolization.     

腔内治疗时代腹主动脉瘤传统开放手术的地位和意义

在过去30多年里,随着腹主动脉瘤腔内治疗(EVAR)技术的出现及其越来越广泛地应用,并逐步超越了开放手术治疗的病例数量,导致腹主动脉瘤的治疗方式发生了巨大变化。虽然EVAR成为目前腹主动脉瘤的主要治疗方式,但最新的长期随访结果显示开放手术可能带来更多的远期获益,尤其对于年轻、预期寿命长、围术期风险低的腹主动脉瘤患者。在此背景下,我们需要重新客观地审视开放手术和EVAR的价值和地位。无论是EVAR还是开放手术,均需要结合动脉瘤的解剖结构、患者特点、医生情况等因素综合评估,以实现动脉瘤的充分隔绝,提高远期生存率,降低远期并发症发生率及经济支出。因此,新生一代的血管外科医生不能过多地依赖EVAR,应同时具备腹主动脉瘤开放手术和EVAR的技能,充分发挥两种治疗方式的优势互补,为患者尽可能提供最佳的个体化治疗选择。     

Preservation of pelvic circulation with hypogastric artery bypass in endovascular repair of abdominal aortic aneurysm with bilateral iliac artery aneurysms

PURPOSE: The endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) with a bilateral common iliac artery aneurysm (CIAA) often requires exclusion of the bilateral hypogastric artery (HA), which can be associated with pelvic ischemic complications such as erectile dysfunction and buttock claudication. This study assessed the effect of HA bypass on improving pelvic circulation. METHODS: Five patients who underwent endovascular repair with HA bypass for an AAA with bilateral CIAA were evaluated. In all patients, the patency of the inferior mesenteric artery and bilateral HAs arteries was confirmed with preoperative computed tomography (CT) scans and angiography. During EVAR, penile blood flow was monitored with pulse-volume plethysmography measuring the penile brachial pressure index (PBI), and bilateral buttock blood flow was monitored with near-infrared spectroscopy measuring the gluteal tissue oxygenation index (TOI). An aortouni-external iliac artery stent graft with a crossover bypass was performed after embolization of the contralateral HA. HA bypass was performed between the crossover bypass graft and the ipsilateral HA via a retroperitoneal incision. RESULTS: Unilateral coil embolization of the contralateral side HA trunk slightly decreased blood flow to the contralateral side buttock but did not cause significant changes in penile blood flow. At the completion of EVAR, the levels of both PBI and the contralateral side TOI were significantly lower than the baseline levels. After ipsilateral side HA revascularization with HA bypass, both PBI and bilateral gluteal flow returned almost to the baseline levels. Postoperative angiography and CT scans demonstrated the patency of all HA bypasses and no endoleaks. None of the patients experienced new onset of erectile dysfunction or buttock claudication 1 month after surgery. CONCLUSION: Bilateral HA interruption during EVAR for AAA with bilateral CIAA was associated with significant depletion of both penile and gluteal blood flow. Intraoperative monitoring of PBI and TOI at the bilateral buttocks showed significant improvement of both parameters after HA bypass. HA bypass is an excellent procedure to improve pelvic circulation despite its increased surgical complexity.     

Ureteric obstruction caused by aneurysm of the hypogastric artery

We present the case of a 70-year-old man with haematuria who was found to have an internal iliac artery aneurysm causing ureteric obstruction. Urgent repair of the iliac artery aneurysm was performed but no urological intervention was necessary.     

复杂主动脉瘤及主动脉夹层的腔内治疗策略

主动脉瘤(aortic aneurysm,AA)与主动脉夹层(aortic dissection,AD)是血管外科的常见病.随着人口老龄化和影像学诊断技术不断提高,其发病率和检测发现率均呈明显上升趋势.     

复杂主动脉瘤及主动脉夹层的腔内治疗策略

主动脉瘤(aortic aneurysm,AA)与主动脉夹层(aortic dissection,AD)是血管外科的常见病.随着人口老龄化和影像学诊断技术不断提高,其发病率和检测发现率均呈明显上升趋势.     

复杂主动脉瘤及主动脉夹层的腔内治疗策略

主动脉瘤(aortic aneurysm,AA)与主动脉夹层(aortic dissection,AD)是血管外科的常见病.随着人口老龄化和影像学诊断技术不断提高,其发病率和检测发现率均呈明显上升趋势.     

复杂主动脉瘤及主动脉夹层的腔内治疗策略

主动脉瘤(aortic aneurysm,AA)与主动脉夹层(aortic dissection,AD)是血管外科的常见病.随着人口老龄化和影像学诊断技术不断提高,其发病率和检测发现率均呈明显上升趋势.     

A technique for combined hypogastric artery bypass and endovascular repair of complex aortoiliac aneurysms

Endovascular repair of complex aortoiliac aneurysms may necessitate distal fixation of the endograft to the external iliac artery and percutaneous embolization of the hypogastric artery for prevention of a retrograde endoleak. However, acute interruption of hypogastric perfusion can result in symptoms of pelvic ischemia. We describe a technique in which a prosthetic graft is used as an external iliac artery conduit to facilitate the passage of the endograft delivery catheter/sheath and after completion of the endovascular portion of the procedure, a surgical bypass is completed with anastomosis of the graft to the hypogastric artery.     

腹主动脉去分支化联合腔内隔绝术患者的术后护理

目的 总结腹主动脉去分支化联合腔内隔绝术治疗14例胸腹主动脉夹层患者的术后护理经验.方法 对14例腹主动脉去分支化联合腔内隔绝术患者,术后实施密切观察肠道、肾脏、脊髓缺血的症状与体征,严密血压监控、抗栓治疗和营养管理以及促进胃肠功能恢复等措施.结果 患者均手术顺利,术后复查主动脉CT血管成像无造影剂渗漏,住院(26.9±7.5)d康复出院.结论 对于复杂胸腹主动脉夹层手术,术后严密的专科监测,细致的病情观察、精细化的治疗与护理,是减少术后并发症、促进患者康复的关键.