外科治疗腹主动脉瘤482例

目的 探讨提高腹主动脉瘤手术安全性的方法。方法 总结了自1960年1月－2001年3月482例腹主动脉瘤切除人工血管移植以及腹主脉瘤腔内隔绝术的经验。本组461例肾动脉水平以下腹主动脉瘤,采用动脉瘤切除人工血管移植430例,31例采用腹主动脉瘤腔内隔绝术,21例胸、腹主动脉瘤采用Crawford方法切除。采用腹膜外途径21例,小切口15例,脐下弧形切口11例。结果 随着腹膜后途径及脐下弧形切口和小切口等应用,动脉瘤近端血流控制,动脉瘤切除以及缝合修补和腔内隔绝术等方法的更新,使手术的危险性明显降低,总手术病死率5．2％,5年存活率达74．4％。结论 手术技术和麻醉监护的进步,使腹主动脉瘤的外科治疗变得更安全、迅速和方便。     

肾动脉水平以下腹主动脉瘤外科治疗的若干问题(附461例报告)

提高肾动脉水平以下腹主动脉瘤手术的安全性。方法：总结１９６０年１月～２００１年３月４６１例腹主动脉瘤切除、人造血管移植及腹主动脉瘤腔内隔绝术的经验。结果：随着腹膜后途径和小切口等技术的应用,动脉瘤近端血流控制、动脉瘤切除以及缝合修补和腔内隔绝术等方法的更新,使手术危险性明显降低,手术死亡率４．８％,５年存活率达７４．４％。结论：手术技术和麻醉监护的进步,使腹主动脉瘤的外科治疗变得更安全、迅速和方便。     

腹主动脉瘤腔内隔绝术后内漏

腹主动脉瘤腔内隔绝术后内漏 (ｅｎｄｏｌｅａｋ)是腹主动脉瘤腔内治疗过程中所产生的并发症[1] 。腔内治疗的方法是在腹主动脉瘤腔内放置带膜的血管支架 ,用移植物将循环血流和动脉瘤囊相隔开 ,使动脉瘤不再承受到循环血流的冲击 ,不再承受动脉压的压力 ,腹主动脉瘤不再增大和破裂。如果经过腔内隔绝术后 ,移植物外层的动脉瘤囊内仍有循环血流进入或进出 ,说明动脉瘤未与循环系统完全隔开 ,动脉瘤继续扩大甚至发生破裂 ,导致腹主动脉瘤隔绝手术的失败[2 ,3] 。所有类型移植物的内漏率是 2 4% (12 4/ 5 2 3) ,即发性内漏率约为 17% (89/ 5 2…     

腔内隔绝术治疗胸、腹主动脉瘤5例

目的 研究腔内隔绝术治疗胸、腹主动脉瘤的方法以及评价其效果。方法 2000年10月-2002年8月共开展腔内隔绝术5例，其中包括胸腹主动脉夹层动脉瘤4例，腹主动脉瘤1例。结果 5例动脉瘤腔内隔绝手术均获得成功，4例夹层动脉瘤的假腔立刻消失，1例腹主动脉瘤瘤体成功隔绝31例术后并发脑梗塞，经非手术治疗好转。结论 腔内隔绝术治疗大动脉瘤具有创伤少、安全、效果确切等优点。在严格选择适应证的基础上，开展腔内隔绝术是有价值的。     

主动脉夹层动脉瘤合并腹主动脉瘤的一期腔内治疗(附1例报告)

目的 :探讨胸主动脉夹层动脉瘤合并腹主动脉瘤病人作一期腔内隔绝术治疗的可行性、手术操作技巧及并发症防治原则。临床资料 :1例StanfordB型胸主动脉夹层动脉瘤合并腹主动脉及双侧髂动脉瘤的病人于 2 0 0 1年 2月在本中心接受了腔内隔绝术。术前CTA显示 :主动脉自弓降部开始出现夹层 ,一直延伸到腹主动脉分叉上6cm ,假腔的最大直径达 6 .6cm ;肾下腹主动脉瘤的最大直径为 4 .5cm ,瘤颈受夹层累及 ;双侧髂总动脉各有一直径 2 .5cm的真性动脉瘤。手术在全麻下进行 ,降主动脉植入规格为 34mm× 34mm× 1 30mm的直管型Talent移植物封闭夹层裂口 ;腹主动脉植入规格为 2 6mm× 1 4mm× 1 4 5mm的分叉型Talent移植物。将腹主动脉瘤和双侧髂动脉瘤隔绝 ,手术耗时 30 0min ,失血 30 0ml,透视 62min ,造影 5次 ,使用造影剂 2 0 0ml。术后病人恢复顺利 ,术后第 2天出ICU ,术后 30d出院。随访 1年 ,病人生活质量良好 ,复查CT示胸主动脉、腹主动脉瘤及髂动脉瘤完全封闭。结论 :腔内隔绝术的微创特点使一期治疗StandordB型主动脉夹层动脉瘤合并腹主动脉瘤成为一种比较安全的手术。术后应先处理胸主夹层处理腹主动脉瘤 ,以减少后半程手术对先前植入物的影响     

腹主动脉腔内隔绝术对血液动力学的影响

腹主动脉瘤常规外科手术方法是动脉瘤切除人造血管替换术,由于该手术创伤大\腹主动脉阻断时间长,术后可能产生心、肺、肾以及脊髓缺血性损伤等并发症。近年来其围手术期死亡率已有所下降,但仍高达2％-10％[1,2]。腹主动脉腔内隔绝术是近几年发展起来的外科新技术,具有创伤小、并发症少及术后康复快等优点。本研究拟比较常规腹主动脉瘤手术和腔内隔绝术对血液动力学、血浆儿茶酚胺浓度及酸碱平衡的影响。     

主动脉瘤40例治疗体会

目的介绍外科与腔内隔绝术治疗主动脉瘤的体会。方法手术与腔内隔绝术治疗主动脉瘤40例,手术治疗30例,Bentall术9例,Bentall 部分弓置换3例,主动脉瘤切除人工血管置换6例,主动脉瘤切除补片修补4例,升主动脉 部分弓置换、主动脉瓣二尖瓣置换 升主动脉折叠缝合术各2例,主动脉瓣置换 升主动脉置换、主动脉瓣置换升主动脉折叠缝合术、主动脉瘤切除直接缝合、主动脉瘤切除人工血管置换 左全肺切除术各1例。腔内隔绝术治疗假性胸降主动脉瘤1例、假性腹主动脉瘤1例、夹层主动脉瘤ⅢA型1例、ⅢB型7例,经股动脉切口植入32~38mm覆膜支架。结果手术后因低心排出量综合征和出血各死亡1例,死亡率6.7%,无截瘫、偏瘫和感染。覆膜支架腔内隔绝术后1~2周内低热8例,无大出血、内漏和死亡。生存38例,随访1个月~5年,无死亡和远期并发症。结论升弓部主动脉瘤的手术治疗效果满意,覆膜支架腔内隔绝治疗DeBakeyⅢ型夹层主动脉瘤创伤小、并发症少、恢复快。     

累及分支动脉的主动脉病变腔内治疗移植物研究进展

主动脉瘤（包括胸、腹主动脉瘤和主动脉夹层动脉瘤）是一类严重威胁人类健康的动脉疾病．其治疗方式在近数十年中一直是研究焦点。随着影像学技术、材料技术的进步，主动脉瘤的治疗方式发生了巨大变化。腔内隔绝术是主动脉瘤治疗方式的重大改进，由于微创、围手术期低死亡率、低并发症率以及良好的近期效果使其得到广泛认同并迅速普及。动脉瘤的瘤颈条件是腔内隔绝治疗首要考虑的因素。以往认为．动脉瘤距锁骨下动脉和腹腔干2．3cm、距肾动脉开口1-2cm是行腔内隔绝的前提，且瘤颈不能有过大的成角和血栓形成。对于涉及分支血供的主动脉瘤（如主动脉弓动脉瘤、胸腹主动脉瘤、肾上型及累及髂内外动脉的腹主动脉瘤等）和短瘤颈的腹主动脉瘤（瘤颈长度〈10mm），采用标准的腔内移植物则会在隔绝动脉瘤的同时造成身体其他部位的缺血性改变，同时也会因开放的侧支增加术后Ⅱ型内漏的风险并影响腔内隔绝术后早期瘤囊的缩退。若在治疗中保留主要分支血供（如左锁骨下动脉、肾动脉），则腔内移植物固定不稳．会增加移位和隔绝失败的风险。如何在隔绝动脉瘤的同时保留分支血供，自然而然地成为研究的重点，也是将来腔内移植物发展的方向。     

腔内隔绝术治疗腹主动脉瘤(附5例报告)

目的探讨腹主动脉瘤腔内隔绝术的适应症及其并发症的防治。方法对5例患者采用经股动脉植入支架-人造血管复合移植物,对腹主动脉瘤进行腔内隔绝术。结果5例手术均获成功,无任何并发症发生。结论腔内隔绝术治疗腹主动脉瘤具有简捷、微创、并发症少、术后恢复快等优点,为治疗本病的首选方法。     

大动脉外科疾病的腔内治疗

发生于大动脉的外科疾病主要是真性动脉瘤、夹层动脉瘤和假性动脉瘤等动脉扩张病。早在1684年,Moore将一段金属丝导入腹主动脉瘤腔内,希望促发瘤内血栓形成。这是人类的首次大动脉腔内治疗尝试,而其真正的发展仅仅是最近20年的事。上世纪80年代中后期开始了动脉瘤腔内隔绝系统的实验研究,到1990年,Parodi成功地施行了世界上第一例腹主动脉瘤腔内隔绝术,在国内,笔者于1997年率先开展了该手术[1],并在此后迅速推广应用于胸主动脉瘤、夹层动脉瘤、假性动脉瘤和动静脉瘘等疾病的治疗。1主动脉真性动脉瘤的腔内治疗发生在主动脉的真性动脉瘤可分…     

237例肾动脉水平以下腹主动脉瘤手术治疗经验

目的提高腹主动脉瘤手术的安全性。方法总结了自１９６０年１月到１９９６年１２月２３７例肾动脉水平以下腹主动脉瘤切除人造血管移植手术治疗的经验。结果随着腹膜后途径的应用,动脉瘤近端血流控制、动脉瘤切除以及缝合修补等方法的改进,使手术的危险性明显降低,手术时间缩短（２～３ｈ）。随访２２７例,手术死亡率低（３．８％）。５年存活率达７４．４％。结论手术技术和麻醉监护的进步,使腹主动脉瘤修补手术变得更迅速、安全和方便。     

Development of cardiovascular procedures before abdominal aortic aneurysm repair over 16 years.

INTRODUCTION: Preoperative screening, interventional and surgical therapy of cardiovascular diseases are of pivotal importance for a successful outcome after abdominal aortic aneurysm (AAA) surgery. METHODS: In a retrospective study all patients who underwent surgery for AAA were reevaluated for preoperative diagnostic and therapeutic interventions for cardiovascular diseases. Two study periods 1980-1989 and 1990-1996 were defined. Of 603 patients operated upon because of AAA between 1980 and 1996, 449 were operated on an elective basis and 154 as an emergency. Preoperative diagnostic studies for coronary artery disease (CAD) were performed in electively operated patients only and were positive in 76.8% (1980-1989: 76.1%, 1990-1996: 77.5%). Coronary angiography was performed in 108 patients (29.6%). Medical therapy of CAD declined by 2.3%, interventional procedures by 18.8%. In contrast, myocardial revascularization with subsequent aneurysm resection increased by 26. 6% and 12 patients (16%) required urgent simultaneous cardiac and aortic surgery. Early mortality after AAA surgery dropped from 4.2% to 2.9%, the frequency of primary cardiac failure as the cause of death was reduced from 33.3% to 22.2% (p < 0.05). CONCLUSIONS: 42.6% more cardiac surgical procedures were performed before AAA surgery since 1990 compared with the period 1980-1989. In contrast, the number of interventional procedures fell by 18.8%. Surgical therapy of cardiac disease reduces early mortality after elective AAA surgery.     

肾下型腹主动脉瘤的外科治疗

目的总结26例肾下型腹主动脉瘤的手术治疗经验。方法回顾性分析近5年多来手术治疗26例肾下型腹主动脉瘤的临床资料，全组26例，术前均经影像检查证实诊断。行择期手术21例，破裂型腹主动脉瘤急诊手术5例。26例均行腹主动脉瘤切除，人工血管重建术。结果围手术期死亡2例，均为急症手术患者，总病死率7．7％，急诊手术病死率40．0％。随访时间1-5年。术后1，3，5年生存率分别为96％，88％，75％。死亡原因均与腹主动脉瘤和手术无关。结论CTA检查是诊断腹主动脉瘤的可靠方法。手术治疗仍是治疗腹主动脉瘤的重要方法。瘤体直径不是决定手术的唯一指征。影响手术的危险因素主要是高龄、严重的心肺疾病和肾功能不全。     

Surgical treatment of abdominal aortic aneurysms associated with aortic valve incompetence: strategies and outcomes

BACKGROUND: The exact incidence of associated aortic valve incompetence (AVI) and abdominal aortic aneurysm (AAA) in the general population is not known. In recent years, we have observed this association with increasing frequency. This observation is probably due to the extensive preoperative screening of the cardiac and vascular status of patients who are candidates for surgical procedures. The choice of the optimal surgical strategy is needed to achieve low operative morbidity and mortality. The present study reviews our experience with a subset of patients suffering the association of AVI and large AAA. Surgical strategy, clinical management and outcome are presented.METHODS: Between January 1982 and May 2000, 76 patients with the association of AAA and AVI have been evaluated in our institution. Forty-four patients have been treated for both AAA and aortic valve (AV) regurgitation. These patients have been divided into three groups on the basis of the surgical strategy adopted. Group 1: combined procedure (16 patients); group 2: AAA repair prior to AV surgery (nine patients); group 3: AV surgery prior to aneurysm repair (19 patients).RESULTS: Hospital mortality was 4.5% (two patients); overall mortality was 6.8% (three patients).CONCLUSIONS: In patients with AAA and AVI, an accurate and complete preoperative evaluation is essential. Surgical strategy should be individualized on the basis of the cardiac preoperative status.     

The epidemiology of surgically repaired aneurysms in the United States.

OBJECTIVE: The purpose of this study was to determine the results of surgery for hospitalized cases of aneurysms in the United States, thereby providing a standard of comparison for new techniques proposed to treat aneurysms. METHODS: Data on hospitalized aneurysm cases were collected from the National Hospital Discharge Survey, a comprehensive database of patients hospitalized in the United States for treatment from the years 1984 to 1994. The National Hospital Discharge Survey samples non-federal, acute-care hospitals with an average length of stay of less than 30 days. All the cases had a diagnosis of or a surgical procedure for a non-cerebral aneurysm. RESULTS: In the year 1994, 51,949 non-cerebral aneurysms were repaired in the United States, and 75% of these procedures were abdominal aortic aneurysm (AAA) surgeries. The operative mortality rates for AAA were higher than previously reported from multi-institutional studies and were found to be 8.4% for elective repair and 68% for emergency AAA repair. The number of aneurysm surgeries per thousand population varied by region: surgery rates were more frequent in the Northeast and less frequent in the West. Surgical volume appeared to decrease for smaller hospitals and increase for larger hospitals for the period between 1990 and 1994. The overall mortality rates for all aneurysm surgeries diminished with hospital size. However, no significant difference was found for the rates of elective AAA repair between hospital sizes. The percentage of men with aneurysms who underwent surgery for repair was significantly higher than for women with aneurysms. In addition, the AAA repair rates increased for men from 1985 to 1994, and the number of women reported with repaired AAAs remained constant. CONCLUSION: The location of aneurysm, urgency of repair, region, sex, and hospital size are important factors related to patient treatment and outcome. These data provide a standard of comparison against which surgeons can compare their own results, and they provide a benchmark for the evaluation of interventional techniques proposed to treat aneurysms.     

Abdominal aortic aneurysm rupture rates: A 7-year follow-up of the entire abdominal aortic aneurysm population detected by screening

Purpose: The goal of the current study was to identify the risk of rupture in the entire abdominal aortic aneurysm (AAA) population detected through screening and to review strategies for surgical intervention in light of this information. Methods: Two hundred eighteen AAAs were detected through ultrasound screening of a family practice population of 5394 men and women aged 65 to 80 years. Subjects with an AAA of less than 6.0 cm in diameter were followed prospectively with the use of ultrasound, according to our protocol, for 7 years. Patients were offered surgery if symptomatic, if the aneurysm expanded more than 1.0 cm per year, or if aortic diameter reached 6.0 cm. Results: The maximum potential rupture rate (actual rupture rate plus elective surgery rate) for small AAAs (3.0 to 4.4 cm) was 2.1% per year, which is less than most reported operative mortality rates. The equivalent rate for aneurysms of 4.5 to 5.9 cm was 10.2% per year. The actual rupture rate for aneurysms up to 5.9 cm using our criteria for surgery was 0.8% per year Conclusion: In centers with an operative mortality rate of greater than 2%, (1) surgical intervention is not indicated for asymptomatic AAAs of less than 4.5 cm in diameter, and (2) elective surgery should be considered only for patients with aneurysms between 4.5 and 6 cm in diameter that are expanding by more than 1 cm per year or for patients in whom symptoms develop. In centers with elective mortality rates of greater than 10% for abdominal aortic aneurysm (AAA) repair, the benefit to the patient of any surgical intervention for an asymptomatic AAA of less than 6.0 cm in diameter is questionable. (J Vasc Surg 1998;28:124-8.)     

Abdominal aortic aneurysmectomy in octogenarian patients

The authors report 56 patients. 80 years of age or older who had an abdominal aortic aneurysm (AAA): twenty seven were operated upon as emergencies, 7 with intra-peritoneal (Group I) and 20 with retro-peritoneal rupture (Group II). Twenty nine underwent elective surgery (Group III). Renal pulmonary and cardiac disease are frequent in octogenarian patients. The surgical repair consisted of 40 knitted bifurcated grafts and 16 aorto-aortic woven grafts. The overall in-hospital mortality rate is high (28.5%: 16 patients) essentially in "emergency" surgery: 71% for the seven Group I patients and 45% for the twenty Group II patients. The in-hospital mortality rate of 6.9% for the Group III of "elective" procedure is higher than the mortality rate of patients of all ages operated on for asymptomatic AAA in our institution which is 4.3%. Once a patient has been operated on successfully his life expectancy tends to parallel that of a normal population for his age group. These results can be improved with preventive measures such as elective surgery for asymptomatic AAA with a diameter of 6 cm or more. Operative contraindications are severe congestive heart failure, advanced pulmonary disease or neoplastic disease. The age "per se" is not a contraindication to aneurysmectomy. Physiologic rather than chronologic age should determine the selection for AAA in the over-80 age group. CT scans and MR are safe fast and non-invasive preoperative examinations for AAA.     

Dissecting aneurysm of the infrarenal abdominal aorta

The aim of this study was to report the case of a patient with chronic dissecting infrarenal abdominal aortic aneurysm (AAA) and to review the literature for this rare vascular disorder. The preoperative assessment, surgical treatment, and postoperative course of a patient with a dissecting AAA and associated left iliac artery dissection were analyzed. The literature is reviewed with respect to etiology and pathogenesis as well as diagnostic and therapeutic management of infrarenal dissecting AAA. The preoperative diagnosis of dissecting infrarenal AAA was made by computed tomography and aortography and confirmed during surgery. Successful repair was accomplished by use of a bifurcated aortobiiliacal Dacron graft. A review of the literature demonstrates the rarity of dissecting aneurysm exclusively involving the infrarenal aortic segment. Primary dissecting aneurysm of the infrarenal abdominal aorta is a rare morphologic finding. Principles of diagnostic and therapeutic management of common atherosclerotic AAA also apply to dissecting AAA.