腹主动脉瘤的治疗

目的 探讨腹主动脉瘤(AAA)的治疗方法。方法 回顾性分析26例AAA的临床资料。结果 26例中夹层动脉瘤3例，真性动脉瘤21例，动脉瘤破裂后再形成的假性动脉瘤1例，动脉瘤穿破十二指肠空肠曲形成腹主动脉肠瘘1例。病变累及肾动脉平面以上者3例，肾动脉平面以下者23例：病变仅累及腹主动脉者4例，病变除累及腹主动脉外，尚合并有单侧或双侧髂总动脉瘤者／2例，合并双侧髂总动脉瘤及一例或双侧髂内动脉瘤者5例，合并一侧髂总、髂内、髂外动脉瘤1例，合并有双侧髂总、髂内、髂外动脉瘤1例。施行紧急手术治疗3例，择期手术治疗14例，施行支架型人工血管腔内微创治疗7例，未手术2例。术后发生并发症3例，无瘫痪、下肢动脉栓塞等发生。术中及术后30d死亡率为3．8％(1例)。支架型人工血管治疗的7例无漏血、移位等并发症发生，均痊愈出院。22例随访3个月至4年，均存活良好。结论 AAA的腔内血管外科治疗具有创伤小，术石恢复快，并发症少等优点，有条件行支架型人工血管作腔内治疗的应优先考虑腔内治疗，传统手术方法在技巧等方面的改进有利于提高手术的成功率，并能为不具备腔内治疗条件的患者解除疾患。     

腔内治疗腹主动脉瘤合并双髂总动脉瘤的疗效分析

目的总结腹主动脉瘤合并双髂总动脉瘤的腔内治疗经验。方法总结2016年4月至2018年11月新疆维吾尔自治区人民医院18例接受腹主动脉腔内修复术(EVAR)的腹主动脉瘤合并双髂总动脉瘤患者。其中6例双侧髂总动脉直径18～25 mm,选择合适口径的髂动脉分支支架完成传统EVAR;9例双侧髂总动脉直径≥25 mm,选择双侧髂外动脉作为锚定区完成EVAR,并行髂总动脉直径较大侧或合并髂内动脉瘤样变侧进行髂内动脉弹簧圈栓塞术;3例双侧髂总动脉直径≥25 mm,选择双侧髂外动脉作为锚定区完成EVAR,并行三明治技术单侧髂内动重建。结果腔内手术均获得成功,手术时间(120±35)min,出血量(100±40)ml。术中无即刻Ⅰ型内漏出现。1例双侧髂外动脉作为锚定区治疗患者术后发生臀肌缺血症状;3例三明治技术单侧髂内动重建患者中,1例髂内动脉Ⅱ型内漏发生,1例髂内动脉闭塞。术后随访3～32个月,平均10.3个月,无动脉瘤破裂,髂动脉直径无明显扩张。结论腹主动脉瘤合并双髂总动脉瘤患者根据髂总动脉直径选择合适的腔内治疗方法可达到理想的治疗效果,重建髂内动脉与否术后生活质量无明显差异。     

双套腹主动脉分支支架对腹主动脉瘤合并双侧髂动脉瘤的近期疗效

<正>腹主动脉瘤(abdominal aortic aneurysm,AAA)是由于腹主动脉退行性变而产生的动脉瘤样扩张,主动脉腔内修复术(endovascular aneurysm repair,EVAR)已成为腹主动脉瘤(abdominal aortic aneurysm,AAA)的主要治疗方式,11%～12%的AAA合并双侧髂总动脉瘤(common iliac aneurysm,CIA)^[1]。     

带髂内分支支架的腔内隔绝术治疗腹主动脉瘤伴双髂动脉瘤

目的探讨带髂内分支支架的腔内隔绝技术在腹主动脉瘤伴双髂动脉瘤治疗中的应用。方法回顾性分析2011年6月～2012年6月我院收治的10例腹主动脉瘤合并双髂动脉瘤患者的临床资料。患者均于术前行CT血管造影(CTA)检查,腹主动脉瘤均为肾下型;髂动脉瘤仅累及髂总动脉8例,累及髂内动脉开口处2例。手术先置入带髂内分支的髂动脉带膜支架,再置入腹主动脉瘤的分叉型带膜支架。结果患者均一次手术成功,无死亡。9例患者获得随访,随访时间3～6个月,患者腹部搏动性肿块均消失,均未出现臀部、骶尾部坏死,无明显性功能障碍,1例出现臀部的轻度间歇性跛行。8例术后3个月行腹主、双髂动脉彩超检查,未见明显内瘘,移植的髂内分支支架血流通畅。3例术后6个月行腹主、双髂动脉CTA检查,未见Ⅰ型、Ⅲ型内瘘,髂内分支支架内血流通畅。结论带髂内分支支架的腔内隔绝技术在腹主动脉瘤伴双髂动脉瘤的治疗中是安全、有效的;可以有效地保留一侧髂内动脉,减少或避免因髂内动脉封闭而带来的并发症。     

一体式覆膜支架在腹主动脉腔内修复中的应用

目的:总结一体式覆膜支架在腹主动脉以及髂动脉病变中的应用效果。方法:回顾性分析应用一体式腹主动脉覆膜支架腔内修复腹主动脉瘤15例、髂动脉瘤5例及腹主动脉或髂动脉夹层5例的临床资料。结果:平均时间42.4 min,手术成功率100%(25/25)。术后无I、III型内漏,发生髂动脉血栓形成1例,围术期无死亡病例。随访3~16个月复查无动脉瘤复发和II型内漏。结论:一体式覆膜支架是腹主动脉瘤和夹层动脉瘤腔内治疗方法的一种较好选择,具有快速、简单、有效的优点;其远期疗效需进一步观察。     

应用一体式分叉支架型人工血管腔内治疗腹主动脉瘤42例

目的总结应用一体式分又支架型人工血管治疗腹主动脉瘤初步经验。方法本组42例，其中腹主动脉瘤39例，腹主动脉假性动脉瘤1例，Ⅲ型夹层动脉瘤1例，降主动脉瘤合并腹主动脉瘤1例。除均在腹主动脉放置一体式分又支架型人工血管外，1例降主动脉瘤合并腹主动脉瘤者共放置5枚支架型人工血管，其中4枚直型支架用于隔绝降主动脉瘤；1例Ⅲ型夹层动脉瘤者，降主动脉近侧破口用直型支架型人工血管封堵；1例因一侧髂外动脉闭塞需先经腹膜外切口行人工血管搭桥后才能放置一体式分叉支架。结果平均手术时间50min。1例死亡，8例附加近侧短的覆膜支架，1例附加远侧Cuff，1例近侧和远侧均加Cuff。8例术后有少量内漏，1周后内漏均消失。5例封堵了双侧髂内动脉，20例封堵了单侧髂内动脉，但均未导致臀肌坏死或疼痛等并发症。2例瘤颈与瘤体呈90度角也获得成功。结论一体式分又支架型人工血管可以达到隔绝腹主动脉瘤的作用，且操作更快捷。     

腹主动脉瘤的诊断和治疗体会

作者报道自1996年11月以来,手术治疗4例腹主动脉瘤的体会。4例中,胸腹主动脉瘤、腹主动脉瘤破裂并十二指肠瘘、腹主动脉瘤+双髂总动脉瘤、腹主动脉瘤+双髂总动脉瘤+双髂内动脉瘤+双股动脉瘤各1例。作者总结了有关腹主动脉瘤的临床诊断,CT、DSA对腹主动脉瘤的诊断意义,以及手术方式选择的初步体会。     

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     

腔内修复术中应用Viabahn支架重建肠系膜下动脉——2例报告

2015年5~12月我科行主动脉腔内修复术(endovascular aortic repair,EVAR)治疗腹主动脉瘤(abdominal aortic aneurysm,AAA),同期应用Viabahn支架重建肠系膜下动脉(inferior mesenteric artery,IMA)2例。1例肾下型AAA合并双髂总动脉瘤样扩张,Riolan动脉弓形成,行EVAR治疗AAA,同期采用"烟囱"技术IMA内植入Viabahn支架成功,术后3个月随访复查CTA示支架位置良好,瘤体隔绝成功,Viabahn支架通畅。1例右侧髂总动脉巨大动脉瘤,行EVAR治疗髂总动脉瘤,髂内动脉弹簧圈栓塞,IMA内植入Viabahn支架成功,术后6个月随访复查CTA示支架位置良好,瘤体隔绝成功,Viabahn支架通畅。我们认为复杂AAA应用Viabahn支架合理重建IMA预防肠缺血,简化手术操作,近期疗效满意。     

高危复杂腹主动脉瘤腔内修复术临床分析

目的 评估应用多种腔内技术治疗高危复杂腹主动脉瘤的可行性.方法 2001年1月至2010年12月,共138例腹主动脉瘤患者接受腹主动脉腔内修复术(EVAR),其中9例患者为高危复杂性腹主动脉瘤.男性8例,女性1例,年龄26～87岁,平均67岁.其中2例近肾腹主动脉假性动脉瘤,5例近肾腹主动脉瘤,1例腹主动脉瘤合并双髂总动脉瘤及左侧髂内动脉瘤,1例EVAR术后右髂内动脉瘤.所采用的腔内技术包括:主动脉支架开窗技术和扇形技术2例,烟囱技术5例,球囊辅助下髂内动脉瘤腔内治疗1例和球囊辅助反转支架技术1例.结果 所有腔内技术均获得成功.术中支架释放后即刻发现内漏4例,其中1例患者为Ⅰ型和Ⅲ型内漏,经大动脉球囊扩张后内漏消失;2例Ⅰ型内漏,其中1例行弹簧栓栓塞成功,另1例行近端裸支架成功.1例Ⅱ型内漏,经随访瘤腔直径未增大,未处理.随访4～79个月,平均25.9个月.无动脉瘤破裂,动脉瘤瘤体直径均有不同程度的缩小.随访过程中7例患者的靶血管(肾动脉、肠系膜上动脉和髂内动脉)均保持通畅.1例髂内动脉重建支架术后18个月血栓形成,但无盆腔缺血等症状.结论 对于不能耐受手术的高危复杂腹主动脉瘤患者,选择合适的腔内技术可以增加EVAR术的成功率,近、中期效果满意.     

Surgical access of the gluteal artery to embolize a previously excluded, expanding internal iliac artery aneurysm

We describe open exposure of the inferior gluteal artery to allow coil embolization on an enlarging internal iliac artery aneurysm after previous abdominal aortic aneurysm (AAA) repair. An 84-year-old man with a stoma had undergone open AAA repair surgery 8 years previously, during which the proximal aortic neck and both proximal external iliac arteries were ligated, followed by an aorta to right external iliac and left common femoral bypass. Eight years later, he complained of abdominal pain, and a computed tomographic (CT) scan revealed persistent flow in the right internal iliac artery with enlargement to 8 cm in diameter. Because prograde access to the internal iliac artery was not possible as a result of the previous exclusion, the inferior gluteal artery was exposed surgically. Coil embolization of the arteries supplying the internal iliac artery aneurysm was successfully performed. The AAA and internal iliac artery aneurysm were treated by the exclusion technique. Eight years after the operation, CT revealed that the iliac artery had expanded to approximately 8 cm in diameter. The patient was placed face down, and a catheter was directly inserted into the internal iliac artery from the inferior gluteal artery. Four embolization coils were placed in the internal iliac artery and its branches. Absence of blood flow and shrinkage of the aneurysm were subsequently confirmed in the aneurysm, as shown by echogram color duplex scanning and CT scanning at 1 year. This technique could also be applicable for persistent blood flow in an internal iliac aneurysm after endovascular AAA repair, and the size of the aneurysm was reduced to approximately 1 cm 1 year after the operation.     

Endovascular Aneurysm Repair or Open Surgery for Treatment of Abdominal Aortic Aneurysm with Involvement of Both Common Iliac Arteries ?

Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) involving the entire common iliac arteries requires proximal coil embolisation of both internal iliac arteries and extension of the stent graft into the external iliac arteries (type E according to the Eurostar classification). A potential complication of this treatment is pelvic ischemia. Therefore, this type of aneurysm is a relative contra-indication for EVAR.

In this case-report we describe a hybrid procedure preserving antegrade circulation in one of the internal iliac arteries in a patient with a type E aneurysm who was unfit for open surgery.     

Internal iliac artery revascularization as an adjunct to endovascular repair of aortoiliac aneurysms.

PURPOSE: Endovascular repair of aortoiliac aneurysms may be limited by extension of the aneurysm to the iliac bifurcation, necessitating endpoint implantation in the external iliac artery. In such cases the circulation to the internal iliac artery is interrupted. Bilateral internal iliac artery occlusion during endovascular repair may be associated with significant morbidity, including gluteal claudication, erectile dysfunction, and ischemia of the sigmoid colon and perineum. We have employed internal iliac artery revascularization (IIR) to allow endograft implantation in the external iliac artery while preserving flow to the internal iliac artery in patients with aneurysms involving the iliac bifurcation bilaterally. METHODS: A total of 11 IIR procedures were performed in 10 patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (9 men, 1 woman; mean age, 74 years). IIR was accomplished via a retroinguinal incision in 9 cases and a retroperitoneal incision in 2 cases. Six-mm polyester grafts were used for external-to-internal iliac artery bypass in 10 cases and internal iliac artery transposition onto the external iliac artery was used in one case. Endovascular AAA repair was performed using a modular bifurcated device (Talent-LPS, Medtronics, Minneapolis, Minn) after IIR. Bypass graft patency was determined immediately after the surgery, at 1 month, and every 3 months thereafter, using duplex ultrasound scanning and computed-tomography angiography. Mean aneurysm diameters were as follows: AAA, 6.4 +/- 0.7 cm; ipsilateral common iliac, 3.7 +/- 1.0 cm; contralateral common iliac, 3.9 +/- 0.8 cm. RESULTS: Successful IIR and endovascular AAA repair were accomplished in all cases. No proximal, distal, or graft junction endoleaks occurred. Two patients demonstrated retrograde aneurysm side-branch endoleaks originating from the lumbar arteries. One thrombosed spontaneously within 3 months. One perioperative myocardial infarction occurred. Reduction in aneurysm size was documented in 5 aortic, 5 ipsilateral iliac, and 3 contralateral iliac aneurysms. Gluteal claudication, erectile dysfunction, colon and perineal ischemia, and mortality did not occur. All IIRs have remained patent during a follow-up period of 4 to 15 months (mean, 10.1 months). CONCLUSIONS: IIR may be used with good short-term to intermediate-term patency to prevent pelvic ischemia in patients whose aneurysm anatomy requires extension of the endograft into the external iliac artery. This may allow endovascular AAA repair to be performed in patients who might otherwise be at risk for developing complications associated with bilateral internal iliac artery occlusion.     

腹主动脉瘤腔内修复术中特殊远端锚定区的处理策略

目的 探讨对腹主动脉瘤腔内修复术(EVAR)中特殊远端锚定区的评估及处理方法.方法 回顾性分析2007年1月至2010年12月应用EVAR治疗的66例复杂远端锚定区腹主动脉瘤患者的临床资料.其中男性45例,女性21例,年龄53～87岁,平均62岁.本组Ⅰ型及ⅡA型病例共20例,其中髂总或髂外动脉＞50％狭窄10例,髂总或髂外动脉严重扭曲者6例,合并以上情况者4例;双髂总合并髂内动脉瘤46例(单侧32例,双侧14例).支架血管移植物采用Medtronic 46例,COOK 14例,Microport 4例,Lifetech 2例.结果 平均手术时间90 min,术中移植物明显短缩22例(33.3％),Ⅱ型内漏18例(18/66,27.3％),Ⅲ型内漏5例(7.6％),髂支＞50％的狭窄2例(3.0％),同时合并Ⅱ、Ⅲ型内漏5例(7.6％),同时合并髂支狭窄及Ⅲ型内漏4例(6.1％).本组随访时间3～36个月,平均22个月,随访期间内移植物向远端移位2例(3.0％),移位均＜10 mm,髂支再狭窄(＞50％)2例,Ⅱ型内漏自行消失18例(18/23,78.3％),Ⅲ型内漏0例;死亡2例.结论 复杂远端锚定区增加了EVAR并发症发生率.熟悉移植物特性,合理应用处理策略,可提高EVAR技术成功率.     

国人腹主动脉瘤累及髂动脉的解剖学特征与髂动脉分支支架适用性：单中心58例分析

目的:通过单中心临床调查,分析腹主动脉瘤(AAA)累及髂动脉国人患者的髂动脉解剖学特点与髂动脉分支支架(IBD)适用性的关系。方法:回顾性分析2015年7月—2017年3月复旦大学附属中山医院血管外科58例累及双侧或单侧髂总动脉的AAA患者,利用3D工作站分析其影像学资料,并进行相关数据测量分析,结合基于解剖特点的使用标准,分析两款IBD(Cook IBD,Gore IBE)在患者中的适用性及其限制因素。结果:58例AAA患中,49例累及双侧髂总动脉,9例累及单侧髂总动脉。病变髂总动脉的平均长度分别为左侧(57.9±18.1)mm,右侧(56.7±17.4)mm,平均最大直径分别为左侧(17.7±7.2)mm,右侧(25.1±9.4)mm。根据两款支架使用标准,Cook IBD与Gore IBE治疗病变髂动脉的适用比率分别为26.1%(28/107)、20.6%(22/107)。Cook IBD最主要的限制因素是髂内动脉直径6或9 mm(50/107,46.7%);Gore IBE最主要的限制因素是髂总动脉直径25 mm(67/107,62.6%)。结论:基于解剖标准的IBD在AAA累及髂动脉国人患者中适用性较低,髂总动脉和髂内动脉直径的不符合是其主要限制因素。     

External iliac artery-to-internal iliac artery endograft: a novel approach to preserve pelvic inflow in aortoiliac stent grafting.

PURPOSE: To describe four patients with abdominal aortic aneurysm and bilateral common iliac artery aneurysms repaired by coil embolization of the ipsilateral internal iliac artery, aortouniiliac endograft extended to the ipsilateral external iliac artery, femorofemoral bypass grafting, and a contralateral external iliac to internal iliac stent graft to preserve pelvic perfusion. METHODS: Four patients with multiple risk factors, abdominal aortic aneurysm (mean diameter, 6.6 cm), and bilateral common iliac artery aneurysms were evaluated with contrast-enhanced computed tomography scanning, arteriography, and intravascular ultrasonography. Aortobiiliac endovascular abdominal aortic aneurysm repair was not feasible because of extension of the common iliac artery aneurysms to the iliac bifurcation bilaterally. RESULTS: The abdominal aortic aneurysms were repaired with an aortouniiliac endograft. The ipsilateral common iliac artery aneurysms were treated by coil embolization of the internal iliac artery and extension of the endograft to the external iliac artery. The contralateral common iliac artery aneurysms were excluded by a custom-made stent graft (n = 2) or a commercial stent graft (n = 2) from the external iliac artery to the internal iliac artery, which preserved pelvic inflow via retrograde perfusion from the femorofemoral bypass. Mean length of stay was 3.5 days. One patient had hip claudication. Follow-up (mean 10 months, range 6 to 17) demonstrated exclusion of the abdominal aortic aneurysm and common iliac artery aneurysms with no endoleak and patent external iliac artery-to-internal iliac artery endografts in all patients. CONCLUSION: Patients with bilateral common iliac artery aneurysms that extend to the iliac bifurcation may be excluded from endovascular abdominal aortic aneurysm repair because of concerns regarding pelvic ischemia after occlusion of both internal iliac arteries. External iliac artery-to-internal iliac artery endografting is a feasible alternative to maintain pelvic perfusion and still allow endograft repair of the abdominal aortic aneurysm in these patients.     

Morphological study of abdominal aortic aneurysm: optimal stent-graft size for Japanese patients.

PURPOSE: We report on the optimal stent-graft (SG) size for Japanese patients with abdominal aortic aneurysm (AAA). MATERIALS AND METHODS: Ninety three Japanese patients undergoing elective AAA repair were selected for this study. The parameters measured were the proximal neck (PN) diameter (D1), the diameter of the right and left common iliac arteries (D2 and D3, respectively), the diameter of the right and left external iliac arteries (D4 and D5, respectively), the distance between the lowest renal artery and the common iliac arterial bifurcation (L1), and the distance between the right and left common iliac arterial bifurcations and the internal iliac arterial bifurcation (L2 and L3, respectively). RESULTS: The following results were obtained: D1: 20.7+/-3.9 mm (14 to 28 mm); D2: 14.0+/-3.0 mm (9.5 to 20 mm); D3: 13.8+/-3.1 mm (9 to 19.5 mm); D4: 7.5+/-1.0 mm (6 to 10 mm); D5: 7.4+/-0.9 mm (6 to 10 mm); L1: 107.7+/-13.4 mm (80 to 130 mm); L2: 40.0+/-10.1 mm (20 to 61 mm); L3: 39.7+/-9.6 mm (20 to 60 mm). CONCLUSION: The results indicate the necessity of exercising adequate care when selecting a device for Japanese patients.     

胸主动脉夹层合并腹主夹层动脉瘤的一期腔内治疗

目的：探讨胸主动脉夹层动脉瘤合并腹主动脉夹层动脉瘤病人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。方法和结果：1例Stanford B型胸主动脉夹层动脉瘤合并腹主动脉夹层动脉瘤及双侧髂动脉瘤的病人于2006年3月在本中心接受了腔内隔绝术。MRA检查提示．主动脉弓降交界处开始出现夹层．真腔受压变窄,以胸腹交界处及腹主动脉中段最明显,最扁窄处为0．5cm;假腔在腹主动脉中段明显,最大径约5．0cm,假腔再人口位于左髂总动脉近端。双侧髂总动脉迂曲并呈瘤样扩张。腹腔干、肠系膜上动脉及双侧肾动脉均发自真腔。手术在全麻下进行：降主动脉植入规格为34-34-100mm的直管型Talent移植物,封闭夹层裂口：腹主动脉植入规格为AOI26-12-170mm Talent移植物,远端连接12．12．68mmTalent移植物至一侧髂外动脉,行双侧股-股转流。瘤体隔绝完全,手术约耗时300min,失血1000ml,透视6min,使用威视派克450ml。术后21d出院。术后随访半年,病人生活质量良好,复查CTA显示：移植物通畅,瘤腔内均完全形成血栓。结论：腔内隔绝术的微创特点使一期治疗Stanford B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。主动脉长段隔绝也有利于降低截瘫的发生率。