腹主动脉瘤破裂的诊治近况

随着医学的发展,择期腹主动脉瘤的治疗已取得了令人满意的效果,但腹主动脉瘤破裂（ruptured abdominal aortic aneurysm,RAAA）的救治却仍无重大突破。近期资料表明,开腹治疗腹主动脉瘤破裂的1个月内死亡率高达34．7％～50．5％,腔内介入治疗手术死亡率也达29．9％t”。Banke等也调查发现即使在术后良好的监护治疗下,腹主动脉瘤破裂患者1个月内的死亡率也高达39％。Grant等则通过对过去13年的资料统计,表明住院腹主动脉破裂患者死亡率仍维持不变,手术死亡率达37．8％,     

破裂性腹主动脉瘤诊治流程

破裂性腹主动脉瘤（RAAA）是血管外科领域最凶险的疾病之一,也是腹主动脉瘤病人最严重并发症。RAAA不仅应该得到血管外科医生重视,更应该得到急诊科、护理部、麻醉科、影像科等多学科的重视。应建立以血管外科为中心、多科配合下的快速有效的诊疗流程,以最大程度降低RAAA病人的病死率。诊疗流程中从早期识别诊断、规范化术前处理措施,到合理地选择治疗策略、术中精细化处理,最终到术后并发症的预防与治疗,其中涉及到的每一环节都至关重要。如何提高RAAA病人的救治率,降低其病死率,不仅是血管外科医生应该考虑的问题,同时应获得医院层面上的支持。诊疗流程的制定和执行需要医生和医院层面共同的努力。     

腹主动脉瘤破裂18例救治体会

１８例腹主动脉瘤破裂，１６例经手术治疗。手术方法主要为腹主动脉瘤切除人造血管植入术，围手术期死亡６例（３７５％）。为提高病人生存率，一旦腹主动脉瘤诊断成立，应积极行择期手术治疗。腹主动脉瘤破裂后，正确及时的诊断尤为重要。手术时应注意阻断腹主动脉的方法以及防止术后下肢缺血     

22例破裂腹主动脉瘤临床诊治分析

对2006年8月-2012年3月收治的22例破裂腹主动脉瘤（RAAA）进行回顾性分析。14例在全身麻醉插管下行腹主动脉瘤切除人工血管置换术,其中10例用Y型血管,3例用直筒血管,1例在手术探查中死亡;2例于入院后第2天行腔内支架成型;另外6例中4例因拒绝手术和2例在术前准备过程中死亡。总死亡率为318％（7／22）,手术组死亡率为7．1％0／14）。入院后快速诊断,检查、准备和手术实行“一条龙”式跟随,手术中以快速止血、尽早恢复自身血液循环为目的,手术后积极预防和处理并发症,就可能提高RAAA的救治成功率。     

肾动脉下破裂性腹主动脉瘤的诊治及预后影响因素

破裂性腹主动脉瘤(ruptured abdominal aortic aneurysm，rAAA）是外科最为凶险的疾病之一，死亡率达80％。本文总结我院治疗肾动脉下破裂性腹主动脉瘤的经验，探讨诊疗方案，分析相关因素对预后的影响。     

破裂腹主动脉瘤的外科治疗

目的探讨急诊腹主动脉瘤切除人工血管移植术治疗破裂腹主动脉瘤的经验。方法总结1999年4月至2005年4月外科手术治疗破裂腹主动脉瘤20例，采用钳夹阻断膈下腹主动脉或Foley氏球囊管腔内阻断瘤颈上腹主动脉后行急诊腹主动脉瘤切除人工血管移植术，应用分叉型人工血管12例，直型人工血管8例。结果急诊腹主动脉瘤切除人工血管移植手术30d围手术期死亡率40％（8例），死亡原因包括急性肾功能衰竭4例，多器官功能衰竭2例，呼吸循环衰竭2例。存活12例，术后合并症包括急性肾功能不全、肺部感染、凝血机制障碍和腹泻等共11例，均经治疗后痊愈。随访观察6～60个月，无人工血管血栓形成和感染等并发症以及随访期死亡发生。结论破裂腹主动脉瘤外科手术治疗死亡率仍然很高，早期确定诊断，紧急外科手术治疗，术后加强围手术期管理是降低破裂腹主动脉瘤死亡率的关键。     

腹主动脉瘤破裂的诊断和治疗

我科自1991年1月至1995年12月间共收治有症状的肾下型腹主动脉瘤16例,包括濒临破裂8例,破裂8例,全部手术或彩色超声多普勒确诊。前者全部治愈,后者手术6例仅3例成功。对濒临破裂患者及早手术是防止破裂,降低腹主动脉瘤死亡率的关键,对于直径小于5cm的腹主动脉瘤应行B超或彩色超声多普勒定期检查,了解增长速度。本文对腹主动脉瘤破裂的有关问题予以讨论,对已破裂的腹主动脉瘤,手术治疗是唯一的生存希望。     

破裂腹主动脉瘤的外科救治体会

目的 探讨破裂腹主动脉瘤(RAAA)外科救治经验.方法 回顾性分析1999年4月至2008年12月救治的38例RAAA患者的临床资料,根据病史、体征、急诊彩超和CT快速诊断,行急诊腹主动脉瘤切除人造血管移植手术.结果 均行急诊RAAA切除人造血管移植手术,围手术期死亡10例(26.3%),其中出血性休克昕致急性肾功能衰竭4例,多器官功能衰竭4例,呼吸循环衰竭2例;其他28例患者经治疗后均痊愈出院.结论 快速早期确定RAAA诊断,紧急外科手术治疗,尽快纠正失血昕致内环境紊乱是提高RAAA救治成功的关键.     

腹主动脉瘤破裂急诊手术与非破裂择期手术对比分析

目的总结腹主动脉瘤破裂（ruptured abdominal aortic aneurysm，RAAA）急诊手术的治疗经验。方法回顾性分析25例RAAA急诊救治过程，并与同期完成的48例择期腹主动脉瘤（abdominal aortic aneurysm，AAA）切除术在输血量、ICU住院天数、瘤体最大直径和死亡率等指标分别进行统计分析比较。结果RAAA急诊手术与择期AAA切除术患者比较，围手术期输血量（2980±2712）ml和（580±314）ml；ICU住院天数（6．8±5．7）d和（2．5±1．5）d；手术死亡率32％（8／25）和2．1％（1／48），差异均有统计学意义（P〈0．01）；瘤体直径（5．9±1．4）cm和（5．3±1．4）cm者差异无统计学意义（P〉0．05）；术后并发症有：脑卒中、肾功能衰竭、成人呼吸窘迫综合征和消化道出血。结论AAA一经发现，应选择尽早择期手术，合理的抢救措施有助于降低RAAA手术死亡率。     

腹主动脉瘤破裂的处理及预后分析

目的探讨腹主动脉瘤破裂的处理及影响预后的主要因素。方法回顾性分析12年间收治的42例腹主动脉瘤破裂的临床资料。85．7％的患者术前行影像学检查确诊。36例行手术治疗,其中35例行腹主动脉瘤切除人工血管植入术,术中80％采用肾动脉下腹主动脉阻断, 14．3％采用膈下腹主动脉阻断,5．7％采用Foley尿管球囊阻断（2例）;1例行覆膜支架腔内隔绝术。结果围手术期死亡率45．24％。单因素统计分析表明在围手术期死亡者年龄（72．1±1．0）岁、合并疾病13例和术前收缩压（82±53）mm Hg;存活者年龄（61．5±17．0）岁、合并症7例、术前收缩压（82±28）mm Hg,之间差异有统计学意义（P〈0．05）,而性别、术前Hb、肌酐、瘤体直径和手术失血量则无显著差异（P〉0．05）。结论手术是治疗破裂腹主动脉瘤的惟一有效方法,高龄、合并其他疾病和休克提示预后不良。     

腹主动脉瘤破裂的危险因素及影像学研究进展

腹主动脉瘤（AAA）是一种临床上较常见的致死性主动脉疾病。AAA破裂与多种因素有关,如动脉瘤大小、形态、血栓形成以及血流动力学变化等。有研究表明,血流动力学变化可能为AAA破裂的主要影响因素之一。AAA有多种影像学检查方法,其中超声多普勒及磁共振血流成像技术可以对AAA的血流动力学变化进行评价。本文就AAA破裂的危险因素和影像学研究进展进行综述。     

形态及生物力学特征评价腹主动脉瘤破裂风险的研究进展

腹主动脉瘤（AAA）是一种常见的致死性主动脉疾患。AAA破裂是多因素参与的过程,包括复杂的生理、病理、生化变化及形态学和生物力学因素影响。本文就近年来从形态学及生物力学角度评价AAA破裂风险的研究进展进行综述。     

腹主动脉瘤破裂行腔内修复术1例

患者女,80岁,因急性脑梗死伴腹痛9h入院。查体:下腹部左侧触及6～7cm搏动性包块,右侧中枢性面瘫,右上肢肌力0级,疼痛刺激无反应,右下肢外旋,可屈曲,无自主运动;左侧肢体肌力Ⅳ级,左侧Babinski征阳性,右侧病理征未引出。既往有糖尿病、高血压及腹主动脉瘤病史。     

Changes in laboratory values and their relationship with time after rupture of an abdominal aortic aneurysm

Purpose  Many laboratory values are abnormal after surgery for a ruptured abdominal aortic aneurysm (RAAA). However, these changes have not been comprehensively evaluated. We analyzed the changes in routine laboratory values and how these changes related to outcome in a consecutive series of RAAA patients. Methods  All patients who underwent surgery for an RAAA between January 1990 and June 2003 at our hospital were included in this study. We analyzed laboratory data acquired during the first week for all patients and at discharge for survivors. We categorized 29 different measurements into six categories based on the related pathological process, including hematology and coagulation, metabolism, systemic inflammation, renal function, liver function, and electrolytes. Results  A total of 290 patients underwent RAAA surgery, with a hospital mortality of 34%. Hemorrhage was the most common cause of early death, whereas multiple-organ failure (MOF) was the most common cause of death several days after surgery. Most laboratory values deviated from normal at multiple time points and they differed significantly between survivors and nonsurvivors. Conclusions  Both survivors and nonsurvivors of RAAA surgery displayed characteristic time-dependent laboratory abnormalities. Awareness of these responses may help us predict patients prone to complications.     

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目的 探讨腹主动脉瘤切除术中常规应用Baxter球囊导管暂时阻断髂动脉，防止下肢动脉栓塞并发症发生的有关问题。方法 对2001年10月至2002年4月应用Baxter阻断球囊导管行标准的腹主动脉瘤切除术25例，对其围手术期并发症作一总结。结果 围手术期除1例于术后第3天死于广泛心肌梗死之外，其余病例无一发生下肢动脉栓塞并发症。结论 术中常规应用Baxter阻断球囊导管具有易于手术操作，有效防止下肢缺血等优点，有助于进一步完善经典的腹主动脉瘤手术，对于国内开展该术式有一定借鉴。     

A systematic review summarizing local vascular characteristics of aneurysm wall to predict for progression and rupture risk of abdominal aortic aneurysms

ObjectiveAt present, the rupture risk prediction of abdominal aortic aneurysms (AAAs) and, hence, the clinical decision making regarding the need for surgery, is determined by the AAA diameter and growth rate. However, these measures provide limited predictive information. In the present study, we have summarized the measures of local vascular characteristics of the aneurysm wall that, independently of AAA size, could predict for AAA progression and rupture.MethodsWe systematically searched PubMed and Web of Science up to September 13, 2021 to identify relevant studies investigating the relationship between local vascular characteristics of the aneurysm wall and AAA growth or rupture in humans. A quality assessment was performed using the ROBINS-I (risk of bias in nonrandomized studies of interventions) tool. All included studies were divided by four types of measures of arterial wall characteristics: metabolism, calcification, intraluminal thrombus, and compliance.ResultsA total of 20 studies were included. Metabolism of the aneurysm wall, especially when measured by ultra-small superparamagnetic iron oxide uptake, and calcification were significantly related to AAA growth. A higher intraluminal thrombus volume and thickness had correlated positively with the AAA growth in one study but in another study had correlated negatively. AAA compliance demonstrated no correlation with AAA growth and rupture. The aneurysmal wall characteristics showed no association with AAA rupture. However, the metabolism, measured via ultra-small superparamagnetic iron oxide uptake, but none of the other measures, showed a trend toward a relationship with AAA rupture, although the difference was not statistically significant.ConclusionsThe current measures of aortic wall characteristics have the potential to predict for AAA growth, especially the measures of metabolism and calcification. Evidence regarding AAA rupture is scarce, and, although more work is needed, aortic wall metabolism could potentially be related to AAA rupture. This highlights the role of aortic wall characteristics in the progression of AAA but also has the potential to improve the prediction of AAA growth and rupture.     

肾下腹主动脉瘤的外科治疗

目的总结肾下腹主动脉瘤(AAA)的手术治疗经验。方法回顾性分析1999年7月至2011年10月行开腹手术治疗的91例肾下AAA患者的临床资料。84例接受择期手术,7例行急诊手术。结果 1例AAA破裂急诊手术患者因失血性休克、弥散性血管内凝血于术中死亡,1例破裂急诊手术患者术后1周因多脏器功能衰竭死亡,1例择期手术患者术后第3日因急性大面积心肌梗死而死亡。82例患者获得随访,平均随访时间5.1年,术后3年死于心肌梗死及脑梗死各1例;其余患者常规性腹部及血管彩超检查,其中远端吻合口闭塞2例,肠梗阻2例,未发现吻合口假性动脉瘤等其它并发症。结论开腹手术治疗AAA效果确切,因手术技巧、麻醉及术后监护水平等的提高,死亡率较低。     

Conservative treatment for rupture of thoracic aortic aneurysm

We present a case of an 88-year-old female with a history of tuberculosis, who was transferred to our hospital due to the sudden onset of epigastralgia and back pain. A chest X-ray demonstrated a bilateral shadow of the upper lung, which suggested the history of tuberculosis. A computed tomography scan demonstrated a large amount of hematoma from the neck to mediastinum and leakage of contrast medium around the distal aortic arch. We diagnosed rupture of thoracic aortic aneurysm, and selected conservative treatment. The patient was intubated under sedation and blood pressure was controlled with vasodepressors. The patient was completely off the ventilator after 65 days of disease, and the patient was discharged after 4 months. This is the first successful case of conservative therapy for ruptured thoracic aortic aneurysm.     

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应用跨肾动脉支架人工血管腔内修复术治疗腹主动脉瘤,并探讨其手术适应证,操作要点及并发症的预防。方法对２例病人采用全麻,在动态数字减影血管造影监测下用跨肾动脉支架分叉型人工血管对腹主动脉瘤进行了腔内修复术,结果手术中ＤＳＡ提示动脉瘤消失,无内漏发生。术后１周及分别随访３和９个月,螺旋ＣＴ检查提示腔内人工血管无移位扭曲,血流通畅无内漏发生,结论腹主动脉瘤腔内修复术手术创伤小,病人恢复快,跨肾动支架人工     

Racial disparities in treatment of ruptured abdominal aortic aneurysms

ObjectiveThe Society for Vascular Surgery has recommended immediate transfer of patients with ruptured abdominal aortic aneurysms (rAAAs) to a regional center when feasible. However, Black patients might be less likely to be transferred and more likely to be turned down for repair. We, therefore, examined the transfer rates, turndown rates, and outcomes for Black vs White patients presenting with rAAAs in two large databases.MethodsWe examined all rAAA repairs in the Vascular Quality Initiative from 2003 to 2020 to evaluate the transfer rates and outcomes for Black vs White patients. We used the National Inpatient Sample from 2004 to 2015 to examine the turndown rates. Mixed effects logistic regression, Cox regression, and marginal effects modeling were used to study the interaction between race, insurance status, surgery type (open repair vs endovascular aortic aneurysm repair), and hospital volume.ResultsWe identified 4935 patients with rAAAs in the Vascular Quality Initiative (6.2% Black) and 48,489 in the National Inpatient Sample (6.0% Black). The rates of transfer were high; however, Black patients were significantly less likely to undergo transfer before repair compared with White patients (49% Black vs 62% White; P = .002). The result was consistent in both crude and adjusted analyses when considering only stable patients and was not modified by insurance status, surgery type, or hospital volume. No significant differences were found in perioperative mortality (22% vs 26%; P = .098) or complications (52% vs 52%; P = .64). However, Black patients were significantly more likely to be turned down for repair (37% vs 28%; odds ratio, 1.5; 95% confidence interval, 1.2-1.9; P < .001). A significant interaction was found between race and insurance status with respect to turndown. Patients with private insurance had undergone surgery at a similar rate, regardless of race. However, among patients with Medicare or Medicaid/self-pay, Black patients were less likely than were White patients to undergo repair (Medicare, 64% vs 72%; P = .001; Medicaid/self-pay, 43% vs 61%; P = .031). Patients with Medicaid/self-pay were also less likely to undergo repair than were patients of the same race with either Medicare or private insurance (P < .05).ConclusionsWe found that Black patients with rAAAs are poorly served by the current systems of interhospital transfer in the United States, because they less often undergo transfer before repair. Although the postoperative outcomes appeared similar, this finding could be falsely optimistic, because Black patients, especially the underinsured, were turned down for repair more often even after adjustment. Significant work is needed to better understand the reasons underlying these disparities and identify the targets to improve the care of Black patients with rAAAs.