内脏动脉瘤诊治经验

目的　探讨内脏动脉瘤的诊断和治疗方法。方法　对 71例内脏动脉瘤的诊断和治疗进行回顾性总结。结果　 71例内脏动脉瘤中包括脾动脉瘤 2 2例 ,肝动脉瘤 16例 ,腹腔干动脉瘤 4例 ,胃、胰十二指肠动脉瘤 13例 ,肠系膜上、下动脉瘤分别为 6例和 1例 ,网膜动脉瘤 3例 ,肾动脉瘤 6例。本组自发性破裂大出血 2 9例 ,其中破裂入胆道 14例 ,上消化道 10例 ,腹腔及腹膜后 5例。术前经内脏动脉造影确诊 (包括DSA) 4 2例 ,螺旋CT血管造影 (SCTA)证实 14例 ,经核磁共振血管造影 (MRA)确诊 4例。手术治疗 5 8例 ,死亡 9例 ;动脉栓塞治疗 7例。结论　内脏动脉瘤术前临床诊断极为困难。DSA、SCTA和MRA具有诊断价值。一旦确诊 ,应尽早手术治疗。     

脾动脉瘤27例诊治分析

目的 探讨脾动脉瘤的早期诊断和治疗方法。方法 对1957年9月－2000年6月诊治的27例脾动脉瘤作一回顾性分析。结果 27例脾动脉瘤中伴动脉粥样硬化12例,门静脉高压症9例,胰腺炎2例,外伤2例,肌纤维发育不良及细菌性心内膜炎所致各1例。发生自发性破裂大出血4例（14．8％）。术前20例经彩超及彩色多普勒血流显像（CDFI）检查初步确诊16例;5例经螺旋CT血管造影（SCTA）、5例经选择性内脏动脉造影、5例数字减影血管造影（DSA）、例经磁共振血管造影三维重建（3D MRA）而确诊;术前依靠临床表现获诊断仅1例;11例经手术探查确诊。本组行包括胰尾脾的脾动脉瘤切除术11例,脾动脉瘤切除加脾动脉重建术6例,脾动脉瘤切除术未重建脾动脉3例,动脉瘤近远端脾动脉结扎术3例,介入栓塞术4例。无死亡病例。结论 重视和警惕脾动脉瘤的可能并通过CDFI、SCTA、3D MRA及DSA等影象技术对脾动脉瘤作出早期诊断;一旦确诊应根据病情微创、安全、有效的腔内介入栓塞治疗或尽早手术。     

腹腔脏器动脉瘤破裂致上消化道大出血23例报告

腹腔脏器动脉瘤急性破裂引起上消化道出血极为罕见。该院３０多年来收治２３例，１２例为肝动脉瘤，９例胃十二指肠和胰十二指肠动脉瘤，肠系膜上动脉及其分支动脉瘤各１例。其中动脉瘤破裂入胆道内致出血１３例，而破裂入胃、上段空肠致出血者１０例。术前确诊困难，唯选择性腹腔动脉和（或）肠系膜上动脉造影最有价值。本组１５例术前由选择性动脉造影确诊。１６例经手术治疗，术后６例死亡。经动脉栓塞治疗３例。预后取决于动脉瘤     

腹腔干动脉瘤九例的诊断与治疗

目的 探讨腹腔干动脉瘤的诊断与治疗方法。方法 回顾总结9例腹腔干动脉瘤的诊治情况。结果 本组腹腔干动脉瘤9例,位于起始部2例。主干2例,分叉处5例,术前经CTY下实5例,行磁共振造影（MRA）检查证实2例,数字减影动脉造影（DSA）证实5例,均予手术治疗,其中肝动脉重建例,肝动脉及脾动脉结扎、脾切除2例,腹腔干重建4例,本组围手术期无死亡。结论 腹腔干动脉诊断一旦明确,应尽早手术治疗,行腹腔干或肝动脉重建术是最佳的手术方式。     

脾动脉瘤11例诊治分析

目的 总结11例脾动脉瘤的临床治疗经验。方法 2001-2014年本院共收治11例脾动脉瘤患者,对其治疗方法及预后等临床资料进行回顾性分析。结果11例中术前经彩超及彩色多普勒血流显像（CDFI）检查初诊9例。4例经螺旋CT血管造影、4例经数字减影血管造影（DSA）、1例经磁共振血管造影三维重建而确诊,剖腹探查确诊2例。本组3例行包括胰尾脾的脾动脉切除术,2例行动脉瘤远近端脾动脉结扎术,1例行脾切除术,1 例行脾动脉瘤切除+脾动脉重建术,4 例行介入栓塞术。11 例随访7 个月至3 年,均获治愈。无死亡及严重并发症。结论 脾动脉瘤发病率低,症状不典型,一旦破裂有致死的危险,手术及介入治疗预后均良好。     

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目的总结9例脾动脉瘤的临床治疗经验。方法1999年12月至2003年3月上海第二医科大学附属仁济医院经多普勒B超、CT、数字减影血管造影术(DSA)或磁共振成像(MRI)检查9例病人术前确诊为脾动脉瘤。手术方法包括动脉瘤体近远端动脉结扎术2例，动脉瘤切除脾动脉重建2例，动脉瘤切除、动脉瘤-门静脉内瘘关闭、脾切除1例，动脉瘤伴胰体尾部切除加脾切除4例。结果随访5个月至3年所有病人均手术治愈。无死亡及严重并发症。随访期间无动脉瘤复发或上消化道出血，腹水消失。结论脾动脉瘤一般起病隐匿．很少有临床症状。选择性内脏动脉造影最具有诊断价值。手术切除是脾动脉瘤最可靠的治疗方法，由于动脉瘤有破裂可能，有症状的脾动脉瘤是手术治疗的绝对指征。     

脾动脉瘤7例诊治分析

目的：探讨脾动脉瘤的诊断和手术治疗方法。方法：回顾性分析7 例脾动脉瘤患者的临床资料。结果：6例经彩色多普勒超声（B超）初步诊断;4例经CT动脉造影（CTA）,2例经数字减影血管造影术（DSA）,1例经磁共振造影（MRA）确诊;无1例依靠临床症状而确诊。单纯脾动脉瘤切除术1例,脾动脉瘤加脾脏切除术1例,脾动脉瘤切除加动脉重建术1例,动脉瘤近远端脾动脉结扎术1例,脾动脉瘤栓塞术2例,脾动脉瘤栓塞术加脾切除术1例。随访2个月至3年。无死亡及严重并发症病例。结论：脾动脉瘤依赖临床表现难以诊断,B超有筛选价值,CTA,MRA,DSA均有诊断价值。一旦确诊应尽早选择腔内介入栓塞治疗或手术方法。     

根治性胃癌切除术后内脏假性动脉瘤破裂出血19例诊治体会

目的总结根治性胃癌切除术后假性动脉瘤(visceral pseudoaneurysms,VP)破裂出血的临床特征和治疗经验。方法1995年9月至2016年4月行根治性胃癌切除术术后出现消化道出血或(和)腹腔出血,经CT血管造影(CTA)或(和)数字减影血管造影(DSA)证实为VP破裂出血病人19例,其中男性14例,女性5例;年龄42~70岁,平均年龄52岁。出血时间为术后10~64 d,平均22 d。19例病人中单支VP破裂出血者15例,其中肝动脉VP破裂出血4例,胃十二指肠VP破裂出血6例,脾动脉VP破裂出血5例。分析19例根治性胃癌切除术后VP破裂出血的临床表现和治疗方法。结果经动脉导管栓塞治疗15例,3例死亡;手术治疗4例,死亡2例。本组14例经手术或介入治疗成功止血病人获随访,随访时间为1~3年,平均随访20个月。随访期间均无动脉瘤复发及再出血,但有4例病人因原发病分别于手术后1~3年死亡。结论CTA或(和)DSA可确诊VP破裂出血,而经动脉导管栓塞治疗是该类病人的首选治疗方法。     

脾动脉瘤的手术及微创治疗

目的 探讨脾动脉瘤的治疗方法及中远期疗效.方法 1999-2011年收治18例脾动脉瘤患者,对18例的治疗方法及预后等临床资料进行回顾性分析.结果 18例患者中男7例,女11例.平均年龄53.8±7.3岁.8例患者无临床症状于体检中发现,7例表现为左上腹疼痛,3例因动脉瘤破裂于急诊首诊.14例经三维血管造影(3DCTA)、3例经数字减影血管造影(DSA)、1例经磁共振血管造影(MRA)确诊.手术治疗11例,其中脾动脉瘤破裂行急诊手术3例,择期性手术8例.手术包括脾动脉瘤及脾切除4例,同时切除胰尾5例,脾动脉瘤切除、断端吻合1例,脾动脉瘤切除加脾及结肠脾区切除1例.另外,行脾动脉瘤介入栓塞治疗3例.本组中,4例无临床症状、且瘤体直径＜2 cm者行随访观察中.围手术期无死亡.随访16例平均3.2年.失访2例,1例于术后4年死于脑溢血.结论 脾动脉瘤发病率低,症状多隐匿,脾动脉瘤破裂多有致死的危险.开腹手术及腔内微创治疗预后良好.     

三维增强核磁共振血管造影在内脏动脉瘤诊治中的应用

目的 探讨三维增强核磁共振血管造影在内脏动脉瘤诊治中的临床价值.方法 对43例内脏动脉瘤患者行三维增强MR血管造影检查,19例同期行数字减影血管造影(digital subtraction angiography,DSA).三维增强MR血管造影用屏气超快速三维梯度回波序列,图像减影后进行三维重建.结果 43例共50个内脏动脉瘤,涉及脾动脉32个(其中5例脾动脉异位起源于肠系膜上动脉),占64%;肠系膜上动脉7个(14%),腹腔动脉干5个(1例为腹腔系膜干),肾动脉4个,肝动脉2个.三维增强MR血管造影能清楚显示动脉瘤部位、大小、形态,并在立体直观显示动脉瘤及其与周围血管脏器关系方面优于DSA.43例中,行栓塞治疗15例,手术9例,保守观察19例.结论 三维增强MR血管造影能尤创、准确诊断内脏动脉瘤,所提供的三维解剖细节有助于临床治疗方案的制定,可作为内脏动脉瘤的首选检查方法.     

肾动脉平面以上主动脉瘤的治疗

目的　探讨肾动脉平面以上主动脉瘤 (AAARA)的治疗经验。方法　回顾性分析12 0例AAARA的临床资料。结果　夹层动脉瘤 84例 ,真性动脉瘤 2 7例 ,假性动脉瘤 9例。病变累及全程主动脉者 12例 ,主动脉弓 9例 ,胸降主动脉 2 0例 ,降胸至腹主动脉分叉部或以下 43例 ,胸腹主动脉 2 5例 ,涉及内脏动脉 11例。施行手术或支架型人工血管微创治疗74例。术中至术后 30d内死亡 11例 (14 9% )。术后并发症 9例 ,无截瘫、偏瘫或卒中发生。 16例腔内治疗病人中无严重并发症或死亡者。随访 48例 ,随访时间 1个月～ 15年 ,5例死亡 (10 4% )。保守治疗 46例中 ,44 1%死于瘤体破裂或其它严重并发症。结论　AAARA开胸手术仍存在着很大风险 ,而多种多样的支架型人工血管腔内置放和腔内开窗治疗有着良好前景 ,腔内血管外科技术将成为治疗AAARA的主流。     

Visceral artery aneurysms

The purpose of this article is to review the etiology, clinical presentation and treatment options of visceral artery aneurysms (VAA) on the basis of our experiences. Visceral artery aneurysms are uncommon lesions with a frequency of 0,1-0,2 % in autopsy statistics. In fact many visceral artery aneurysms still present first with a rupture (22 %) and despite emergency laparotomies the mortality rate is about 8,5 %. The course of disease often is disastrous due to rupture of the aneurysms or thromboembolic complications, emphasizing the importance to be aware of this differential diagnosis of abdominal pain. This article covers 9 patients with VAA. 3 patients each revealed an a. lienalis aneurysm and a. gastrica aneurysm, resp. In the other 3 patients an aneurysm of the a. gastroepiploica, the a. pancreatico-duodenalis and the a. mesenterica superior resp. was proven. In 8 of 9 patients a surgical therapy of the VAA took place. Only 2 patients (22 %) were interventionally treated. 1 patient deceased due to postoperative hemorrhage. Both the surgical and the radiological intervention therapy are available for treatment of the VAA. The decision on the choice of the therapeutic procedure should be made on an individual basis.     

Visceral artery aneurysm rupture

PURPOSE: Aneurysms of the visceral arteries are infrequently encountered. Many are found incidentally and are thought to have a benign outcome. To better characterize these lesions and their clinical course, we reviewed our experience with visceral artery aneurysms (VAAs) at a single institution. METHODS: A retrospective analysis of all VAAs diagnosed at our institution over the past 10 years was performed. The presentation, management, and outcome of therapy was examined for each patient. RESULTS: Thirty-four VAAs in 26 patients were diagnosed over the past 10 years. Four patients had multiple VAAs: splenic (17), hepatic (7), celiac (3), superior mesenteric (2), gastroduodenal (2), pancreaticoduodenal (1), right gastric (1), ileal (1) artery aneurysms. Associated aneurysms were found in 31% of patients and involved the thoracic aorta (3 patients), abdominal aorta (4 patients), renal arteries (2 patients), iliac artery (3 patients), lower extremity (1 patient), and intracranium (1 patient). In 15 patients (58%), VAAs were detected before rupture by chance or because abdominal symptoms resulted in diagnostic evaluation. Eight of these underwent elective surgery, and there were no deaths. Of those 15 patients with known VAAs, one patient died of rupture and hemorrhage from an untreated splenic artery aneurysm. Eleven patients (42%) presented unexpectedly with rupture, and two died despite prompt surgical treatment. The mortality rate in patients who had ruptured VAAs was 25%, including those who presented with ruptured aneurysms and those observed whose aneurysms eventually ruptured. CONCLUSIONS: Aneurysms of the visceral arteries are rare but important vascular lesions. Associated aneurysms are common. Because of the risk of rupture, often with a fatal outcome, an aggressive approach to the treatment of VAA is essential.     

Nonoperative management of unruptured visceral artery aneurysms: treatment by transcatheter coil embolization

PURPOSE: To describe our experiences with the treatment of visceral artery aneurysms (VAA) by transcatheter coil embolization and to propose indications for treating VAA by this method. METHODS: We treated 22 patients with VAA by coil embolization; 9 had splenic-, 7 renal-, 4 pancreaticoduodenal arcade-, and 2 proper hepatic artery aneurysms. All nine splenic artery aneurysms patients presented with chronic hepatitis-C; four had hepatocellular carcinoma. Of the seven renal artery aneurysms patients, four were hypertensive and three had rheumatoid arthritis. Both pancreaticoduodenal arcade artery aneurysms patients manifested severe stenosis of the celiac axis. Our transcatheter coil embolization procedure includes coil embolization and coil-packing of the aneurysmal sac, preserving the native arterial circulation. RESULTS: Transcatheter coil embolization with aneurysm packing was technically successful in 16 (72.7%) of the 22 patients and the native arterial circulation was preserved. Postprocedure angiograms confirmed complete disappearance of the VAA. In four of the nine splenic artery aneurysm patients, the native arterial circulation was not preserved. In one renal artery aneurysm patient, stenosis at the aneurysmal neck necessitated placement of a stent before transcatheter coil embolization. Magnetic resonance angiographs obtained during the follow-up period (mean 27 months) demonstrated complete thrombosis of the VAA in all 22 patients. Infarction occurred in one splenic- and two renal artery aneurysms patients; the latter developed flank pain and fever after the procedure. CONCLUSIONS: Transcatheter coil embolization is an effective alternative treatment for patients with saccular and proximal VAA. In particular, the isolation technique using coil embolization is advantageous in splenic artery aneurysm patients.     

Diagnosis and management of visceral artery aneurysms: report of 24 cases

During the past 30 years 24 patients were treated for visceral artery aneurysms in our hospital. There were 12 hepatic, 7 gastroduodenopancreatic, 3 splenic, and 2 superior mesenteric artery aneurysms. Perilous ruptures occurred in 20 patients, among them 13 ruptured into the biliary tract, 4 into the upper gastrointestinal tract, and 3 into the abdominal cavity. Correct preoperative diagnosis was often difficult. Selective celiac and superior mesenteric angiography was most valuable, and 14 patients were correctly diagnosed preoperatively by the procedure. Nineteen underwent emergent surgery and 8 died. Prognosis depended on the anatomic location of the aneurysms and the general condition of the patients.     

The endovascular management of visceral artery aneurysms and pseudoaneurysms

OBJECTIVE: Visceral artery aneurysms may be treated by aneurysm exclusion, excision, revascularization, and endovascular techniques. The purpose of this study was to review the outcomes of the management of visceral artery aneurysms with catheter-based techniques. METHODS: Between 1997 and 2005, 90 patients were identified with a diagnosis of visceral artery aneurysm. This was inclusive of aneurysmal disease of the celiac axis, superior mesenteric artery (SMA), inferior mesenteric artery, and their branches. Surveillance without intervention occurred in 23 patients, and 19 patients underwent open aneurysm repair (4 ruptures). The endovascular treatment of 48 consecutive patients (mean age 58, 60% men) with 20 visceral artery aneurysms (VAA) and 28 visceral artery pseudoaneurysms (VAPA) was the basis for this study. Electronic and hardcopy medical records were reviewed for demographic data and clinical variables. Original computed tomography (CT) scans and fluoroscopic imaging were evaluated. RESULTS: The endovascular treatment of visceral artery aneurysms was technically successful in 98% of 48 procedures, consisting of 3 celiac axis repairs, 2 left gastric arteries, 1 SMA, 12 hepatic arteries, 20 splenic arteries, 7 gastroduodenal arteries, 1 middle colic artery, and 2 pancreaticoduodenal arteries. Of these, 29 (60%) were performed for symptomatic disease (5 ruptured aneurysms). Procedures were performed in the endovascular suite under local anesthesia with conscious sedation (94%). The femoral artery was used as the preferential access site (90%). Coil embolization was used for aneurysm exclusion in 96%. N-butyl-2-cyanoacrylate (glue) was used selectively (19%) using a triaxial system with a 3F microcatheter for persistent flow or multiple branches. The 30-day mortality was 8.3% (n = 4). One patient died from recurrent gastrointestinal bleeding after gastroduodenal embolization, and the remaining died of unrelated causes. All perioperative deaths occurred in patients requiring urgent or emergent intervention in the setting of hemodynamic instability. No patients undergoing elective intervention died in the periprocedural period. Postprocedural imaging was performed after 77% of interventions at a mean of 16 months. Complete exclusion of flow within the aneurysm sac occurred in 97% interventions with follow-up imaging, but coil and glue artifact complicated CT evaluation. Postembolization syndrome developed in three patients (6%) after splenic artery embolization. There was no evidence of hepatic insufficiency or bowel ischemia after either hepatic or mesenteric artery aneurysm treatment. Three patients required secondary interventions for persistent flow (n = 1) and recurrent bleeding from previously embolized aneurysms (n = 2). CONCLUSION: Visceral artery aneurysms and pseudoaneurysms can be successfully treated with endovascular means with low periprocedural morbidity; however, the urgent repair of these lesions is still associated with elevated mortality rates. Aneurysm exclusion can be accomplished with coil embolization and the selective use of N-butyl-2-cyanoacrylate. Current catheter-based techniques extend our ability to exclude visceral artery aneurysms, but imaging artifact hampers postoperative CT surveillance.     

Treatment of Visceral Artery Aneurysms: Description of a Retrospective Series of 42 Aneurysms in 34 Patients

Visceral artery aneurysms (VAA) can be treated by revascularization, ligation, or, most often, endovascular techniques depending on clinical presentation, hemodynamic status, and location. From 1975 to 2002 a total of 42 VAA in 34 patients were treated. The lesion involved the splenic artery (SA; 19), pancreaticoduodenal artery (PDA; 6), celiac trunk (CT; 5), superior mesenteric artery (SNA; 4), common hepatic artery (CHA; 3), gastroduodenal artery (GDA; 2), left hepatic artery (LHA; 1), a branch of the inferior mesenteric artery (BIMA; 1), and a branch of the SMA (BSMA; 1). Twenty-seven VAA in 21 patients (64%) were uncomplicated (group I) and 15 VAA in 13 patients (36%) had ruptured (group II) (PDA; 6; CT, 3; SA, 1; CHA, 1; LHA, 1; BSMA, 1; BIMA, 1). In group I VAA were treated by embolization (n = 11), splenectomy (n = 6), bypass (n = 7), ligation (n = 2), and aneurysmorraphy (n = 1). No deaths were observed. The morbidity rate associated with surgical treatment was 12% including hepatic bypass thrombosis without ischemic complications in two cases. The morbidity rate associated with endovascular treatment was 18% including cholecystitis in one case and bile duct stenosis in one case. The VAA recanalization rate following embolization was 9%. In group II, 12 VAA (80%) were treated by ligation in association with splenectomy in two cases and left hepatectomy in one case. Only one bypass procedure was performed and embolization was used to treat two VAA (1 SMA and 1 PDA). The mortality rate was 20% (3/15). The morbidity rate associated with surgical treatment was 46% (6/13) including bile duct stenosis in one case, ischemic cholecystitis in one case, duodenal fistula in one case, pancreatic fistula in one case, bile tract fistula in one case, and colonic ischemia in one case. No patient died after endovascular treatment and the morbidity rate was 50% (1/2) with duodenal stenosis occurring in one case. In sum, VAA can rupture. Emergency cases can be treated by ligation in most cases or by embolization if the hemodynamic status of the patient allows. Regardless of treatment technique, the morbidity and mortality rate remains high after rupture, especially in cases involving PDA. Embolization can be proposed as a first-line treatment for most VAA. Because of the risk of rupture, endovascular or open repair is warranted for VAA and has a favorable prognosis.     

腹部脏器假性动脉瘤诊治体会

目的 总结腹部脏器假性动脉瘤的诊断和治疗经验。方法 回顾性分析1990～2001年16例腹部脏器假性动脉瘤,其中肝动脉瘤6例、脾动脉瘤6例、胃十二指肠动脉瘤4例。全部病例均获得随访,平均2年。结果 16例假性动脉瘤病人中15例表现为破裂出血。手术3例,成功2例,死亡1例。经动脉导管栓塞13例,全部成功且无并发症及复发。结论 数字减影血管造影术对腹部脏器假性动脉瘤急诊有确诊价值,经动脉导管栓塞术是绝大多数病人首选而有效的治疗方法。