腹主动脉瘤腔内治疗现状

1991年,Parodi等发明人工血管内支架（stent graft,SG）并用于临床成功治愈腹主动脉瘤（abdominal aortic aneurvsm,AAA）,此后腹主动脉瘤腔内治疗（endovascular abdominal aortic aneurysm repair,EVAR）取得迅速发展。由于EVAR避免了传统开腹手术创伤大和出血多的缺点,使高龄或伴有心、肺、肝、肾功能不全的患者获得积极治疗的机会。一般来讲,腔内治疗主要是指肾下型腹主动脉瘤。     

Endovascular abdominal aortic aneurysm repair

Around two-thirds of abdominal aortic aneurysms (AAA) are incidentaldiscoveries during the investigation of backache, hip pain orurinary tract complaints. They are much more common in men thanwomen (5:1) and account for 2% of all deaths in men aged >60yr. Open surgical repair of the aneurysm is considered as thestandard, traditional method of treatment. Surgery is recommendedwhen the AAA exceeds 55 mm in anteroposterior diameter as measuredby ultrasound scan. The risk of spontaneous rupture dependson aneurysm size, ranging from <1% per annum for AAA <55mm diameter to >17% per annum for aneurysms >60 mm diameter.Ninety per cent of AAAs are located distal to the renal arteries. Endovascular repair of an aortic aneurysm using an in-situ prostheticgraft was suggested as a technique in 1969 by Dotter, but wasonly first performed successfully by Parodi and colleagues in1990. Over the last 10 yr, the availability of endovascularstent grafts has provided an alternative treatment for patientswith AAA, especially the elderly with significant co-existingmedical conditions. Endovascular repair is much less invasive.However, it is challenging technically and requires a multidisciplinaryapproach. During endovascular surgery, an aortic stent graft is passedvia the femoral arteries through the aortic lumen to fit tightlyabove and below the AAA. The aim is to exclude the aneurysmsac from the systemic circulation, thereby decreasing or eliminatingthe risk of future rupture. The procedure is performed throughincisions in one or both groins; no laparotomy is required.However, certain anatomical considerations apply.     

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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     

Endovascular abdominal aortic aneurysm repair in women

The objective of this review is to establish the role of endovascular aortic aneurysm repair (EVAR) in women. A step by step approach is taken looking at sex and gender differences in epidemiology, pathogenesis and natural history. We then proceed to discuss the results from the three randomized controlled trials comparing EVAR to open repair. Finally, sex-specific secondary prevention, risk factor management and medication, is discussed. Women seem to have higher mortality and more complications after EVAR. Risk factors such as diabetes and hypertension are associated with worse outcome in women compared to men. The role of EVAR in women is poorly investigated and its definite role remains to be determined. Aggressive treatment of risk factors and the optimisation of medication in women are indicated and deserve more attention in clinical practice and future research.     

Endovascular versus open surgical repair of abdominal aortic aneurysm with concomitant malignancy

BACKGROUND: The management of patients with abdominal aortic aneurysm (AAA) and concurrent malignancy is controversial. This study retrospectively assessed the outcome of endovascular repair (EVAR) and open repair (OR) for the treatment of AAA in patients undergoing curative treatment for concomitant malignancies. METHODS: All patients who underwent surgery for a nonruptured infrarenal AAA of > or =5.5 cm and concomitant malignancy between 1997 and 2005 were retrospectively reviewed. RESULTS: Identified were 25 patients (22 men; mean age, 70.3 years) with nonruptured infrarenal AAA of > or =5.5 cm (mean size, 6.4 cm) and concomitant malignancy amenable for curative treatment. EVAR was used to treat 11 patients, and 14 underwent OR. The EVAR patients had a smaller mean aneurysm size (5.9 cm vs 6.8 cm; P = .006) than the OR patients. The mean cumulative length of stay for all patients who received treatment for both AAA and cancer was 12.8 days (range, 4 to 26) for EVAR and 18.2 days (range, 9 to 42 days) for OR. In the EVAR group, no patients died perioperatively; in the OR group, three patients died perioperatively (21.4%; P = NS). Postoperative complications occurred in one patient in the EVAR group and in seven in the OR group for a morbidity rate, respectively, of 9.1% and 50% (P = .04). One late complication (9.1%) occurred in the EVAR group. The mean follow-up was 37.7 months (range, 16 to 60 months) in the EVAR group and 29.6 months (range, 11 to 55 months) in the OR group. At 1 and 2 years, survival rates were 100% and 90.9% in the EVAR group and 71.4% and 49% in the OR group (log-rank P = .103) CONCLUSIONS: With low morbidity and mortality, EVAR is a safe technique for the treatment of AAA in patients with concomitant malignancy and could be considered as an alternative to OR.     

腔内修复术在复杂型肾下腹主动脉瘤中的应用

目的:探讨对于复杂型肾下腹主动脉瘤(AAA)行腔内修复(EVAR)治疗的操作要点和治疗效果。方法:回顾行EVAR治疗的15例复杂型肾下AAA患者的临床资料,分析术中操作要点和临床结局。结果:手术技术成功率为100%,无中转开腹病例,1例(6.67%)术后5 d死于急性心衰。瘤颈成角过大2例患者均使用肱-股双导丝技术完成手术;髂动脉狭窄患者7例,4例利用肱-股双导丝技术及球囊扩张后置入支架,其余经球囊扩张完成操作;1例左髂动脉闭塞的患者采用对侧髂动脉进入导丝通过闭塞段完成手术;8例重度扭曲患者通过超硬导丝将扭曲段纠正后释放支架。术中无瘤体破裂、血管穿孔及医源性血管夹层等严重并发症出现。随访期间,1例患者术后2年出现腰椎结核,死于多脏器功能衰竭;内漏3例,二次手术干预1例。结论:随着经验的积累,技术的进步及支架的不断完善,EVAR治疗复杂型肾下AAA是可行、有效的。     

Endovascular stent-graft repair of failed endovascular abdominal aortic aneurysm repair

Despite high initial technical success, the long-term durability of endovascular abdominal aortic aneurysm repair (EVAR) continues to be a concern. Following EVAR, patients can experience endoleaks, device migration, device fractures, or aneurysm growth that may require intervention. The purpose of this study was to review all patients treated with secondary endovascular devices at our institution for failed EVAR procedures. Over an 8-year period, 988 patients underwent EVAR, of whom 42 (4.3%) required secondary interventions involving placement of additional endovascular devices. Data regarding patient characteristics, aneurysm size, initial device type, time until failure, failure etiology, secondary interventions, and outcomes were reviewed. The mean time from initial operation until second operation was 34.1 months. Failures included type I endoleaks in 38 patients (90.5%), type III endoleaks in two patients (4.8%), and enlarging aneurysms without definite endoleaks in two patients (4.8%). The overall technical success rate for secondary repair was 92.9% (39/42). Perioperative complications occurred in nine patients (21.4%), including wound complications (n = 6), cerebrovascular accident (CVA) (n = 1), foot drop (n = 1), and death (n = 1). Mean follow-up following secondary repair was 16.4 months (range 1-50). Eighty-six percent of patients treated with aortouni-iliac devices had successful repairs compared to 45% of patients treated with proximal cuffs. Ten patients (23.8%) had persistent or recurrent type I or type III endoleaks following revision. Of these, four had tertiary interventions, including two patients who had additional devices placed. Failures following EVAR occur in a small but significant number of patients. When anatomically possible, endovascular revision offers a safe means of treating these failures. Aortouni-iliac devices appear to offer a more durable repair than the proximal cuff for treatment of proximal type I endoleaks. Midterm results indicate that these patients may require additional procedures but have a low rate of aneurysm-related mortality. Longer-term follow-up is necessary to determine the durability of these endovascular revisions.     

Endovascular repair of late abdominal aortic aneurysm rupture owing to mixed-type endoleak following endovascular abdominal aortic aneurysm repair

We report the successful endovascular repair of a ruptured abdominal aortic aneurysm (AAA) in a multimorbid patient 8 months after endovascular abdominal aortic aneurysm repair (EVAR). A 74-year-old man with a history of EVAR 8 months earlier presented with hypotension, severe back pain, and tenderness on abdominal palpation. A contrast-enhanced computed tomographic scan showed a large retroperitoneal hematoma and confirmed the diagnosis of secondary abdominal aortic rupture. Because the patient had severe comorbidities, the endovascular method was chosen for further management. Two stent grafts were placed appropriately to eliminate a type 1a and a type 3 endoleak owing to modular separation of the left iliac graft limb from the main body stent graft. An additional self-expanding stent was deployed in the solitary right renal artery to open its origin, which was partially overlapped by the proximal cuff. The patient was discharged on the tenth postoperative day and is alive and well 1 year postoperatively. This case indicates that endovascular repair is feasible not only in cases of primarily ruptured AAAs but also in secondarily ruptured AAAs after failure of EVAR.     

Endovascular repair of abdominal aortic aneurysm in renal transplantation

Successful endovascular correction of a 12-cm abdominal aortic aneurysm (AAA) is described in a 76-year-old man with a functional pelvic renal transplant and 18-month follow-up. Endovascular treatment is a safe alternative to surgery for AAA correction in the elderly post-transplantation patient since it does not require flow interruption during the procedure.     

Endovascular repair of the ruptured abdominal aortic aneurysm.

The present knowledge on endovascular repair of ruptured abdominal aortic aneurysms (rAAA) prevents firm conclusions when to use this method in comparison to open repair. This review article briefly summarizes results from case series, and discusses how to achieve reliable information despite the absence of randomized controlled trials. At present a careful conclusion might be that dedicated centers with an adequate organization and reasonably high volume of abdominal aortic aneurysm (AAA) should use detailed registry protocols to achieve experience and data to create an as reliable basis as possible for future recommendations.     

Endovascular repair of abdominal aortic aneurysm: current status

INTRODUCTION: Endovascular aneurysm surgery (EVAR) was introduced a decade ago. Early results are promising, however, there remain concerns regarding the longer-term durability of this technique. Consequently, the national multi-centre EVAR trial has been commenced to define the role of endovascular surgery in the management of abdominal aortic aneurysm. DISCUSSION: Successful EVAR requires accurate pre-operative assessment of aneurysm morphology. Current stent-grafts allow 60% of all infra-renal AAA to be treated. Reduced physiological stress and low peri-operative morbidity and mortality rates have been demonstrated with this technique when compared to open repair. Endoleak is an Achilles heel of EVAR, although in itself does not accurately predict outcome. First and second generation devices are estimated to have a 1% per year risk of rupture. CONCLUSIONS: Increased understanding of the issues surrounding aneurysm morphology and successful stent-grafting have allowed a major reduction of early type I endoleak. Late endoleak and graft migration remain problematic. Type I and III endoleaks are risk factors for subsequent rupture although the significance of type II endoleak remains uncertain. More robust indicators of outcome success/failure are required so that follow-up may be rationalised.     

腹主动脉瘤血管腔内治疗与开放手术治疗的疗效比较

目的 比较腹主动脉瘤血管腔内治疗与开放手术治疗的近期疗效。方法 对34例肾下型腹主动脉瘤患者的临床资料进行分析，比较腔内治疗组（15例）与传统开放手术治疗组（19例）的术前状况、手术相关情况、术后并发症、死亡率及手术前后的实验室检查数据。结果 腔内组术中出血量和输血量明显少于手术组（P=0．005、P=0．015），腔内组术后平均禁食时间和平均住院时间较手术组明显缩短（P〈0．0l、P：0．001）。手术组术后并发症发生率明显高于腔内组（P〈0．01）。术后第3天白细胞计数腔内组明显低于手术组（P=0．020）；术后第5天红细胞计数及血肌酐水平在腔内组均明显高于手术组（P=0．011、P=0．034）。结论 腹主动脉瘤血管腔内治疗具有安全、微创、对人体内环境干扰小的优点，近期疗效较传统开放手术好。     

Endovascular repair of abdominal aortic aneurysm without preoperative arteriography

OBJECTIVE: Clinical trials of endovascular aortic aneurysm repair (EVAR) have required both preoperative aortography and computed tomography (CT). We codeveloped specialized three-dimensional (3-D) reconstruction and computer-aided measurement, planning, and simulation software (3-D CAMPS) based on CT or magnetic resonance imaging, to eliminate the need for preoperative arteriography. METHODS: EVAR with 3-D CAMPS as the sole preoperative imaging method was performed in 196 patients from 1996 to 2001, with six endograft types in three configurations. Physical examination, abdominal radiography, and CT (3D-CAMPS) were performed at 1, 6, and 12 months, then annually. RESULTS: For a subset of cases in which a comparison could be made, 3-D CAMPS was superior to angiography for prediction of endograft length and iliac access. Hospital mortality was zero, and 30-day mortality was 0.5%. In three patients immediate conversion to open repair (1.5%) was necessary because of previously unknown stent-graft mechanical limits. Incidence of endoleak was 15% at 1 month, 10% at 6 months, 6% at 12 months, and 7% at 24 months, and 92% of endoleaks were type II. Mean follow-up was 18 months. Aneurysm-related mortality was zero. Nineteen secondary procedures (all endovascular) were performed in 16 patients (8%). For all graft types, freedom from secondary procedure was 94% at 1 year and 90% at 2 years, and this was better for endografts ultimately approved by the US Food and Drug Administration (96% at 1 year, 95% at 2 years; P =.02). No known measurement-related complications occurred in the series. Results for secondary intervention and endoleak compare favorably to series with similar endograft types. CONCLUSIONS: EVAR can be performed with 3-D CAMPS as the sole preoperative imaging method to achieve outcomes comparable to the best series published for each endograft type. CT with 3-D CAMPS can effectively eliminate the need for preoperative arteriography and avert associated morbidity, expense, and exposure to contrast agent and radiation.     

"Fast-track" abdominal aortic aneurysm repair

The "open" repair of abdominal aortic aneurysm (AAA) continues to evolve with incorporation of less invasive methods for surgical exposure and the use of patient care pathways for shorter hospital stays. In a consecutive series of 30 patients with infrarenal AAA, a "fast-track" hospital care pathway was implemented that included the following: AAA exposure via a limited (10-15 cm) retroperitoneal incision, use of self-retaining retractor and special vascular clamps/instruments, and prosthetic graft endoaneurysmorrhaphy. Excellent anatomic exposure for graft implantation was achieved with an average operative time of 175 minutes. Use of oral metoclopromide and patient-controlled epidural analgesia resulted in patient ambulation and oral diet on postoperative day 1. Average length of hospital stay was 3.6 days (range: 3-7 days), and no patient required readmission for AAA repair-related or gastrointestinal problems. One patient died (30-day mortality rate of 3.3%) caused by delayed recognition of a splenic injury, and 1 patient sustained an intraoperative ureter injury that was repaired and stented. Although stent-graft exclusion for AAA repair has become popular, the major advantages of endovascular therapy, such as shorter ICU and hospital stays, earlier dietary feeding, and reduction in postoperative morbidity, can also be achieved by using minimal incision exposure for AAA interposition grafting combined with traditional hand-sewn vascular anastomoses. "Fast-track" AAA repair is applicable to the majority of patients with infrarenal AAAs, and vascular surgeons can easily master the technique of "limited" incision retroperitoneal exposure. This approach avoids the concerns of endovascular stent-graft durability and the mandatory vascular imaging follow-up to identify endoleak development and AAA enlargement.