联合股-股动脉旁路移植术的单臂支架腔内修复腹主动脉瘤的经验

目的探讨联合股-股动脉旁路移植术(cross-femoral bypass grafting,CFBG)的单臂支架型血管(aortouniiliac,AUI)腔内修复腹主动脉瘤(endovascular aneurysm repair,EVAR)的疗效。方法1997年5月~2007年2月,对8例因髂动脉的特殊解剖条件无法应用分叉支架型血管的腹主动脉瘤采用联合CFBG的AUI支架型血管进行EVAR治疗。术后观察内漏、缺血并发症、股股旁路血管的通畅性以及下肢血供情况等。结果围手术期无死亡,1例因急性心肌梗死于术后15个月死亡。3例原发性内漏分别于术后1、3、6个月自愈。8例平均随访24个月(3~72个月),旁路均通畅,1例于术后1年吻合口轻微狭窄但无下肢缺血症状。结论因髂动脉解剖条件复杂不能应用分叉支架型血管的腹主动脉瘤采用联合CFBG的AUI支架型血管进行EVAR是安全、有效的。     

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。     

合并双髂总动脉瘤的腹主动脉瘤的腔内治疗

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2009年1月～2012年3月,126例腹主动脉瘤接受腔内修复术（endovascularaneurysmrepair,EVAR）,其中33例合并双髂总动脉瘤（直径〉18mm）。27例双侧髂总动脉直径〉18-〈25mm,选择合适口径的髂腿移植物完成传统EVAR;6例因-侧髂总动脉直径≥25mm,选择该侧髂外动脉作为锚定区完成EVAR,并行髂内动脉栓塞术。结果所有腔内技术均获得成功,手术时间（115±36）min,出血量（173±65）m1。术中发现即刻内漏7例（21．2％）：I型内漏3例（近端1例,远端2例,均经球囊扩张后内漏消失）;11I型内漏1例,经扩张后内漏消失;II型内漏2例,Ⅳ型内漏1例,经随访瘤体直径未增大,未予处理。33例术后随访6～39个月,平均15．3月,无动脉瘤破裂,无远端迟发型I型内漏发生,髂动脉直径无明显扩张。结论对于部分合并双髂动脉瘤的腹主动脉瘤患者,根据髂总动脉直径选择合适的腔内治疗方法可以达到理想的治疗效果,近期效果满意。     

“烟囱”技术在Ⅲ型夹层动脉瘤和腹主动脉瘤腔内修复术中的应用

目的 总结“烟囱”技术在主动脉瘤腔内修复术中的应用体会和一期效果.方法 在30例主动脉瘤腔内修复术中使用“烟囱”技术增加近端覆膜支架锚定区,其中25例DebakeyⅢ型夹层动脉瘤使用“烟囱”支架保留左锁骨下动脉(23例)或左颈总动脉(3例),肾下腹主动脉瘤使用“烟囱”支架保留肾动脉(5例).结果 所有病例均顺利完成操作,放置“烟囱”支架的分支动脉术中造影均通畅.其中2例夹层动脉瘤(8％)和1例腹主动脉瘤残留(20％)少量Ⅰ型内漏,1例夹层动脉瘤左锁骨下动脉“烟囱”病例术后5d猝死,考虑为远侧破口所致夹层动脉瘤破裂.其余22例夹层动脉瘤和4例肾下腹主动脉瘤均无内漏.随访28例(90.3％),随访1～19个月,平均(6±5)个月.随访期超声或CTA示“烟囱”血管血流均通畅.1例腹主动脉瘤仍有内漏,2例夹层内漏病例随访中(尚未行CTA),其他病例瘤腔血栓形成.结论 “烟囱”技术能够有效的延长覆膜支架在主动脉瘤腔内修复术中的近端锚定区并保持重要分支动脉通畅.     

腔内治疗主动脉瘤时锚定区不足的处理

目的 探讨主动脉夹层、胸主动脉瘤、胸腹主动脉瘤腔内治疗远近端锚定区缺乏的现阶段处理体会.方法 2005年8月至2009年2月,我科共治疗主动脉扩张性疾病包括主动脉夹层、胸主动脉瘤、胸腹主动脉瘤129例,其中主动脉夹层近端锚定区不足6例,胸主动脉瘤近端锚定区不足3例,腹主动脉瘤远端锚定区不足4例.分别进行升主动脉一双侧颈总动脉一左锁骨下动脉转流、双侧颈总动脉一左锁骨下动脉转流、腹主动脉一肠系膜上动脉一双侧肾动脉转流、髂内动脉栓塞重建锚定区后成功腔内治疗.结果 患者均获技术和临床成功,无围手术期死亡和重大并发症.随访期间支架人造血管无移位,夹层或动脉瘤腔血栓形成良好,无明显内漏,瘤体未增大;桥血管通畅.结论 对于缺乏锚定区的主动脉扩张性病变,通过人造血管旁路手术或栓塞非必须血管等方法重建或扩大锚定区是扩大腔内治疗适应证的安全、有效的手段.     

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.     

腹主动脉瘤腔内修复术中髂动脉瘤的处理策略

目的:探讨腹主动脉瘤合并髂动脉瘤的腔内修复术(EVAR)方法。方法:回顾性分析2007年8月—2014年3月35例腹主动脉瘤合并髂动脉瘤行EVAR术患者资料,其中9例合并单侧髂内动脉瘤,1例合并双侧髂内动脉瘤,14例合并单侧髂总动脉瘤(直径18 mm),11例合并双侧髂总动脉瘤,所用腔内技术包括栓塞髂内动脉瘤后覆盖,髂内动脉瘤单纯覆盖,"喇叭口"支架,以及"三明治"技术重建一侧髂内动脉等。结果:所有腔内技术均获得成功,手术时间(125±40)min,出血量(173±65)m L。术中发现内漏8例(22.9%),其中I型内漏4例(近端2例,远端2例)均经球囊扩张后内漏消失,III型内漏1例,经扩张及部分加弹簧圈栓塞后内漏消失,II型内漏2例及IV型内漏1例,均未予处理。35例术后随访6~60个月,无动脉瘤破裂,2例术后6个月发现腹主动脉瘤体增大,造影确诊远端I型内漏,经弹簧圈栓塞后内漏消失,其余33例瘤体直径无增大。结论:对于合并髂动脉瘤的腹主动脉瘤患者,有效处理髂内动脉,然后根据髂总动脉直径选择合适的治疗方法可以达到理想的近期效果。     

彩色多普勒超声辅助无造影剂腹主动脉瘤合并髂内动脉瘤腔内覆膜支架修复术

目的探索常规多普勒超声辅助腹主动脉瘤腔内覆膜支架修复术(EVAR)的技术可行性和有效性。方法对1例造影剂肾功能受损的腹主动脉瘤合并左侧髂总动脉瘤和左侧髂内动脉瘤患者,行无造影剂的术中常规超声辅助EVAR和左侧髂内动脉瘤栓塞术,总结该患者的临床资料。结果透视下借助常规超声辅助,主动脉支架释放成功,左侧髂内动脉瘤弹簧圈栓塞成功,腹主动脉瘤及左侧髂总动脉瘤隔绝成功。术中超声显示来自肠系膜下动脉的Ⅱ型内漏,右侧髂支Ⅰb型内漏。患者的手术时间为120 min,术中出血量为20 m L。术后1周常规彩超显示,右侧髂支Ⅰb型内漏消失,来自肠系膜下动脉的Ⅱ型内漏仍然存在,于术后1周顺利出院。等待后续随访结果。结论常规超声辅助EVAR治疗解剖条件良好的腹主动脉瘤时,能清楚显示近远端锚定区域以及内漏情况,尤其适合存在碘造影剂禁忌的患者。     

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.     

肾下腹主动脉瘤105例腔内修复的早中期疗效

目的 评估肾下腹主动脉瘤腔内修复治疗的早中期疗效.方法 回顾分析2001年1月至2007年2月105例肾下腹主动脉瘤行腔内修复治疗的经过、结果和并发症.结果 所有患者均获技术成功,82例(78.09%)获随访,随访时间1～73个月,平均(8.9 4±5.8)个月.围手术期死亡3例(2.86%),分别死于急性心肌梗死、多系统器官功能衰竭和上消化道大出血.1例(1.21%)术后30个月死于肝癌.原发性内漏21例:Ⅰ型18例,其中10例行球囊扩张(9例)或延伸段植入(1例)后治愈,8例自愈;2例Ⅱ型内漏自愈;1例Ⅲ型内漏支架植入后治愈.1例于术后2周支架的一侧髂支血栓形成,急诊行股-股动脉人工血管旁路术.4例迟发性Ⅰ型内漏.随访观察.1例于术后6年支架向远心端移位,无明显内漏而随访观察.2例支架感染发生于术后1和3个月,行清创引流和抗感染治疗后痊愈.随访期间,9例股-股或髂-股动脉旁路和3例髂内动脉旁路通畅.结论 腔内修复治疗肾下腹主动脉瘤安全、有效,早、中期疗效较好.     

腹主动脉瘤腔内修复术中特殊近端锚定区的处理

目的探讨腹主动脉瘤腔内修复术（EVAR）中特殊近端锚定区的处理方法。方法1997年7月至2005年7月对41例特殊类型腹主动脉瘤（瘤颈过短、严重成角、严重钙化、附壁血栓、形态不规则等）的腔内修复术中，根据情况分别采用近端裸支架跨肾动脉技术、覆盖部分肾动脉并肾动脉支架成形技术、针对成角选择合理产品、近端裸支架内支撑技术、近端延长支架型血管内支撑技术、“凹口”状支架型血管保留肾动脉技术来处理特殊近端锚定区的病变。结果41例EVAR中原发性近端Ⅰ型内漏发生率17．1％（7／41），随诊发现原发性内漏4例自愈，3例转化为持续性内漏，另发现4例继发性内漏。术后30d近端Ⅰ型内漏发生率17.1％（7／41）。无中转开腹手术及术中瘤体破裂、肾梗死等情况发生。结论对特殊近端锚定区的病例，通过相关技术处理可以使之适合腔内治疗。     

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.     

Iliorenal artery bypass grafting to facilitate endovascular abdominal aortic aneurysm repair

Effective endovascular repair of an infrarenal abdominal aortic aneurysm (AAA) requires adequate proximal and distal landing zones to allow secure endograft attachment. We report a patient with an infrarenal AAA originating 3 mm below the left renal artery with cardiac morbidity that precluded open AAA repair. Left renal artery relocation with retroperitoneal iliorenal bypass grafting was performed to lengthen the proximal landing zone, which facilitated successful endovascular AAA repair. Postoperative surveillance after 3 years showed aneurysm reduction with a patent iliorenal bypass graft. This case underscores the utility of a combined open and endovascular approach in treatment of a challenging aortic aneurysm.     

腹主动脉瘤腔内修复术后髂支闭塞的原因及治疗策略

目的:探讨腹主动脉瘤(AAA)腔内修复术(EVAR)后髂支闭塞的原因及治疗策略。方法:回顾性收集2016年1月—2018年7月中南大学湘雅医院血管外科收治130例行EVAR的AAA患者临床资料,对其中并发髂支闭塞患者的临床资料进行分析。结果:130例成功接受EVAR的AAA患者中,6例(4.61%)发生术后髂支闭塞,均为单侧闭塞,发生闭塞的平均时间为(55±87)d。临床表现主要为间歇性跛行和静息痛。治疗方式包括:股动脉切开取栓+股-股动脉转流术2例,髂动脉支架植入术1例,股动脉切开取栓+髂动脉支架植入术3例。术后患肢缺血症状均消失。术后随访时间12个月,所有患者均未再次出现下肢缺血症状。结论:髂支闭塞是EVAR术后较为常见的并发症之一,其原因包括瘤颈条件差、髂动脉入路扭曲、髂支远端锚定区解剖异常等;股动脉切开取栓和(或)髂动脉支架植入是行之有效的治疗方法。     

盐酸沙格雷酯在腹主动脉瘤腔内修复术后防治臀肌和下肢缺血的初步观察

目的观察盐酸沙格雷酯在腹主动脉瘤腔内修复术后防治臀肌和下肢缺血的作用。方法回顾性收集我院血管外科2006年1月至2011年1月期间收治的腹主动脉瘤行腔内修复术(EVAR)治疗的患者174例,年龄(71.8±8.2)岁,其中男148例,女26例。腹主动脉瘤直径(55.2±12.9)mm,累及髂总动脉52例(29.9%)。EVAR治疗方法包括置入分叉型人工血管支架169例(97.1%),单臂型5例(2.9%)。其中术中封闭单侧髂内动脉29例,封闭双侧髂内动脉10例,术后均口服盐酸沙格雷酯100 mg,3次/d,阿司匹林100 mg,1次/d 2～4周。随访观察术后患者臀肌和下肢发生缺血情况。结果全部病例行EVAR术顺利,无中转开腹;行全身麻醉88例(50.6%),硬膜外阻滞麻醉52例(29.9%),局部麻醉34例(19.5%);术中失血量为(125.2±43.1)ml,术中无输血,手术时间为(145.5±38.7)min;术后ICU观察时间和禁食时间分别为(14.7±5.2)h和(7.2±4.3)h;术后平均住院时间为(9.1±2.7)d。围手术期并发症发生率为12.6%(22/174),术后30 d死亡率为1.1%(2/174)。术中封闭单侧髂内动脉29例中2例出现同侧臀肌轻度疼痛,行走疼痛加重,跛行距离100 m,5例出现同侧下肢乏力,间歇性跛行距离100～200 m;封闭双侧髂内动脉10例中4例术后出现臀肌轻度疼痛,跛行距离200 m,均采用口服盐酸沙格雷酯和阿司匹林扩血管、祛聚治疗后2～4周好转,间歇性跛行距离均大于500 m,无臀肌坏死发生,无再行介入或外科干预治疗,中位随访时间16.1个月,未诉特殊不适。结论盐酸沙格雷酯在EVAR术后防治臀肌和下肢缺血疗效满意,尤其适合于封闭双侧或一侧髂内动脉和合并下肢动脉硬化闭塞者。     

Preservation of pelvic circulation with hypogastric artery bypass in endovascular repair of abdominal aortic aneurysm with bilateral iliac artery aneurysms

PURPOSE: The endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) with a bilateral common iliac artery aneurysm (CIAA) often requires exclusion of the bilateral hypogastric artery (HA), which can be associated with pelvic ischemic complications such as erectile dysfunction and buttock claudication. This study assessed the effect of HA bypass on improving pelvic circulation. METHODS: Five patients who underwent endovascular repair with HA bypass for an AAA with bilateral CIAA were evaluated. In all patients, the patency of the inferior mesenteric artery and bilateral HAs arteries was confirmed with preoperative computed tomography (CT) scans and angiography. During EVAR, penile blood flow was monitored with pulse-volume plethysmography measuring the penile brachial pressure index (PBI), and bilateral buttock blood flow was monitored with near-infrared spectroscopy measuring the gluteal tissue oxygenation index (TOI). An aortouni-external iliac artery stent graft with a crossover bypass was performed after embolization of the contralateral HA. HA bypass was performed between the crossover bypass graft and the ipsilateral HA via a retroperitoneal incision. RESULTS: Unilateral coil embolization of the contralateral side HA trunk slightly decreased blood flow to the contralateral side buttock but did not cause significant changes in penile blood flow. At the completion of EVAR, the levels of both PBI and the contralateral side TOI were significantly lower than the baseline levels. After ipsilateral side HA revascularization with HA bypass, both PBI and bilateral gluteal flow returned almost to the baseline levels. Postoperative angiography and CT scans demonstrated the patency of all HA bypasses and no endoleaks. None of the patients experienced new onset of erectile dysfunction or buttock claudication 1 month after surgery. CONCLUSION: Bilateral HA interruption during EVAR for AAA with bilateral CIAA was associated with significant depletion of both penile and gluteal blood flow. Intraoperative monitoring of PBI and TOI at the bilateral buttocks showed significant improvement of both parameters after HA bypass. HA bypass is an excellent procedure to improve pelvic circulation despite its increased surgical complexity.