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。     

腹主动脉瘤腔内修复术中特殊远端锚定区的处理经验

目的探讨腹主动脉瘤腔内修复术中特殊远端锚定区的处理方法以及并发症。方法自1997年5月至2006年12月在150例包括髂总动脉瘤、髂内动脉瘤、髂动脉狭窄、严重成角等特殊远端锚定区的腹主动脉瘤腔内修复术中,根据情况选择不同的处理方式,术后观察内漏、缺血并发症、髂动脉瘤形态以及旁路血管的通畅性。结果围手术期死亡率4％（6／150）,总死亡率42．5％（51／120）。6例原发性远端I型内漏,5例自愈,1例转化为持续性内漏;3例髂内动脉返流引起的Ⅱ型内漏随访中均自愈。7例单臂支架型血管,股股旁路手术2年通畅率为86％;4例髂内动脉旁路手术2年通畅率为100％。11例栓塞单侧髂内动脉出现臀肌缺血症状,平均症状消失时间42 d（5-90 d）。结论结合传统外科技术以及腔内技术,并选择合适的产品处理腹主动脉瘤特殊远端锚定区可取得满意疗效。中远期结果仍需观察。     

肾下型腹主动脉瘤腔内修复治疗的并发症分析

目的：总结腔内修复治疗腹主动脉瘤的经验,探讨并发症的及防治策略。方法：回顾分析及随访已接受腔内修复治疗的43例肾下型腹主动脉瘤患者的临床资料,分析腔内修复手术并发症的病因和防治。结果：本组发生了内漏、支架移位、移植物综合征、手术入路损伤等支架相关并发症。最常见的是内漏,发生原发性内漏11例,Ⅰ型8例,Ⅱ型1例,Ⅲ型2例。Ⅱ型内漏术中未处理,Ⅰ、Ⅲ型内漏经过球囊扩张、植入支架型血管或裸支架等处理后仍残留2例J型内漏。4例手术入路损伤经内膜剥脱治愈。随访发现迟发性内漏4例,继续随访1～2年,未见瘤体明显增大;手术结束时残留的3例原发性内漏自愈,但其中1例出现内漏复发及支架移位,导致动脉瘤复发破裂而再次接受腔内治疗。结论：支架相关并发症与动脉瘤血管解剖条件、移植物缺陷和操作技术有关,其防治需要良好把握手术适应证、合理选择支架及成熟的操作经验。     

腔内修复术治疗肾下型腹主动脉瘤的内漏防治：附43例报告

目的：总结应用腔内修复术治疗腹主动脉瘤的经验,探讨内漏的防治策略。方法：回顾性分析齐鲁医院及莱钢医院2007年1月—2012年12月接受腔内治疗的43例肾下型腹主动脉瘤患者临床资料,分析内漏的发生原因、预防和处理。结果：术后发生原发性内漏11例,其中I型8例,III型2例;植入分叉型支架发生9例,植入直管型支架发生2例。1例II型因漏血量小未处理;经一期经过球囊扩张、植入支架型血管或裸支架等处理后,除2例I型内漏仍有残留,其余I,III型内漏均消失。39例患者获随访4~50个月,发现迟发性Ib型、II型内漏各2例,继续随访1~2年,未见瘤体明显增大。3例残留原发性内漏自愈,术后半年复发Ia型内漏1例,导致动脉瘤复发破裂而再次接受腔内治疗。结论：内漏的发生与动脉瘤的解剖学条件、移植物缺陷和操作技术有关;防治内漏需要把握好手术适应证、合理选择支架,并有成熟的操作经验。

     

腹主动脉腔内修复术后II型内漏的栓塞治疗：附3例报告

目的:探讨腹主动脉腔内修复术(EVAR)后Ⅱ型内漏的治疗方法。方法:回顾性分析2011—2016年中南大学湘雅医院血管外科治疗的3例EVAR术后比较严重的Ⅱ型内漏患者的临床资料,1例胸腹主动脉瘤行杂交手术(开放手术重建内脏血管+EVAR)后瘤体继续增大,检查发现为腹腔干动脉反流性内漏;另外2例均为腹主动脉瘤行EVAR术后肠系膜下动脉反流性内漏。结果:腹腔干动脉反流性内漏患者用Interlock可解脱弹簧圈系统栓塞,另外2例采用普通弹簧圈栓塞。3例栓塞均获得成功,内漏消失。结论:EVAR术后Ⅱ型内漏采用不同的入路栓塞是行之有效的方法。     

腹主动脉腔内修复术后内漏的原因分析及处理

腹主动脉腔内修复术(endovascular aortic repair,EVAR)是目前治疗腹主动脉瘤的重要手段,和传统的开放手术相比可提高患者的早期生存率[1]。内漏是血管腔内修复术特有且最常见的并发症,对手术效果及患者预后均有影响,是目前EVAR治疗腹主动脉瘤的难点。根据术后瘤腔血流来源,可将内漏分为Ⅰ~Ⅴ型[2]。本文将对各型内漏发生的原因及相应的处理作一论述。     

弹簧圈栓塞治疗腹主动脉瘤腔内修复术后持续性Ⅱ型内漏

目的探讨分支血管栓塞治疗腹主动脉瘤腔内修复(endovascular aneurysm repair,EVAR)术后持续性Ⅱ型内漏的效果。方法回顾性分析2014年6月～2018年6月312例EVAR资料,268例资料完整,复查主动脉CTA诊断Ⅱ型内漏34例(12.7%),其中5例为持续性Ⅱ型内漏,均为男性,年龄(64.8±10.0)岁,行分支血管弹簧圈栓塞。结果 5例Ⅱ型内漏均为肠系膜下动脉逆灌注瘤腔,其中经肠系膜上动脉-肠系膜下动脉侧支血管汇入瘤腔3例,腹腔干动脉-肠系膜下动脉侧支血管汇入瘤腔2例。术前主动脉CTA和术中DSA造影均见迂曲血管及支架外瘤腔内对比剂着色。5例均经股动脉入路,避开重要分支血管行弹簧圈栓塞瘤腔供血分支动脉,均获技术成功。术后随访3～18个月,平均10个月,Ⅱ型内漏供血分支动脉栓塞确切,瘤腔体积缩小率4.8%～25.5%,(12.7±8.1)%,无严重并发症发生。结论对于EVAR术后持续性Ⅱ型内漏,分支血管栓塞治疗操作简单安全,疗效确切。     

肾动脉下腹主动脉瘤腔内治疗后并发症的防治

目的　总结肾动脉下腹主动脉瘤腔内治疗后常见并发症的预防与处理。　方法对已施行腔内治疗的 71例肾下腹主动脉瘤患者的临床资料进行回顾性分析 ,讨论常见并发症发生的原因、处理、结果及预后。　结果　 71例接受腔内治疗的肾动脉下腹主动脉瘤患者技术成功率1 0 0 % ,无中转开腹手术者。原发性内漏 8例 ,神经并发症合并急性血栓形成 1例。一过性缺血性肠炎 2例。无肾动脉梗死、肢体栓塞等并发症。平均随访时间 (2 6± 5)个月。围手术期病死率 1 3 % (1 /71 ) ,总病死率 4 2 % (3/ 71 )。死亡原因 2例为急性心肌梗死 ,1例为急性心功能衰竭。随访过程中发现 3例原发性内漏转为持续性内漏 ,另发现继发性内漏 4例。本组患者 1个月后内漏发生率 9 8%(7/ 71 )。 2例继发性Ⅰ型内漏随访中瘤体增大 ,1例进行二期腔内治疗。　结论　动脉瘤的腔内治疗具有创伤小、技术操作可行、效果肯定的优点 ,内漏血是该技术主要并发症。对漏血量及瘤体有增大趋势的内漏应积极处理     

降主动脉瘤的腔内移植物治疗

目的 探讨腔内移植物治疗降主动脉瘤的可行性。方法 12例降主动脉瘤接受了血管腔内技术治疗,包括5例真性动脉瘤、6例Stanford B型夹层动脉瘤及1例假性动脉瘤。13枚支架型血管在局部（n=2)或全身麻醉（n=10)下经一侧股动脉切开安装在病变部位。结果 腔内技术成功率100％。无瘤体破裂、截瘫、脏器及肢体缺血等并发症。早期并发症：3例早期内漏血。CT及MRA随访1－30个月：5例真性动脉瘤4例被完全旷置,1例内漏转化为持续性。6例Stanford B型夹层入口4例一期封堵满意,2例少量内漏血自愈,4例假腔内完全血栓形成2,例部分形成。1例假性动脉瘤效果满意。结论 腔内移植物治疗降主动脉瘤是一种安全、可靠、实用的新方法。但其远期治疗效果有待继续观察,尤其是夹层动脉瘤的腔内治疗具有更多的不确定性。     

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。     

Endoleak after endovascular repair of abdominal aortic aneurysm.

PURPOSE: We sought to assess the role of endovascular techniques in the management of perigraft flow (endoleak) after endovascular repair of an abdominal aortic aneurysm. METHOD: We performed endovascular repair of abdominal aortic aneurysm in 114 patients, using a variety of Gianturco Z-stent-based prostheses. Results were evaluated with contrast-enhanced computed tomography (CT) at 3 days, 3 months, 6 months, 12 months, and every year after the operation. An endoleak that occurred 3 days after operation led to repeat CT scanning at 2 weeks, followed by angiography and attempted endovascular treatment. RESULTS: Endoleak was seen on the first postoperative CT scan in 21 (18%) patients and was still present at 2 weeks in 14 (12%). On the basis of angiographic localization of the inflow, the endoleak was pure type I in 3 cases, pure type II in 9, and mixed-pattern in 2. Of the 5 type I endoleaks, 3 were proximal and 2 were distal. All five resolved after endovascular implantation of additional stent-grafts, stents, and embolization coils. Although inferior mesenteric artery embolization was successful in 6 of 7 cases and lumbar embolization was successful in 4 of 7, only 1 of 11 primary type II endoleaks was shown to be resolved on CT scanning. There were no type III or type IV endoleaks (through the stent-graft). Endoleak was associated with aneurysm dilation two cases. In both cases, the aneurysm diameter stabilized after coil embolization of the inferior mesenteric artery. There were two secondary (delayed) endoleaks; one type I and one type II. The secondary type I endoleak and the associated aneurysm rupture were treated by use of an additional stent-graft. The secondary type II endoleak was not treated. CONCLUSIONS: Type I endoleaks represent a persistent risk of aneurysm rupture and should be treated promptly by endovascular means. Type II leaks are less dangerous and more difficult to treat, but coil embolization of feeding arteries may be warranted when leakage is associated with aneurysm enlargement.     

Infrarenal Abdominal Aortic Aneurysm Complicated by Persistent Endotension After Endovascular Repair: Report of a Case

Endoleak and endotension may prevent the successful exclusion of an aneurysm after endovascular aortic aneurysm repair (EVAR). The pressurization in the excluded aneurysm sac caused by endotension may lead to rupture of the aneurysm; however, the cause of endotension and its underlying mechanisms remain unclear. We report a case of infrarenal abdominal aortic aneurysm (AAA) complicated by persistent endotension after EVAR. Although no endoleaks were found on conventional double-phase computed tomographic scans, a thrombosed endoleak existed in the side branch and attachment site of the endograft. After treating the undetectable thrombosed endoleaks, physical examination revealed that the pressure of the excluded aneurysm had diminished, with shrinkage of the aneurysm. This case report suggests that a high-pressure undetectable type I or type II endoleak could be a major cause of endotension. Thus, postoperative evaluation of the attachment site of an endograft is important after EVAR.     

Management of endoleak after endovascular aneurysm repair: cuffs,coils, and conversion

OBJECTIVE: The effectiveness of endovascular treatment of abdominal aortic aneurysm (AAA) may be limited by persistent perfusion of the aneurysm sac (endoleak). Endoleak that results in persistent systemic pressurization of the aneurysm or in continued AAA expansion is believed to require treatment to prevent rupture. This report describes the results of three techniques used to treat endoleak. METHODS: Endovascular repair of AAA was performed in 597 patients between January 1996 and September 2002. Seventy-three endoleaks that required treatment developed in 70 patients (11.7%). These involved the graft attachment site (type I) or the graft junction site (type III) or originated from collateral side-branch vessels (type II) and were associated with an increase in aneurysm size. Endoleak type was confirmed at angiography in all cases. Average time between the initial endovascular procedure and endoleak treatment was 14.5 +/- 5.7 months. The techniques used for endoleak treatment were deployment of an endovascular extension graft or cuff (n = 44), coil embolization (n = 24,) and conversion to conventional open repair (n = 5). Configurations of endovascular grafts in which endoleak developed were bifurcated (n = 44), aortouniiliac (n = 15), and aortoaortic-tube (n = 11). Mean follow-up after endoleak treatment was 24.5 +/- 12.2 months (range, 1-60 months). RESULTS: Endovascular extension grafts or cuffs were used to treat 41 attachment site endoleaks and 3 graft junction endoleaks, with overall technical success rate of 97%. Embolic coils were used to treat 16 retrograde side-branch endoleaks and 8 attachment site endoleaks, with overall technical success rate of 87%. Conversion to open surgery was performed in 4 patients with attachment site endoleaks and 1 patient with a graft junction site endoleak, and was successful in all cases. After endoleak treatment, aneurysm size decreased (>5 mm) in 38% of patients, stabilized in 58% of patients, and increased (>5 mm) in 4% of patients. Major morbidity occurred in 7.0%, with no perioperative deaths. CONCLUSIONS: Endovascular extension grafts, coil embolization, and conversion to open surgery each may be used to effectively repair endoleak. Selection of the treatment method used is determined by the anatomic characteristics of the endoleak and the patient's ability to tolerate conventional repair. Conversion to open repair was uniformly successful. Deployment of an extension cuff was successful when complete closure of the endoleak was achieved. Embolic coils were effective for retrograde endoleaks and provided stabilization of AAA size in selected patients with attachment site endoleaks in limited follow-up.     

Conformational changes associated with proximal seal zone failure in abdominal aortic endografts

OBJECTIVE: Endovascular aneurysm repair (EVAR) has become a popular treatment for abdominal aortic aneurysm (AAA). This study examines conformational changes in the infrarenal aortas of patients in whom proximal seal zone failures (PSF) developed after EVAR. METHODS: All 189 patients with aortic endograft underwent routine post-EVAR computed tomographic scan surveillance. Patients identified with proximal type I endoleaks, type III endoleaks, or proximal component separation without demonstrable endoleak underwent three-dimensional reconstruction of the computed tomographic scans from which measurements of the migration, length, volume, and angulation of the infrarenal aorta were made. RESULTS: Five patients (3%) had PSF develop, four of whom had aortic extender cuffs. Although changes in the AAA volume and aortic neck angle were slight or variable, the mean AAA length increased 34 mm and the mean aortic body angulation increased 17 degrees (P =.03 and.01, respectively). Lengthening and migration caused proximal component separation in four patients, with concomitant migration in two patients. Two patients underwent endovascular repair, two patients needed explantation of the endograft, and one patient awaits endovascular repair. Proximal component separation and type III endoleak recurred in one patient and were repaired with a custom-fitted graft. CONCLUSION: PSF of aortic endografts is associated with proximal angulation and lengthening of the infrarenal aorta. These findings reinforce the importance of proper initial deployment to minimize the need for aortic extender cuffs, which pose a risk of late endoleak development.     

Laparoscopic transperitoneal clipping of the inferior mesenteric artery for the management of type II endoleak after endovascular repair of an aneurysm

We report the case of a high risk patient with an abdominal infrarenal aortic aneurysm (AAA) who was treated by endovascular technique and the subsequent management of a type II endoleak by the laparoscopic approach. In this case, a 74-year-old woman with a 6-cm infrarenal AAA underwent endovascular repair using a bifurcated stent-graft device. Surveillance CT scan showed a persistent type II endoleak at 1 week and 3 months after the operation. Angiography confirmed retrograde flow from the inferior mesenteric artery (IMA). Attempted transarterial embolization of the IMA via the superior mesenteric artery was not successful. Laparoscopic transperitoneal IMA clipping was performed. Subsequent aortic duplex scan and CT scan confirmed complete elimination of the type II endoleak. We conclude that a combination of endovascular and laparoscopic procedures can be used to manage AAA successfully.     

What is the significance of endoleaks and endotension

Endovascular repair has been used over a decade as a treatment of abdominal aortic aneurysm, and has become a widely accepted treatment method with a low rate of perioperative complications. Endoleak, perigraft blood flow outside endograft but within aneurysmsac, has been intensively studied during the last 10 years of endovascular aneurysm repair (EVR). The natural history of aneurysms with endoleak and the true clinical significance of various types of endoleaks remains unclear. Type I/III endoleak has been found to be associated with aneurysm rupture, while the risk of rupture of aneurysms with type II endoleak and endotension appears very small. In endotension, the aneurysm sac remains pressurized, even if there is no evidence of an endoleak. Currently,it is accepted that type I/III endoleaks should be corrected, preferably by endovascular means, due to the risk of rupture. If endovascular repair is not possible, then open conversion should be considered. The risk of conversion should be weighed against the risk of aneurysm rupture. Treatment of type II endoleaks and endotension is more controversial. In those with aneurysm enlargement,secondary interventions are often performed.     

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.