老年腹主动脉瘤患者腔内隔绝围手术期脑保护

目的探讨老年腹主动脉瘤患者腔内隔绝围手术期脑保护及其临床意义。方法根据有无实施脑保护将69例老年腹主动脉瘤行腔内隔绝治疗的患者随机分成两组:保护组38例,对照组31例。对两组术后脑血管意外及脑功能障碍情况进行对比分析。结果两组的年龄、入院时血压、手术时间差异均无统计学意义。两组均未发生死亡和出血性脑卒中。保护组术后谵妄发生率低于对照组(分别为5.3%和41.9%,P<0.05),术后住院时间少于对照组(分别为9.1±3.2d和16.7±5.8d,P<0.05);术后缺血性脑卒中保护组0例,对照组3例,两组比较无统计学意义(0%和9.7%,P>0.05)。结论对老年腹主动脉瘤接受腔内隔绝治疗的患者围手术期采取脑保护能降低脑血管意外和维持大脑功能,有利于患者术后恢复。     

单中心主动脉腔内隔绝术治疗胸降主动脉扩张性疾病的疗效评价

目的 评价主动脉腔内隔绝术治疗胸降主动脉扩张性疾病的近期和远期疗效及安全性.方法 选择沈阳军区总医院2002年4月至2013年10月行主动脉腔内隔绝术治疗胸降主动脉扩张性疾病的患者449例,其中男349例,女100例,年龄（54.3±11.9）岁.经股动脉切开植入覆膜支架封堵胸降主动脉夹层破口或隔绝胸主动脉瘤,主动脉造影确认疗效;合并严重冠状动脉狭窄的患者,于腔内隔绝术后3-7 d完成经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗.观察主动脉疾病患者PCI治疗的疗效.结果 主动脉腔内隔绝术操作成功率为100％,共植入416枚主体覆膜支架及56枚短体覆膜支架.43例患者完全封闭左锁骨下动脉开口,仅1例患者出现严重窃血综合征,行血管旁路移植术.34例患者行PCI治疗成功率为100％,对37支靶血管共植入45枚冠状动脉支架,无出血、心肌梗死等并发症.68例患者出现腔内隔绝术后综合征,76例患者术后有残余漏,其中11例因内漏明显同台或再次行手术治疗.住院期间主动脉破裂病死率为1.3％（6/449）.术后随访（68±29）个月,随访率为79.0％（350/443）.随访期间共死亡患者23例（6.6％）：明确主动脉血管破裂死亡4例,急性心肌梗死1例,脑出血4例,肾功衰竭死亡3例,多器官功能衰竭2例,恶性肿瘤4例,猝死5例（原因不明）.25例联合PCI治疗患者临床造影随访主要心血管事件发生率为8.0％（2/25）.结论 主动脉腔内隔绝术治疗胸降主动脉扩张性疾病近期及长期疗效好,并发症发生率低.合并冠状动脉粥样硬化性心脏病患者择期二次行PCI治疗安全可行,主要心血管事件发生率低.     

Preliminary results of endovascular abdominal aortic aneurysm exclusion with the AneuRx stent-graft

OBJECTIVES: This study evaluated the clinical effectiveness of the Medtronic AneuRx stent-graft in patients with infrarenal abdominal aortic aneurysms (AAAs) who were treated in an endovascular suite. BACKGROUND: The use of endovascular stent-graft prosthesis for the treatment of AAAs is receiving increasing attention as an alternative to standard surgical repair. Endovascular treatment of AAAs offers the potential to avoid the significant morbidity and mortality associated with surgical repair. METHODS: In this series, 215 patients have undergone AAA exclusion with the AneuRx stent-graft. Six-month follow-up is available in 132 patients; one-year follow-up is available in 84 and two-year follow-up in 22. RESULTS: Of the patients, one hundred ninety-two (89%) were male; 87% had hypertension, and 58.6% were American Society of Anesthesiologists grade IV or higher. The procedural success was 99.5%; we were unable to place the device in one patient. There was no procedural or one-month mortality. There were no acute conversions to surgical repair. One patient had a non-Q-wave myocardial infarction 24 h after the procedure. Endoleaks were present in 82 patients (42%) at discharge, 15 patients (11.3%) at six months and 10 patients (11.9%) at one year. Twenty-two patients had a secondary procedure for endoleak repair of which three were conversions to surgical repair. Twelve late deaths have occurred, none due to device failure or AAA rupture. Mean hospital stay was 1.9 days. CONCLUSIONS: These results reveal that infrarenal AAAs can be safely and successfully treated in an endovascular suite with the AneuRx stent-graft. Further follow-up is needed to determine the long-term efficacy of endoluminal treatment to prevent rupture and death due to AAAs.     

覆膜支架腔内隔绝术治疗高龄胸腹主动脉瘤的疗效

目的：探讨主动脉腔内隔绝术治疗高龄患者胸腹动脉瘤的临床效果。方法：回顾性分析我院2004年2月至2011年7月25例实行覆膜支架腔内隔绝术的高龄胸腹主动脉瘤患者（年龄均≥65岁）的临床资料,总结手术效果,术后并发症和死亡率。结果：24例（96％）康复出院,术后并发症发生率24％（6／25）,病死率4％（1／25）,平均住院时间为（14．36±2．46）d,术后住院时间为（9．50±1．58）d。结论：覆膜支架腔内隔绝术可作为治疗高龄主动脉瘤首选方式,但须严格把握手术指征。     

Hemangiosarcoma after endovascular aortic aneurysm repair.

PURPOSE: To report a rare case of hemangiosarcoma after endovascular aneurysm repair (EVAR). CASE REPORT: A 50-year-old man with Klinefelter syndrome presented 5 years after EVAR with a mass at the infrarenal aorta outside the stent-graft. Radiomorphologic and clinical signs were misleading because there had been evidence of an inflammatory process for more than a year. The stent-graft with the surrounding aorta was removed and replaced by a conventional tube graft. Systemic chemotherapy followed. The tumor recurred after 12 months, with pulmonary metastases and tumor embolic occlusion of his left femoral artery. Thrombectomy was performed, and a second course of chemotherapy was administered. The patient died 24 months after the conversion procedure. CONCLUSION: Morphological changes of the aneurysm wall seen on computed tomographic scans of EVAR patients may not be incidental or signs of infection; rather, a malignant tumor of the aorta or lymphatic disease, although rare, have to be taken into consideration as well.     

Dissecting aortic aneurysm involving a right-sided aortic arch.

In this case, the first reported instance of aortic dissection involving a right-sided arch, an anomalous fourth arch vessel, the left subclavian artery, arose from a congenital aortic diverticulum. This report emphasizes the need for precise anatomic definition with aortography to permit appropriate therapy when congenital anomalies of the aortic arch are complicated by dissecting hematoma.     

Left cervical aortic arch associated with aortic aneurysm.

An aortic arch extending into the neck is a rare congenital anaomaly. Left-sided cervical aortic arch was thought to be much less common than right-sided, but they are now almost equal in incidence in the published reports. This paper describes a case of left-sided cervical aortic arch in an adult, with a previously undescribed association, aneurysm of the descending thoracic aorta. Cervical aortic arch must be considered in the differential diagnosis of pulsatile cervical swellings. The embryological development of the aortic arch is discussed. This is still controversial and it is not possible to be sure of the embryological explanation of this congenital anomaly of the aortic arch from a study of the adult anatomy.     

Aortoesophageal fistula following endovascular exclusion of a thoracic aneurysm.

The aim of this study was to report a case of aortoesophageal fistula following endovascular exclusion of a thoracic aneurysm, treated conservatively with fatal outcome. Endovascular exclusion of a thoracic aneurysm was performed in a 64-year-old female patient. Three months later the diagnosis of an aortoesophageal fistula was made and minimal surgery (cervicotomy and jejunostomy) was performed, combined with antibiotherapy and catheter flushing of the infected excluded aneurysm thrombus. The patient died in septic shock 9 weeks later. As reported, following conventional thoracic aortic aneurysm surgery, endovascular stenting of the thoracic aorta can be complicated by aortoesophageal fistula. Management should be surgical, since the outcome under conservative management seems invariably fatal. However, it looks as if the poor condition of these patients may not permit open surgical treatment.     

A double-barrel stent-graft for endovascular repair of the aortic arch.

PURPOSE: To extend the role of endovascular aneurysm repair in the presence of angulation and dilatation of the distal arch that compromise the proximal implantation site. CASE REPORT: A 70-year-old man with an asymptomatic 7-cm thoracic aortic aneurysm was treated with a TAG stent-graft. However, attempts to gain secure hemostatic implantation of the endograft resulted in inadvertent coverage of the subclavian and left carotid arteries. Flow to the left carotid artery was re-established by transcarotid insertion of a self-expanding covered stent alongside the primary stent-graft. CONCLUSION: This technique may have a role as an intended part of endovascular repair when there is no suitable implantation site in the descending thoracic aorta.     

Endovascular exclusion of mycotic aortic aneurysm

The presence of prohibitive risk may preclude usual surgical management. Such was the case for a critically ill, 60-year-old woman who presented with concomitant, life-threatening conditions. The patient presented with acute central cord syndrome and lower-extremity paraplegia after completing a 6-week course of intravenous antibiotics for methicillin-sensitive Staphylococcus aureus bacteremia and osteomyelitis of the thoracic spine. Radiologic examination revealed bony destruction of thoracic vertebrae T4 through T6, impingement on the spinal cord and canal by an inflammatory mass, and a separate 2.5-cm mycotic aneurysm of the infrarenal aorta. The clinical and radiologic findings warranted immediate decompression and stabilization of the spinal cord, aneurysmectomy, and vascular reconstruction. However, the severely debilitated patient could not tolerate 2 simultaneous open procedures. She underwent emergent endovascular exclusion of the mycotic aneurysm with a stent-graft, followed immediately by laminectomy and stabilization of the thoracic spine. Intraoperative microbiology specimens showed no growth. The patient was maintained on prophylactic antibiotic therapy for 6 months. Fourteen months postoperatively, her neurologic function was near full recovery, and neither surveillance blood cultures nor radiologic examinations showed a recurrence of infection or aneurysm.Although the long-term outcome of endovascular stent-grafts in the treatment of culture-negative mycotic aneurysms is unknown, the use of these grafts in severely debilitated patients can reduce operative risk and enable recovery in the short term.     

Relapsing polychondritis with aortic arch aneurysm and aortic arch syndrome

Summary A case of relapsing polychondritis with aortic arch aneurysm and aortic arch syndrome is described. The pattern of vascular involvement supports the inclusion of relapsing polychondritis within the spectrum of systemic vasculitides.     

One-stage hybrid procedure without sternotomy for treating thoracic aortic pathologies that involve distal aortic arch: a single-center preliminary study

Objective

This study aims to evaluate the initial results of a hybrid procedure without sternotomy for treating descending thoracic aortic disease that involves distal aortic arch. It also intends to report our initial experience in performing this procedure.

Methods

A total of 45 patients (35 males and 10 females) with descending thoracic aortic disease underwent a hybrid procedure, namely, thoracic endovascular aortic repair (TEVAR) combined with supra-arch branch vessel bypass, in our center from April 2009 to August 2014. Right axillary artery to left axillary artery bypass (n=20) or right axillary artery to left common carotid artery (LCCA) and left axillary artery bypass (n=25) were performed. The conditions of all patients were followed up from the 2^nd month to the 65^th month postoperative (mean, 26.0±17.1). Mortality within 30 days, complications such as endoleak after the hybrid procedure, and stenosis or blockage of the bypass graft during the follow-up period was assessed.

Results

All the patients underwent a one-stage procedure. One case of death and one case of cerebral infarction were reported within 30 days. One patient died of the sudden drop in blood pressure during the 2^nd day of operation. Meanwhile, another patient suffered from cerebral infarction. Two patients underwent open surgery, and one of them had to undergo a second TEVAR during the follow-up period. Moreover, endoleak occurred in two patients and a newly formed intimal tear was observed in one patient. Overall, 93.2% of the patients survived without any complication related to the hybrid procedure.

Conclusions

Initial results suggest that the one-stage hybrid procedure is a suitable therapeutic option for thoracic aortic pathologies that involve distal aortic arch. However, this procedure is not recommended for type-B aortic dissection, in which a tear is located in the greater curvature or near the left subclavian artery (LSA), because of the high possibility of endoleak occurrence.     

胸主动脉腔内隔绝术治疗DeBakey Ⅲb型夹层动脉瘤的效果

目的:观察胸主动脉腔内修复(EVR)治疗胸主动脉夹层动脉瘤的方法和疗效。方法:15例DeBakeyⅢb型胸主动脉夹层患者行腔内隔绝术。术后对所有患者行CT随访,评价其临床改善程度与真假腔的变化。结果:15例患者全麻下均成功进行了覆膜支架胸主动脉腔内隔绝术,术中造影显示夹层动脉瘤裂口完全封闭或内漏明显较少。术后1～22个月随访,术后30d内死亡1例,1例术后出现左下肢体运动障碍,余13例无明显术后并发症。结论:胸主动脉腔内隔绝术治疗DeBakey Ⅲb型夹层动脉瘤并发症少,术后恢复较好。     

Ruptured right aortic arch aneurysm

A case of a ruptured right aortic arch aneurysm in a 74-year-old woman presenting with shock is reported. The diagnostic and operative findings are presented. We discuss the surgical approach and review the literature.     

Bare metal stents with or without coil embolization for abdominal aortic aneurysm exclusion in high-risk patients.

The objective of the study was to determine if uncovered self-expanding metallic stents with or without polyester-covered coils can exclude abdominal aortic aneurysms (AAA). Exclusion using uncovered metal stents with or without coils has been shown to be successful in the animal model. Twelve patients underwent aneurysmal therapy with uncovered self-expanding metallic stents and polyester covered metallic coils (male, 8; female, 4; mean age, 74 +/- 8 years) because no other therapeutic alternative was available. Indications were severe aorto-iliac disease, presumptively high surgical risk due to comorbidities, a previously failed endograft attempt, and a hostile abdomen as a result of prior surgeries. Under local anesthesia, stents were introduced percutaneously via 10 or 11 Fr sheaths into the femoral artery and deployed in an overlapping fashion to cover the length of the AAA. All endoluminal procedures were successful, and no major complications were encountered. The average hospital stay was 33 +/- 21 hr. At a mean follow-up of 18 +/- 13 months, there was no rupture, leak, or evidence of aneurysm expansion in any of the patients. There was one mortality that was not AAA-related. The remaining patients had no aneurysm-related symptoms. Endoluminal exclusion of an AAA using self-expanding bare metal stents with or without coil embolization may be a viable treatment option for patients who cannot undergo standard surgical or endovascular repair. However, these data do not demonstrate that this methodology actually precludes rupture since the cohort is of small size. Cathet Cardiovasc Intervent 2001;54:12-18.     

Renal consequences of endovascular abdominal aortic aneurysm repair.

Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) is less invasive and has a lower operative mortality than conventional surgery. The relationship between renal function and outcome following open AAA repair has been extensively investigated, but less work has been undertaken with respect to renal function and outcome after EVAR. We reviewed the literature (Medline and PubMed databases) between 1991 and 2007 to investigate the relationship between EVAR and renal dysfunction. Our review found that perioperative renal dysfunction is attenuated by EVAR. However, dialysis rates after EVAR are similar to those after open surgery. EVAR patients develop progressive deterioration in renal function over time. The etiology is unclear and probably multifactorial, involving embolization, contrast media, and graft misplacement. The effect of transrenal endograft fixation on long-term renal function is unknown, but the technique may be associated with a significantly increased risk of renal infarction. The etiology of the renal injury during and after EVAR needs further evaluation, and techniques aimed at renal preservation should be pursued.