感染性股动脉假性动脉瘤的外科治疗

目的 探讨感染性股动脉假性动脉瘤的外科治疗方法.方法 回顾性分析2003年1月至2008年6月期间我院收治的45例感染性股动脉假性动脉瘤行外科治疗患者的资料.43例感染性股动脉假性动脉瘤采用瘤体切除及彻底清创后行人工血管旁路移植治疗; 另2例由于感染严重及瘤体巨大被迫采用瘤体切除并行近、远端动脉结扎.结果 随访3～12个月,平均7.82个月,人工血管旁路移植病例全部保肢成功,切口均二期愈合,无间歇性跛行; 行动脉结扎的2例中,1例因缺血坏疽行膝上高位截肢; 另1例保肢成功,但有间歇性跛行.结论 动脉瘤切除及彻底清创后行人工血管旁路移植是感染性股动脉假性动脉瘤安全、有效的治疗方法.     

注射吸毒所致感染性假性股动脉瘤的股动脉结扎治疗

目的总结股动脉结扎治疗注射吸毒所致感染性假性股动脉瘤的体会。方法对45例注射吸毒所致感染性假性股动脉瘤患者资料进行回顾性分析。采用股动脉或髂外动脉结扎+瘤体切除术治疗感染性假性股动脉瘤,术后预防血栓形成及抗感染治疗,并随访患肢功能。结果44例患者保肢成功,近期患肢行走功能良好。1例术后因深静脉血栓形成,出现肢体坏死而截肢。结论34例(75.6%)获3～12个随访,疗效满意。股动脉结扎是治疗感染性假性股动脉瘤的有效方法。     

血管重建治疗注射毒品所致股动脉假性动脉瘤

目的探讨注射毒品所致股动脉假性动脉瘤的外科治疗方法。方法对14例注射毒品所致股动脉假性动脉瘤患者的临床资料进行回顾分析。9例直接采用ePTFE人工血管行原位移植间置术;4例采用自体大隐静脉原位间置移植术;1例行单纯股深动脉结扎术。结果全部病例术后患肢供血良好,无肢体缺血表现,其中11例患者成功随访1～45个月,1例患者出院后出现伤口感染,余患者伤口均在1个月内愈合,现患肢均无缺血症状,活动自如。结论吸毒所致股动脉假性动脉瘤切除后血管重建有利于保证下肢血供,在患者不能提供合适的自体大隐静脉移植时,人工血管原位移植仍是治疗假性股动脉瘤的有效方法。术中彻底清创及术后伤口引流、加强抗炎是预防术后人工血管并发感染的最主要措施。     

注射吸毒致股动脉假性动脉瘤的围手术期护理

目的总结注射吸毒致股动脉假性动脉瘤的围手术期护理经验。方法回顾分析我院2009年7月~2010年7月收治的35例注射吸毒致股动脉假性动脉瘤患者的临床资料,对围手术期护理经验进行总结分析。结果 35例患者中2例因动脉缺血引起肢体坏死行患肢截肢术,33例行股动脉假性动脉瘤瘤体切除加人工血管旁路移植术治愈出院。结论加强对股动脉假性动脉瘤患者的围手术期护理包括心理护理,术前疼痛、大出血的护理及术后采取预防感染的措施将有利于患者的康复。     

肢体假性动脉瘤的临床诊治(附30例报道)

目的 探讨肢体假性动脉瘤的病因、发病机理以及手术方式的选择,评价各种手术的治疗效果,以提高对假性动脉瘤的诊治水平.方法 30例假性动脉瘤患者(股动脉18例,腘动脉7例,肱动脉2例,桡动脉3例),其中8例为感染或破裂性假性动脉瘤,1例肢体坏死.30例患者均行外科手术治疗,其中11例行假性动脉瘤破口修补术,2例行股动脉结扎术,2例行血管端端吻合术,8例行自体大隐静脉移植术,6例行人工血管移植术,1例行截肢术.结果 30例患者术后恢复顺利,除1例行下肢截肢术外,其余29例术后效果良好.随访7个月～8年,平均(4.4±2.3)年;行人工血管移植术者4例移植段发生血栓,经溶栓治疗后好转,其余血供状况良好.结论 外科手术治疗肢体假性动脉瘤是一种有效的方法.     

毒品注射致股动脉假性动脉瘤破裂出血的诊治

目的探讨注射毒品引起股动脉假性动脉瘤形成并破裂出血的诊断与治疗方法。方法回顾性分析2003年3月—2009年12月收治的22例因反复注射毒品致股动脉假性动脉瘤形成并破裂出血患者的临床资料。结果 22例患者均接受手术治疗,术中行瘤体切除、清创后,8例行股动脉破口修补术;4例行破口两侧股动脉结扎术;10例行髂外动脉-股动脉人工血管移植术。22例均手术成功,手术后早期出现人工血管与股动脉吻合口破裂出血1例,急诊手术重新吻合,随后出现切口感染,经换药后切口愈合。术后患侧下肢功能均好。随访6个月至7年,平均3年。1例患者术后2年出现人工血管感染,1例出院后14d发生吻合口出血,均经再次血管吻合治愈;2例股动脉结扎患者遗留轻间歇性跛行。结论治疗股动脉假性动脉瘤形成并破裂出血的手术方式,以股动脉假性动脉瘤切除+清创+股动脉修补术最为简单、安全有效;人工血管移植术疗效确定,能最大限度保证患肢血供;股动脉修补或结扎术在选择病例中也是有效的治疗方法。     

注射毒品所致假性股动脉瘤18例的外科治疗

目的 探讨注射毒品所致假性股动脉瘤的外科疗法。方法 对18例注射毒品所致辞假性动脉瘤患者的临床资料进行回顾分析。13例直接采用ePTFE人工血管行旁路髂外动脉和股浅动脉端侧吻合术；3例采用自体大隐静脉间置移植术，其中１例吻合口破裂出血改用ePTFE人工血管行旁路髂外动脉和股浅端侧吻合术；2例股动脉结扎术。结果 全部病例保肢成功。血管移植术后复查彩色多普勒超声显示移植血管通畅。结论 在患者不能提供合适的自体大隐静脉移植时，人工血管移植仍是治疗假性股动脉瘤的有效方法。术中彻底清创及避免污染是预防术后人工血管并发感染的最主要措施     

经闭孔旁路术治疗股动脉感染性动脉瘤

目的：探讨采用经闭孔旁路术治疗股动脉感染性动脉瘤的方法和疗效。 方法：回顾性分析2004年8月—2014年7月间采用经闭孔旁路术治疗的4例股动脉感染性假性动脉瘤患者的临床资料。 结果：患者男3例，女1例，平均年龄26.5（22~31）岁，病因为注射吸毒损伤股动脉3例，下肢动脉栓塞介入治疗穿刺点并发症1例。3例接受单纯股动脉结扎及感染性动脉瘤清创术治疗，术后出现下肢缺血，二期行经闭孔髂动脉到股动脉旁路术，1例行同期股动脉结扎、动脉瘤清创加经闭孔髂外动脉到股浅动脉旁路术治疗。平均随访27（8~60）个月，4例患者术后患肢踝肱指数（ABI）为1.0~1.1，无间歇性跛行及其他不适。 结论：同期或分期经闭孔旁路是治疗股动脉感染性假性动脉瘤可避免术后的下肢缺血症状。     

下肢动脉旁路移植术后人工血管感染15例治疗分析

目的 总结下肢动脉旁路移植术后人工血管感染的治疗经验,探讨人工血管感染的防治方法.方法 对2004年1月至2009年12月15例下肢动脉旁路移植术后人工血管感染患者的临床资料进行回顾性分析.男性14例,女性1例,平均64.8岁.感染发生在人工血管末次重建术后5 d～59个月,平均6.4个月.临床表现包括伤口不愈合人工血管外露8例,窦道脓液渗出5例,与人工血管相通的窦道不愈合1例,切口积液并人工血管游离1例.均予以广谱抗生素治疗.外科治疗包括局部清创引流4例,清创并转移皮瓣1例,单纯去除感染闭塞的人工血管5例(其中1例初次旁路移植时同期截肢),去除感染闭塞的人工血管后截肢3例,1例仅行部分去除感染通畅的人工血管(原闭塞支架再通),1例去除通畅感染的人工血管并一期解剖外镀银涤纶人工血管旁路移植术.结果 保肢9例,截肢4例,1例死于术后心肌梗死,1例清创并转移皮瓣术后伤口未愈出院后失访.随访13例,2例随访中分别因结肠癌和脑出血死亡.生存11例随访1～70个月,平均22.3个月,保肢8例未出现严重缺血或感染症状,截肢3例无特殊.本组累积病死率20%(3/15),截肢率26.7%(4/15),人工血管闭塞率53.3%(8/15).结论 下肢动脉旁路移植术后人工血管感染,多数感染的人工血管需取出,如出现严重缺血症状需再次旁路移植,对通畅人工血管的局限性感染也可以考虑保留人工血管.     

下肢动脉旁路移植术后人工血管感染15例治疗分析

目的 总结下肢动脉旁路移植术后人工血管感染的治疗经验,探讨人工血管感染的防治方法.方法 对2004年1月至2009年12月15例下肢动脉旁路移植术后人工血管感染患者的临床资料进行回顾性分析.男性14例,女性1例,平均64.8岁.感染发生在人工血管末次重建术后5 d～59个月,平均6.4个月.临床表现包括伤口不愈合人工血管外露8例,窦道脓液渗出5例,与人工血管相通的窦道不愈合1例,切口积液并人工血管游离1例.均予以广谱抗生素治疗.外科治疗包括局部清创引流4例,清创并转移皮瓣1例,单纯去除感染闭塞的人工血管5例(其中1例初次旁路移植时同期截肢),去除感染闭塞的人工血管后截肢3例,1例仅行部分去除感染通畅的人工血管(原闭塞支架再通),1例去除通畅感染的人工血管并一期解剖外镀银涤纶人工血管旁路移植术.结果 保肢9例,截肢4例,1例死于术后心肌梗死,1例清创并转移皮瓣术后伤口未愈出院后失访.随访13例,2例随访中分别因结肠癌和脑出血死亡.生存11例随访1～70个月,平均22.3个月,保肢8例未出现严重缺血或感染症状,截肢3例无特殊.本组累积病死率20%(3/15),截肢率26.7%(4/15),人工血管闭塞率53.3%(8/15).结论 下肢动脉旁路移植术后人工血管感染,多数感染的人工血管需取出,如出现严重缺血症状需再次旁路移植,对通畅人工血管的局限性感染也可以考虑保留人工血管.     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Immunomodulation in Transplantation with Photopheresis

Abstract: Photopheresis is a technique in which peripheral blood mononuclear cells, in the presence of a photoacti-vatable compound, are exposed extracorporeally to ultraviolet A light and reinfused, inducing a host autoregula-tory immune response. Experimental work and ongoing clinical studies are helping to define the role of this novel, safe, and non-toxic immunomodulating technology in the field of transplantation.