一站式杂交手术治疗复杂胸腹主动脉疾病

目的总结应用Hybrid技术,腹主动脉去分支化联合降主动脉腹主动脉腔内修复术治疗复杂胸腹主动脉疾病的经验及效果。方法 2016年10月～2020年10月我院收治胸腹主动脉病变病人10例,其中胸腹主动脉瘤1例,胸腹主动脉夹层9例。根据主动脉疾病累及范围,先行相应累及部位的内脏动脉旁路手术,再一期或二期行主动脉腔内覆膜支架修复。随访3～48个月,中位随访时间24.5个月。结果所有手术均成功完成,其中9例一期腔内修复,1例二期腔内修复。同期手术平均手术时间8.5小时,平均腔内手术时间2.0小时。术后30天无死亡病例,围术期5例急性肾损伤,5例急性肝损伤,3例肠梗阻,1例肠漏。其中肠漏瘘病人术后3个月出院。至随访结束时,所有病人无内漏、截瘫,随访期间所有旁路血管通畅,无狭窄。结论杂交技术治疗复杂胸腹主动脉病可行,近中期疗效满意,长期效果有待进一步随访。     

胸腹主动脉瘤围手术期脑脊液引流对脊髓的保护

轻瘫及截瘫是胸腹主动脉瘤传统开放手术和腔内隔绝术严重的并发症之一，其发生率为3．6％～12．0％，长期的康复锻炼和护理给患者、家庭、社会增加了沉重负担。目前主要的治疗方法包括脑脊液引流、系统应用糖皮质激素、控制血压、利尿及物理治疗等，其中脑脊液引流被认为是逆转神经损害最为有效的方法。     

胸降主动脉瘤腔内修复41例治疗体会

目的 总结胸降主动脉瘤腔内修复治疗方法和经验.方法 回顾分析2001年1月至2007年7月41例胸降主动脉瘤患者腔内修复诊治经过、结果和并发症,其中4例行辅助性右-左颈总动脉、左颈总动脉-左锁骨下动脉旁路术,二期(1周后)或一期行腔内修复治疗.结果 41例移植物均被放置在预定位置.2例患者(4.9%)围手术期分别因多器官功能衰竭和急性心肌梗死而死亡.18例患者(43.9%)术后即时造影显示近端Ⅰ型内漏;其中4例内漏量大,行球囊扩张后内漏消失.2例(4.9%)患者围手术期出现急性肾功能不全,1例透析时间超过30 d.其余患者围手术期无脑卒中、截瘫、动脉瘤破裂或肢体严重缺血等并发症.26例(63.4%)患者获随访,随访时间为1～60个月[平均(18.6 ±4.2)个月].1例术后4年发生支架型人工血管移位并发Ⅰ型内漏,1例术后2年于支架型人工血管连接处出现Ⅲ型内漏,均再次行腔内修复治疗.2例死于其他疾病.其余患者术后3个月CT证实瘤腔内完全血栓形成,无支架移位和内漏.随访期间动脉瘤最大直径缩小0～22 mm,平均(8.3±4.5)mm,4例辅助性动脉旁路均通畅.结论 腔内修复治疗胸降主动脉瘤技术上可行,具有创伤小、术后恢复快和并发症少等优点.有条件者,特别对不能耐受传统手术的患者应优先考虑腔内修复治疗.     

脑脊液引流防治胸腹主动脉瘤腔内修复术后脊髓损伤疗效及安全性的系统评价和Meta分析

目的:系统评价应用脑脊液引流术(CSFD)防治胸腹主动脉瘤(TAAA)腔内修复术后脊髓损伤(截瘫、轻瘫)的疗效和安全性。方法:计算机检索多个国内外文献数据库,并辅以手工检索。收集公开发表的关于CSFD防治TAAA腔内修复术后脊髓损伤的随机对照试验(RCT)。采用RevMan 5.3统计软件进行系统评价和Meta分析。结果:共纳入5个RCT,424例患者,其中行CSFD治疗232例(CSFD),未行CSFD治疗192例(对照组)。Meta分析结果显示,CSFD组较对照组脊髓损伤发生率明显低于对照组(OR=0.45,95%CI=0.26～0.76,P=0.003);治疗和随访期末,CSFD组的总病死率低于对照组,但差异无统计学意义(OR=0.67,95%CI=0.31～1.44,P=0.31);CSFD组6例发生CSFD治疗引起的相关并发症,对照组0例发生,但两组并发症发生率差异无统计学意义(OR=4.38,95%CI=0.75～25.49,P=0.10)。结论:CSFD预防和治疗TAAA腔内修复术后脊髓缺血损伤疗效确切,但是证据质量和推荐等级较低。操作风险尚存在一定争议,对于有高度截瘫风险或者是已表现为截瘫的患者,实施CSFD治疗是可取的;而对于发生截瘫风险较低且存在出血等并发症的患者,应充分评估风险-获益比,谨慎操作。     

肾动脉平面以上主动脉瘤的治疗

目的　探讨肾动脉平面以上主动脉瘤 (AAARA)的治疗经验。方法　回顾性分析12 0例AAARA的临床资料。结果　夹层动脉瘤 84例 ,真性动脉瘤 2 7例 ,假性动脉瘤 9例。病变累及全程主动脉者 12例 ,主动脉弓 9例 ,胸降主动脉 2 0例 ,降胸至腹主动脉分叉部或以下 43例 ,胸腹主动脉 2 5例 ,涉及内脏动脉 11例。施行手术或支架型人工血管微创治疗74例。术中至术后 30d内死亡 11例 (14 9% )。术后并发症 9例 ,无截瘫、偏瘫或卒中发生。 16例腔内治疗病人中无严重并发症或死亡者。随访 48例 ,随访时间 1个月～ 15年 ,5例死亡 (10 4% )。保守治疗 46例中 ,44 1%死于瘤体破裂或其它严重并发症。结论　AAARA开胸手术仍存在着很大风险 ,而多种多样的支架型人工血管腔内置放和腔内开窗治疗有着良好前景 ,腔内血管外科技术将成为治疗AAARA的主流。     

胸腹主动脉瘤腔内治疗的发展与现状

胸腹主动脉瘤是一种凶险的血管疾病,传统手术操作复杂、难度大、死亡率和并发症发生率高,为提高手术的治疗效果,已有应用腔内技术治疗胸腹主动脉瘤。文中简要介绍胸腹主动脉瘤腔内治疗的现状,包括腔内治疗适应证、禁忌证、手术方法和结果,以及术后截瘫等并发症的研究现状。     

瘤颈捆扎治疗腹主动脉瘤腔内修复术后持续内漏的疗效分析

目的总结瘤颈捆扎治疗腹主动脉瘤腔内修复术后持续内漏的疗效。方法回顾性分析2019年6月至2022年4月北京大学人民医院10例行瘤颈捆扎手术患者的临床及随访资料。结果手术指征为术后持续Ⅰ型内漏6例、Ⅱ型内漏3例、存在内张力1例, 均合并动脉瘤增大或破裂。全麻下经腹入路套带控制肾下近端瘤颈后使用捆扎带进行加固。10例患者均获得手术成功, 无内漏残留, 无支架移植物闭塞。围手术期并发症包括1例伤口愈合延迟和1例不完全性肠梗阻, 无围手术期死亡。中位随访时间13个月, 未发现内漏复发。1例患者术后6个月因胸降主动脉瘤接受胸主动脉瘤腔内修复术;无其他主动脉相关二次手术或主动脉相关死亡。结论瘤颈捆扎治疗腹主动脉瘤腔内修复术后持续内漏相对微创, 可以有效消除内漏。     

胸腹主动脉瘤修复术后脊髓缺血损伤的发生机制及其防治

胸腹主动脉瘤修复术因其高病死率和高并发症率,一直是心血管外科极具挑战的手术。目前临床上常用于治疗胸腹主动脉瘤的手术方式有传统开放手术、杂交手术、腔内修复术。术后主要的并发症脊髓缺血损伤可导致患者截瘫,严重影响患者远期生存率和生活质量。本文主要针对胸腹主动脉瘤修复术后脊髓缺血损伤的发病机制、危险因素、防治措施进行总结和思考。     

开窗型支架治疗胸腹主动脉瘤(附1例报告)

胸腹主动脉瘤是指同时累及胸主动脉和腹主动脉的动脉瘤以及累及肾动脉领域及以上的腹主动脉瘤,其常规手术复杂,创伤巨大。腔内修复治疗胸腹主动脉瘤尚处于起步阶段,国内近期仅完成3例。近期,中国医科大学附属第一医院成功应用腔内修复技术救治Ⅳ型胸腹主动脉瘤1例。报告如下。     

胸腹主动脉瘤手术中辅助方法的应用

胸腹主动脉瘤修复手术难度大,术后并发截瘫及内脏功能障碍的发生率高。为提高胸腹主动脉瘤手术的治疗效果,在术中已采用许多辅助方法。本文着重介绍了这些辅助方法的优缺点及其研究进展。     

胸腹主动脉瘤手术中脑脊液引流对脊髓的保护作用

目的探索胸腹主动脉瘤手术患者脑脊液引流(CSFD)对脊髓的保护作用。方法将2008年12月至2009年8月北京安贞医院的30例胸腹主动脉瘤手术患者,按照术中是否行CSFD,采用计算机随机法分为CSFD组(15例,其中男12例,女3例;平均年龄45.0岁)和对照组(15例,其中男11例,女4例;平均年龄45.8岁),进行升主动脉和主动脉弓部置换+降主动脉支架植入或胸腹主动脉联合置换术,部分患者同时行Bentall手术或半弓置换手术,CSFD组行CSFD。术中和术后固定时间点采取血清样本,测定其血清S100B蛋白、神经胶质原纤维酸性蛋白、神经元特异性烯醇化酶,术前、术后72 h和出院时按美国国立卫生研究院卒中量表和脊髓损伤神经学分类国际标准评分。结果对照组4例出现中枢神经系统(CNS)并发症:1例发生脑损伤和脊髓损伤而死亡;1例发生脊髓损伤,早期行CSFD等治疗,截瘫有所恢复后出院;2例患者发生脑损伤,其中1例死亡,另1例同时出现肾功能衰竭和呼吸衰竭等并发症,经治疗后恢复出院。CSFD组仅1例因呼吸衰竭继发多器官功能衰竭而死亡,其余患者恢复良好出院。随访3个月无死亡。CSFD组患者血清S100B(F=7.153,P=0.012)、神经胶质原纤维酸性蛋白(F=3.263,P=0.082)和神经元特异性烯醇化酶(F=4.927,P=0.035)值均低于对照组,且差异有统计学意义。结论脑脊液选择性引流具有明确的脊髓保护作用,在胸腹主动脉瘤手术中安全、有效并可行。     

Endovascular repair for a descending thoracic aortic aneurysm with a stent-graft covering the celiac artery: Report of two cases

An adequate landing zone for fixation and sealing is necessary for endovascular aneurysm repair (EVAR). This report presents two cases of a successful EVAR for thoracic aortic aneurysms (TAA) with a stent-graft covering the celiac artery (CA) to secure a distal landing zone. Case 1 was a 61-year-old man with a chronic traumatic descending TAA 12 mm away from the CA. Case 2 was a 79-year-old man with a descending TAA proximal to the CA. Preoperative angiography and computed tomography (CT) scan revealed a normal visceral blood flow including the peripancreatic arteries. Endovascular aneurysm repair with coverage of the CA was performed in both cases. Angiography after the EVAR demonstrated good blood flow to the CA branches via the peripancreatic arteries and a CT scan showed thrombosed aneurysms. Both patients were discharged without any abdominal symptoms. Endovascular aneurysm repair with a stent-graft covering the CA may therefore be an acceptable endovascular approach in treating selected TAA patients with a limited distal landing zone.     

Survival in Thoracic or Thoracoabdominal Aortic Aneurysm: Comparison between patients with or without surgical treatment

The surgical mortality among 22 patients treated for thoracic or thoracoabdominal aneurysm was compared with the mortality in 47 patients managed without surgery. Surgical mortality (<30 days) was low (1/13) in ascending aortic aneurysm, but higher (3/8) in aneurysm of the descending or thoracoabdominal aorta (including both acute and elective operations). Of the 20 non-surgically managed patients in the latter group, 15 died after a mean of 1.1 year. The only patient operated on for aortic arch aneurysm died of cerebral ischaemia 2 days postoperatively. Most of the 19 non-operated patients with aneurysm of the arch or total aorta (mean age 76 years) were never considered for surgical treatment. The analysis supports aggressive management of patients with aneurysm of the ascending, descending or thoracoabdominal aorta. Many of our patients with aneurysm of the arch or involving most of the aorta were old and had other, concomitant diseases, and in such cases an aggressive treatment strategy does not seem justified.     

Surgical treatment of thoracoabdominal aortic aneurysm after repairs of descending thoracic or infrarenal abdominal aortic aneurysm.

OBJECTIVE: The outcome of thoracoabdominal aortic aneurysm repair after operations for descending thoracic or infrarenal abdominal aortic aneurysm was investigated. METHODS: Between May 1982 and July 2000, 102 patients underwent thoracoabdominal aortic aneurysm repair. Of these patients, 36 had previously undergone operations for descending thoracic or abdominal aortic aneurysm. To evaluate the influence of previous descending thoracic or infrarenal abdominal aortic aneurysm repair on the results of TAAA replacement, patients were divided into two groups: one group of patients who had previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group I, n=36) and one group of patients who had not previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group II, n=66). RESULTS: Patients with previous descending thoracic or infrarenal abdominal aortic aneurysm repair had more chronic dissection and extensive thoracoabdominal aortic aneurysm. The distal aortic perfusion time and total aortic clamp time were both longer in group I. The total selective visceral and renal perfusion time and operation time did not differ significantly between the two groups. In 30-day mortality rates were 5.5% in group I and 13% in group II. Major postoperative complications included paraplegia in 14% of patients in group I and 3.1% in group II, renal failure requiring hemodialysis in 22% of patients in group I and 19% of patients in group II, respiratory failure in 36% of patients in group I and 30% of patients in group II, postoperative hemorrhage in 11% of patients in group I and 16% of patients in group II. CONCLUSION: The presence of a previous descending thoracic or infrarenal abdominal aortic aneurysm did not adversely affect the outcome of thoracoabdominal aortic aneurysm repair.     

Thoracoabdominal aortic aneurysm repair through redo left-sided thoracotomy

BACKGROUND: The outcome of thoracoabdominal aortic aneurysm repair through redo-left thoracotomy after operations for descending thoracic aortic aneurysms was investigated. METHODS: Between May 1982 and March 2003, 100 patients underwent thoracoabdominal aortic aneurysm repair in elective surgery without profound hypothermic circulatory arrest. Thirty of these patients had previously undergone operations for descending thoracic aortic aneurysms. To evaluate the influence of previous descending thoracic aortic aneurysm repairs on the results of thoracoabdominal aortic aneurysm replacements, patients were divided into two groups: (1) patients who had previously undergone descending thoracic aortic aneurysm repair (group I; n = 30), and (2) patients who had not previously undergone descending thoracic aortic aneurysm repair (group II; n = 70). RESULTS: The distal aortic perfusion time and operation time were both longer in group I than in group II, but there was no significant difference between the two groups in total selective visceral and renal perfusion time or aortic clamp time. In-hospital mortality rates were 13% in group I and 19% in group II (p = 0.52). Major postoperative complications included paraplegia (10% of patients in group I and 4.3% of patients in group II; p = 0.36), renal failure requiring hemodialysis (20% of patients in group I and 11% of patients in group II; p = 0.35), respiratory failure (30% of patients in group I and 19% of patients in group II; p = 0.22). CONCLUSIONS: Previously descending thoracic aortic aneurysm and redo-left thoracotomy do not adversely affect the outcome of thoracoabdominal aortic aneurysm repair.     

Urinary retention after endovascular treatment for aortic aneurysm: A single hospital experience

ObjectiveAfter endovascular aortic repair (EVAR) for aortic aneurysm, some patients may develop urinary retention that may be vasogenic or neurogenic. This single-institution study investigated the characteristics of patients who developed urinary retention after EVAR for aortic aneurysm.Materials and MethodsPatients with thoracic or abdominal aortic aneurysms and who underwent EVAR between November 2005 and October 2012 were reviewed. Those with post-operative urinary retention requiring urodynamic evaluation with filling cystometry (CMG) were identified. Their characteristics, surgical details, and urodynamic findings were collected for analysis.ResultsDuring the study period, 736 patients received endovascular treatment. Ten patients (nine males and one female; mean age at surgery, 71 ± 15.0 years) developed post-operative urinary retention, for an incidence rate of 1.36%. Two had co-morbid benign prostatic obstruction but all had aneurysm involving the thoracic aorta, with the largest mean aneurysm diameter at 64.8 ± 22.6 mm. All of the distal landing zones were above the celiac trunk and without occlusion of the blood supply to the urinary bladder. Seven patients had cerebrovascular complications or spinal cord ischemia. The CMG done within three months showed detrusor normoreflexia or over-activity in five, poor compliance of the urinary bladder in three, and acontractile detrusor in two patients. Those with acontractile detrusor had detrusor over-activity on follow-up CMG. Eight had successful decatheterization, while two with poor compliance of the urinary bladder needed long-term catheterization. The mean urethral catheter retention duration was 51.4 ± 33.1 days.ConclusionsUrinary retention is a rare complication after EVAR for thoracic aortic aneurysm. Spinal cord ischemia or cerebrovascular complications may be contributory.     

Thoracoabdominal or descending aortic aneurysm repair after preoperative demonstration of the Adamkiewicz artery by magnetic resonance angiography

Objective: The outcome of thoracoabdominal or descending aortic aneurysm repair after preoperative demonstration of the artery of Adamkiewicz (ARM) by magnetic resonance angiography (MRA) was investigated. Methods: Between January 2000 and December 2001, 40 consecutive patients who had aneurysms of the thoracoabdominal or descending aorta underwent preoperative MRA to visualize the ARM. Thirty-two patients underwent replacement of the aneurysms, and 25 patients (TAAA, 11; TAA, 14) underwent replacement of the aneurysms with preoperative detection of the ARM. Only intercostal or lumbar arteries in aneurysms, which were detected as the origin of the ARM, were reattached to the graft. The results of thoracoabdominal aortic aneurysm operations in 11 patients in whom the ARM was preoperatively detected (group I) were compared with the results of TAAA operations in 26 patients in whom the ARM was not preoperatively detected (group II). Results: MRA demonstrated the ARM in 29 (73%) of the 40 patients. The laterality of the arteries originated from the left side in 29 (100%) and between Th9 and Th12 in 25 (86%), between Th9 and L1 in 28 (97%) of the 29 patients. No spinal cord injury occurred in patients (TAAA and TAA) in whom the ARM had been preoperatively detected. Major complications following TAAA operations included paraplegia (0% in group I and 8% in group II), respiratory failure (9% in group I and 23% in group II), and renal failure requiring hemodialysis (18% in group I and 22% in group II). Operation times were 439±99 min in group I and 620±200 min in group II (P=0.008). Conclusions: Preoperative detection of the ARM is possible by MRA and is very useful for reducing the incidence of ischemic injury of the spinal cord and for reducing the time of an operation for repair of an aneurysm of the thoracoabdominal or descending aorta.     

Descending or Thoracoabdominal Aortic Aneurysm Repair Without Intercostal Vessel Reconstruction Using Contrast Magnetic Resonance Angiography: Report of Two Cases

Two high-risk patients underwent a graft replacement for descending thoracic or thoracoabdominal aortic aneurysms without the reconstruction of any intercostal and lumbar arteries. The first patient was an 81-year-old woman with asthma and renal dysfunction who was diagnosed to have a descending thoracic aortic aneurysm extending from the Th8 to Th12 level. Contrast magnetic resonance angiography (MRA) demonstrated the Adamkiewicz artery to originate from the left second lumbar artery. The second patient was a 59-year-old man with left ventricular dysfunction due to aortic and mitral stenoses who was diagnosed to have a Crawford type IV thoracoabdominal aortic aneurysm. Contrast MRA showed the Adamkiewicz artery to originate from the left ninth intercostal artery. In general, the reestablishment of the spinal cord's blood supply, whenever possible, is generally considered to be necessary in such patients to prevent spinal cord injury. However, the reimplantation of intercostal vessels is the most complex aspect of this surgical modality, and therefore, it may cause a substantial increase in the cardiopulmonary bypass time. However, at least in some cases, such as the two cases presented herein, the use of contrast MRA was found to reduce the risk in surgery for descending thoracic or thoracoabdominal aortic aneurysms by eliminating the need for any intraoperative management of the intercostal and lumbar arteries. Received: April 6, 2001 / Accepted: September 11, 2001     

主动脉弓降部病变的外科综合治疗

目的探讨开胸体外循环直视手术、解剖外旁路联合动脉腔内修复(endovascular aneurysm repair,EVAR)杂交手术以及完全EVAR手术治疗主动脉弓降部病变的方法及疗效。方法 2006年10月-2011年9月,收治48例主动脉弓降部病变患者。男31例,女17例;年龄28～81岁,平均52.4岁。病程1～90 d,平均10.2 d。累及弓部分支的B型主动脉夹层30例,主动脉弓降部真性动脉瘤11例,主动脉弓降部假性动脉瘤3例,主动脉弓穿透性溃疡伴壁间血肿3例,主动脉食管瘘1例。15例行开胸体外循环直视手术,12例行解剖外旁路联合EVAR杂交手术,21例行完全EVAR手术。结果开胸体外循环直视手术患者中术后发生出血1例,昏迷1例,短暂精神症状3例,肺炎4例,急性肾功能不全2例,多器官功能衰竭2例;最终3例死亡。解剖外旁路联合EVAR杂交手术患者术后1例出现右顶枕叶大面积梗死伴肺炎、肾功能衰竭。完全EVAR术后无并发症发生。术后41例获随访,随访时间2～60个月,平均28.6个月。3例患者出现左锁骨下动脉窃血综合征表现,因症状轻微,未予特殊处理,均自行缓解。其余患者均恢复正常生活。结论对于主动脉弓降部病变,采用开胸体外循环直视手术创伤大、风险高,将逐步被EVAR替代,解剖外旁路联合EVAR杂交手术是治疗此病变的重要方法,完全EVAR手术是其发展方向。     

主动脉腔内修复术治疗腹主动脉瘤或夹层合并腹部恶性肿瘤

目的 观察主动脉腔内修复术（EVAR）治疗腹主动脉瘤（AAA）或腹主动脉夹层（AAD）合并腹部恶性肿瘤的价值。方法 回顾性分析17例接受EVAR治疗的AAA（n=14）/AAD（n=3）合并腹部恶性肿瘤患者,其中12例于EVAR后接受腹腔镜肿瘤切除术、1例接受开腹肿瘤切除术,4例因心肺功能欠佳仅接受药物治疗;观察EVAR治疗效果。结果 EVAR成功率为100%,术中无严重不良反应及并发症;术后1个月CTA显示支架位置良好、通畅。术后随访1~28个月,期间均未见明显并发症,亦未见AAA/AAD相关死亡病例。结论 EVAR治疗AAA/AAD合并腹部恶性肿瘤效果较佳。