腹主动脉瘤腔内隔绝术后缺血性结肠炎的诊治①

为探讨腹主动脉瘤术后并发缺血性结肠炎的诊断和治疗,作者回顾性分析了1997年3月～2000年1月间施行的腹主动脉瘤腔内隔绝术40例,其中30例保留双侧髂内动脉(双侧组),10例保留单侧髂内动脉或移植物远端固定于双侧髂外动脉、手术重建单侧髂内动脉(单侧组).统计两组患者的术后肠蠕动恢复时间及肠道并发症.两组患者中仅双侧组1例于术后第28天始出现持续性中下腹隐痛,经纤维结肠镜检查确诊为缺血性结肠炎,经CTA发现术后继发双侧髂内动脉闭塞,经扩血管、促进侧支循环建立等保守治疗缓解;其余患者除并发其他并发症的3例外,均于术后第二天恢复普食及排气排便.提示腔内隔绝术中保留单侧髂内动脉可避免术后缺血性结肠炎的发生;继发于术后双侧髂内动脉阻塞的慢性缺血性结肠炎,在肠镜随访观察下进行有效的保守治疗是首选治疗方法.     

CTA融合导航技术在腹主动脉瘤腔内修复及保留髂内动脉治疗中的应用北大核心CSCD

目的探讨CTA融合导航技术在腹主动脉瘤腔内修复(EVAR)术中的应用价值,评价CTA融合导航在髂内动脉保留策略中的技术优势。方法选取2020年12月至2021年6月在珠海市人民医院接受CTA融合导航EVAR术治疗的12例肾下型未破裂出血腹主动脉瘤患者。术前CTA扫描确诊,术中配准术前CTA与术中DynaCT扫描重建图像后,将融合图像叠加至术中透视影像,作为导丝等器械的路径导引。融合图像可作为双肾动脉支架锚定的参照。融合导航下根据髂动脉受累程度行髂内动脉单侧或双侧保留治疗。结果12例融合导航手术均获得成功。其中5例单侧髂内动脉栓塞并保留一侧髂内动脉,1例双侧髂内动脉重建,6例支架远端固定于髂总动脉远端并保留双侧髂内动脉。术后均未发现严重并发症。结论CTA融合导航技术辅助EVAR手术安全可行,无需使用对比剂,有助于保留髂内动脉,技术优势明显,值得临床推广。     

腹主动脉瘤腔内隔绝术与传统手术后的护理特点比较

为探索腹主动脉瘤腔内隔绝术与传统经腹手术的护理学差异,对1989年9月－2000年4月手术治疗的148例腹主动脉瘤进行了回顾性研究,其中传统经腹腔或经腹膜后长路腹主动脉瘤切除人工血管重建术96例,腹主动脉瘤腔内隔绝术52例,主要对两组间术后的住院时间、卧床时间、镇痛时间和恢复饮食时间进行对比研究。结果发现,两组患者术前一般状况无显著差异,术后的住院时间、卧床时间、镇痛时间和恢复饮食时间腔内隔绝术组明显缩短。说明在腹主动脉瘤的手术治疗中,腔内隔绝术具有术后患者痛苦小、恢复快的优点,有助于优化临床护理工作模式,减轻术后护理强度。     

ⅡC型腹主动脉瘤腔内隔绝术中髂内动脉的处理

目的：总结累及髂动脉分叉的ⅡC型腹主动脉瘤（AAA）的处理方法。方法：自1997年3月至2002年10月共对42例ⅡC型AAA实施了腔内隔绝术，其中包括单侧髂动脉分叉受累者19例，双侧髂动脉分叉受累者23例。针对髂总动脉不同的病变情况，采取了保留健侧髂内动脉、一侧髂内动脉重建、髂总动脉外绑扎等不同的处理方法。结果：即时操作成功41例（97.6％），手术结束时无Ⅰ型内漏存在。术后出现臀、股部疼痛3例（7.5％），便血2例（5.0％），未发生臀、股部和结、直肠坏死。结论：通过对髂内动脉作不同的处理，应用腔内隔绝术治疗ⅡC型AAA完全可以取得满意疗效。术中应尽可能保留一侧髂骨动脉，避免同时封闭双侧髂内动脉。     

主动脉腔内修复术中髂内动脉保留技术

主动脉腔内修复术(EVAR)是腹主动脉瘤的主要治疗手段,腹主动脉瘤伴发髂动脉瘤时保留髂内动脉已成为共识,可避免发生臀肌缺血、乙状结肠缺血及男性性功能障碍等并发症.随着近年腔内器械不断更新,EVAR术中保留髂内动脉成为可能.目前EVAR术髂内动脉重建术包括腔内髂分支支架技术、三明治技术、髂总动脉覆膜支架喇叭口技术、髂外动脉-髂内动脉腔内分流技术(反向“烟囱”技术)以及弹簧圈栓塞技术,该文就此作一总结.     

三明治技术在腹主动脉瘤累及髂总动脉腔内治疗中保留髂内动脉的疗效分析

【摘要】 目的 分析三明治技术应用于腹主动脉瘤（AAA）累及髂总动脉腔内治疗保留髂内动脉的近期疗效。 方法 回顾性分析重庆医科大学附属第二医院2016年6月至2018年7月采用主动脉腔内修复术（EVAR）治疗的9例AAA累及髂总动脉患者（累及单侧髂总动脉3例，双侧6例），术中均接受髂内动脉三明治重建。术后观察和随访围手术期死亡率、腔内修复效果、内漏、支架一期通畅情况及手术相关并发症发生情况。 结果 9例患者EVAR术和髂内动脉三明治重建技术均获成功，围手术期无死亡。术中即刻造影显示9例支架均获通畅，瘤腔均成功修复。出现1例Ⅰ型内漏，2例Ⅲ型内漏，随访时自行消失；1例左上肢急性缺血，再次予急诊肱动脉修复术；3例左肱动脉切口处血肿形成，2例右股动脉穿刺点处血肿形成。术后1周、3个月、6个月复查CTA分别显示支架通畅9例、8例、8例，均无肠缺血、脊髓缺血或瘫痪症状。 结论 三明治技术在AAA累及髂总动脉腔内治疗中保留髂内动脉安全可行，术后臀肌跛行发生率低，近期随访支架通畅率可，值得临床推广，但远期效果尚需进一步随访及更大临床样本验证。     

改良“八爪鱼技术”治疗复杂瘤颈腹主动脉瘤一例

本文介绍1例复杂瘤颈腹主动脉瘤患者,男,78岁,瘤颈短,瘤体较大且严重扭曲,采用改良“八爪鱼技术”重建内脏动脉联合腹主动脉覆膜支架进行腔内修复治疗。术后3个月复查腹主动脉瘤完全隔绝,未见内漏,双肾动脉、肠系膜上动脉及双髂内、外动脉通畅,双肾中下极部分肾梗死,取得了较好的短期疗效。     

肾下腹主动脉瘤的腔内治疗

目的：评价腔内人造血管隔绝术治疗肾下腹主动脉瘤早期临床疗效。方法：4例肾下腹主动脉瘤病人接受腔内人造血管隔绝术，其中1例合并双髂总、左髂内动脉瘤病人，在腔内隔绝术后行耻骨上髂外一股动脉转流术。术前均行彩超、DSA造影及三维重建螺旋CT检测。结果：术后即刻DSA造影显示：4例动脉瘤消失，近远端人造血管与宿主动脉结合处无内漏，腔内人造血管及转流血管通畅，无移植移位，4例病人临床均获成功。术后3个月、6个月彩超随访显示：腔内人造血管无移位、无内漏、动脉瘤残腔无增大及血流。结论：腔内人造血管隔绝术是一种创伤小、恢复快的治疗肾下腹主动脉瘤的安全、有效的新方法，但远期疗效有待随访。     

腔内治疗肾下型腹主动脉瘤8例临床疗效观察

目的:探讨肾下型腹主动脉瘤的腔内治疗技术与疗效.方法:收集随访我院2014年3月至2017年8月收治的8例接受腔内治疗的腹主动脉瘤(abdominal aortic aneurysm,AAA)患者的临床资料,统计并分析术后疗效.结果:腔内治疗8例AAA,手术全部成功.3例SchumacherⅡB型,4例SchumacherⅡC型,1例SchumacherⅢ型;2例扭曲成角Ⅰ级,4例扭曲成角Ⅱ级,2例扭曲成角Ⅲ级.8例患者术后出现1例髂动脉急性血栓形成,置管溶栓后血管通畅;1例术中髂动脉出现Ⅰ型内漏,经植入支架延长段和球囊扩张后内漏消失;1例术中双侧髂内动脉栓塞,术后未出现相应症状;其中5例使用烟囱技术,术后随访肾动脉通畅;结论:EVAR结合烟囱技术治疗AAA是安全、有效的,提高了成功率,降低了并发症及病死率.     

腹主动脉瘤腔内修复术22例围手术期处理回顾性总结

目的 总结腹主动脉瘤腔内修复术(EVAR)围手术期处理的临床经验.方法 回顾分析22例腹主动脉瘤患者EVAR临床经过,通过术前对主要脏器功能进行评估和保护,CTA测量近远侧瘤颈长度、直径、角度和构型,瘤体与分支动脉的关系,最低肾动脉开口至腹主动脉分叉的距离,导入途径的直径、扭曲和钙化程度.根据CTA测量结果,选择覆膜支架和手术方式.术时采用局麻20例,中转全麻l例,1例通过髂总动脉重建导人途径采用硬膜外麻醉,1例合并Stanf.0rd A型主动脉夹层,术时采用全麻.在支架释放前准确定位最低肾动脉位置,至少保留一侧通畅的髂内动脉,若双侧需要覆盖,分期覆盖或髂内动脉重建.支架植入后复查造影,有无内漏.正确判断内漏类型并进行相应处理.支架近端Ⅰ内漏2例,球囊扩张1例,植入Cuff 1例;支架远端Ⅰ内漏1例,球囊扩张时,动脉破裂,行人工血管补片修补术;Ⅲ型内漏3例,球囊扩张后支架植入1例.1例合并Starford A型主动脉夹层先行胸主动脉腔内修复术,后行EVAR.术后7一10 d复查CTA,以后每年复查1次.结果 EVAR手术全获成功.主要并发症为单侧髂肢扭结继发血栓形成,Fogarty导管取栓并支架植人1例;腹壁切口裂开1例,清创缝合;无手术死亡,随访6个月～5年,患者均存活.结论 CTA图像质量高、测量准确,是EVAR术前评估和术后随访的金标准.EVAR是高危、高龄腹主动脉瘤患者有效的治疗方法.     

腹主动脉瘤腔内隔绝术后神经缺血性损伤

目的：探讨在腹主动脉瘤（AAA）腔内隔绝术（EVE）中神经缺血性损伤的发生原因及防治。临床资料：我科在施行AAA EVE中遇到1例术后发生神经缺血性损伤。患者为Ⅱa型AAA，选用Talent分叉型移植物行EVE，手术顺利。术后出现双侧股部酸痛不适、乏力，伴右侧屈髋无力。行肌电图检查提示双侧腓总神经、胫神经、H反射传导速度均减慢，双侧股神经未能引出动作电位。给予甲钴胺0.5mg肌内注射，隔日1次，地巴唑10mg3次/d，并辅以高压氧治疗和股四头肌功能锻炼。治疗2个月后患者股部疼痛、乏力逐步缓解，无明显功能障碍。复查下肢肌电图无明显改善。结论：AAA EVE后可能会发生脊髓的缺血性损伤，但发生率很低，术中封闭腰动脉是导致脊髓缺血的原因。脊髓缺血性损伤早期治疗最为重要，后期的神经营养治疗和功能锻炼也可以改善部分症状。     

不使用造影剂的腹主动脉瘤腔内隔绝术

目的：探讨一种不使用造影剂的腹主动脉瘤（AAA）腔内隔绝术（EVE），治疗合并肾功能不全的AAA患者。方法：对3例合并肾功能不全的AAA患者在不使用造影剂条件下实施AAA EVE，并对术前评估内容进行分析。结果：3例患者手术均获成功，2例采用分叉型移植物，1例采用直型移植物。术后随访结果表明，动脉瘤被完全隔绝，无内漏，瘤腔内血栓形成；移植物内血流通畅，周围无异常血充。结论：选择近端瘤颈较长的患者，术前对肾动脉及髂内动脉开口位置等指标进行准确评估，不使用造影剂同样可以完成AAA EVE。     

腹主动脉瘤腔内隔绝术术中及术后移植物相关流出道狭窄的认识和处理

目的：探讨腹主动脉瘤（AAA）腔内隔绝术（EVE）术中及术后移植物相关流出道狭窄的认识和处理。方法：回顾性分析我科1997年3月至2002年10月间施行AAA EVE术中8例出现流出道狭窄，术后出现流出道狭窄3例，均为放置分叉型移植物。狭窄多发生于分叉起始端（5例）。7例给予球囊扩张，2例置入金属支架，2例股股交叉转流术。结果：术后随访1个月-2个年，无下肢缺血表现。结论：对于AAA EVE术中及术后移植物相关流出道狭窄，要及时诊断，判明原因，根据原因采取不同的治疗方法。     

Bilateral hypogastric artery occlusion in endovascular repair of abdominal aortic aneurysms and its clinical significance

PURPOSE: Endovascular treatment of aortoiliac aneurysms near or involving the hypogastric artery (HGA) requires HGA occlusion before endografting to avoid retrograde filling of the aneurysm. The purpose of this study is to evaluate clinical outcomes of bilateral HGA occlusion and determine if benefits gained by endovascular aneurysm repair (EVAR) outweigh the morbidity associated with the procedure. MATERIALS AND METHODS: Between 1999 and 2004, 128 patients with abdominal aortic aneurysm (AAA) were treated with bifurcated endograft placement. Bilateral coverage or embolization of HGAs was performed in 14 patients (10.9%). Embolization was achieved by deployment of coils and coverage was accomplished by extending the endoprosthesis into the external iliac artery. Clinical follow-up and computed tomographic angiography were performed at 1, 3, 6, 9, and 12 months and annually thereafter to detect potential aneurysm growth and endoleaks. RESULTS: During follow-up (range, 1-72 months), buttock claudication was noted in four patients (28.6%), including unilateral claudication in two and bilateral claudication in two. One patient experienced claudication longer than 12 months, which resolved within 18 months. De novo erectile dysfunction was seen in one patient, and pelvic ischemia was not found in any patient. There was no evidence of endoleak, aneurysm enlargement, or death associated with HGA occlusion. CONCLUSIONS: In our series, complications of bilateral HGA occlusion before EVAR were moderate and resolved over time. The benefits gained from EVAR outweigh the clinical problems caused by bilateral HGA occlusion, as there are no technical complications added to the EVAR procedure.     

Stanford B型胸主动脉夹层动脉瘤合并肾缺血的诊治(附3例报告)

为探讨合并肾缺血的StanfordB型胸主动脉夹层动脉瘤的诊断和处理 ,分析 1996年 1月至 2 0 0 0年 4月收治的StanfordB型胸主动脉夹层动脉瘤 2 9例 ,其中合并肾缺血 3例 ,为急性期 2例 ,慢性期 1例。急性期 1例发病后第 3天死亡 ,另 1例同时合并肾缺血和双下肢缺血 ,经夹层隔膜开窗术缓解 ;慢性期 1例经腔内隔绝术治愈夹层后肾缺血自行缓解。提示合并肾缺血的StanfordB型胸主动脉夹层动脉姑息性转流手术有助于缓解症状 ,提高生存率 ;对于慢性StanfordB型胸主动脉夹层动脉瘤合并肾缺血的患者 ,腔内隔绝术在治愈夹层动脉瘤的同时恢复了真腔供血 ,肾缺血可同时治愈     

腹主动脉复合动脉瘤的腔内隔绝术治疗

目的：讨论复合腹主动脉病变进行腔内隔绝术（EVE）的可行性。方法：1例腹主动脉并存真性、假性和夹层动脉瘤患者，经双侧股动脉切开、肱动脉切开引入贯穿导丝，利用导丝导向技术和牵张技术成功置入模块式支架-人造血管移植物，以隔绝瘤体。结果：腔内隔绝操作技术完全成功，3个瘤体同时被隔绝，未加用任何延伸移植，未出现内漏、移位等并发症，重建血流通畅。结论：本例为EVE扩大适应证提供了经验。     

腹主动脉瘤腔内隔绝术后迟发型远端内漏Ⅱ期腔内治疗

目的：探讨腹主动脉瘤（AAA）腔内隔绝术EVE后迟发型远端内漏的Ⅱ期腔内治疗方法的价值。方法：为3例AAA EVE3年以后迟发型远端内漏患者进行了Ⅱ期延伸移植物置入治疗，2例经双侧动脉切开、两侧各置入1枚延伸移植物，1例经腹膜后径路和股动脉径路完成3枚延伸移植物置入。结果：3例均应用了贯穿导丝牵张技术，延伸移植物置入完成后均将内漏消除。结论：Vanguard支架-人造血管系统的结构特点可能是导致远期远端内漏的原因；延伸移植物是治疗的有效方法。导丝牵张技术有助于手术成功并节约手术时间。     

Endovascular treatment of aortoiliac aneurysms: From intentional occlusion of the internal iliac artery to branch iliac stent graft

Approximately 20%-40% of patients with abdominal aortic aneurysms can have unilateral or bilateral iliac artery aneurysms and/or ectasia. This influences and compromises the distal sealing zone during endovascular aneurysm repair. There are a few endovascular techniques that are used to treat these types of aneurysms, including intentional occlusion/over-stenting of the internal iliac artery on one or both sides, the “bell-bottom” technique, and the more recent method of using an iliac branch stent graft. In some cases, other options include the “snorkel and sandwich” technique and hybrid interventions. Pelvic ischemia, represented as buttock claudication, has been reported in 16%-55% of cases; this is followed by impotence, which has been described in 10%-17% of cases following internal iliac artery occlusion. The bell-bottom technique can be used for a common iliac artery up to 24 mm in diameter given that the largest diameter of the stent graft is 28 mm. There is a paucity of data and evidence regarding the “snorkel and sandwich” technique, which can be used in a few clinical scenarios. The hybrid intervention is comprised of a surgical operation, and is not purely endovascular. The newest branch stent graft technology enables preservation of the anterograde flow of important side branches. Technical success with the newest technique ranges from 85%-96.3%, and in some small series, technical success is 100%. Buttock claudication was reported in up to 4% of patients treated with a branch stent graft at 5-year follow-up. Mid- and short-term follow-up results showed branch patency of up to 88% during the 5-6-year period. Furthermore, branch graft occlusion is a potential complication, and it has been described to occur in 1.2%-11% of cases. Iliac branch stent graft placement represents a further development in endovascular medicine, and it has a high technical success rate without serious complications.     

Internal iliac artery embolization with bilateral occlusion before endovascular aortoiliac aneurysm repair-clinical outcome of simultaneous and sequential intervention

PURPOSE: To retrospectively evaluate the clinical outcome of patients after simultaneous or sequential internal iliac artery (IIA) embolization for bilateral IIA occlusion. MATERIALS AND METHODS: Sixteen patients (65-88 y; mean, 75.6 y; two women), 11 with aortobiiliac aneurysms, three with bilateral common iliac artery (CIA)/IIA aneurysms, and two with unilateral CIA/IIA aneurysms, underwent IIA occlusion before endovascular aortoiliac repair. Eight patients underwent simultaneous bilateral IIA embolization before endovascular aortic repair (EVAR). Eight patients had sequential bilateral IIA occlusion. The outcome was assessed by clinical follow-up. RESULTS: There were no severe ischemic complications such as buttock necrosis or acute bowel, bladder, or spinal cord ischemia. Early ischemic complications occurred in 25% (buttock/thigh claudication, n = 3, 18.8%; and sexual dysfunction, n = 1, 6.2%) and had an onset not later than 6 months after intervention: buttock claudication resolved (n = 2) or persisted after aggravation by inferior mesenteric artery embolization for type II endoleak (n = 1). Impotence in a fourth patient persisted. The ischemic complication rate after 6 months was 30% (three of 10) because of a fifth patient who developed ischemic colitis with aggravation of ischemic heart disease after 15 months. The mean follow-up duration was 19.7 months. Patients with simultaneous embolization had a lower complication rate than those with sequential embolization (one of eight [12.5%] vs four of eight [50%], respectively). CONCLUSIONS: IIA embolization for bilateral IIA occlusion can be performed with a complication rate comparable with results of previous studies of unilateral IIA embolization. Chronic buttock claudication may be aggravated by embolization of aortic side branches. Late complications can have an insidious course and be initiated by low-output cardiac failure. Bilateral IIA occlusion is recommended only in patients who are considered unfit for aortic surgery.     

Endovascular treatment of isolated iliac artery aneurysms: 2-year follow-up

PURPOSE: The aim of this study was to assess the effectiveness of endovascular treatment of isolated iliac artery aneurysms (IAAs). MATERIALS AND METHODS: Between March 1999 and March 2004, 15 isolated IAAs in 13 patients (mean age: 71.8 years) were selected for endovascular repair by means of a covered stent or stent-graft: 12 were in the common iliac artery (2 with the proximal end 12 mm from the aortic bifurcation and 2 involving the distal hypogastric artery), and three were in the external iliac artery. The preoperative study and the follow-up (at 3, 6 and 12 months and yearly thereafter) were performed by computed tomography (CT) angiography. RESULTS: Primary technical success was obtained in all cases, without periprocedural complications. Two patients died within 3 months and were not considered for follow-up. Follow-up (mean duration: 25 months, range: 6-60 months) in the remaining 11 patients, affected by 13 aneurysms, showed aneurysm exclusion in nine cases and progressive shrinkage of the aneurysmal sac in four cases, whereas in the other five, the size of the aneurysm remained unchanged. In a patient with bilateral IAA, bilateral proximal endoleaks were observed after 2 years, and the patient was treated with a bifurcated aortic stent-graft. In another patient with a large aneurysm, a left aortofemoral bypass became necessary after 2 months because of stent-graft dislodgement. In another patient, an endoleak from the hypogastric artery occurred after 2 years but was not treated. CONCLUSIONS: Endovascular treatment of isolated IAA is a feasible procedure that is less invasive than surgery and yields excellent short-and midterm results. However, a longer follow-up and larger patient series are needed to verify the long-term efficacy of this form of treatment.