主动脉病变的手术治疗与腔内血管外科治疗

目的 探讨主动脉病变的手术治疗和腔内血管外科治疗方法。方法 回顾性分析45例胸腹主动脉病变外科治疗的临床资料。结果 男37例，女8例。年龄2l～85(平均年龄64、7)岁。其中胸主动脉夹层ll例；降主动脉夹层破裂并假性动脉瘤形成伴椎骨破损2例；肾上，下型腹主动脉瘤各为3，23例；腹主动脉瘤破裂2例；腹主动脉瘤空肠瘘l例；腹主动脉外伤性破裂3例。45例患者中腔内治疗者l8例，25例行人工血管置换治疗，3例行腹主动脉修补。围手术期死亡率为6．7％(3／45)。随访36例，随访时间2个月～4年，均生存良好。结论 腔内血管外科治疗有着创伤小，术后恢复快，并发症少等优点，有条件行支架型人工血管腔内治疗的可优先考虑腔内治疗。传统手术方法在技巧等方面的改进有利于提高手术的成功率，并能为不具备腔内治疗条件的患者解除疾苦。     

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目的 总结马凡综合征合并降主动脉瘤的外科治疗经验.方法 回顾性分析复旦大学附属中山医院血管外科1998-2005年治疗16例马凡综合征合并降主动脉瘤的临床资料.结果 12例行腹主动脉瘤切除人造血管移植术,2例行开窗术,2例行人工血管腔内治疗.围手术期内死亡2例.13例(81%)随访4个月至7年,其中1例因发生胸主动脉夹层破裂而猝死,伴有高血压的10例病人中有6例术后血压恢复正常,另4例需口服药物后方可控制血压;另2例情况良好.结论 马凡综合征合并腹主动脉瘤的动脉管壁结构比一般病人更加薄弱,Bentall术后仍有夹层动脉瘤复发的危险;对该类病人应首先考虑传统手术,以尽最大可能切除病变血管,腔内治疗的应用指征有待进一步探讨.     

长鞘联合大球囊阻断技术在破裂腹主动脉瘤腔内治疗应用

目的 评价长鞘联合大球囊阻断技术在破裂腹主动脉瘤腔内治疗的效果及其治疗经验.方法 回顾性分析新疆维吾尔自治区人民医院血管外科2009年2月-2014年6月共11例破裂腹主动脉瘤患者的临床资料.其中男性9例,女性2例;年龄69 ～ 88岁,平均76岁.动脉粥样硬化性腹主动脉瘤7例,腹主动脉假性动脉瘤2例,感染性腹主动脉瘤2例.11例术前均完成CT动脉造影检查,急诊行腔内修复术,术中使用长鞘联合大球囊阻断技术.结果 术中无患者死亡.术后1例患者出现造影剂肾病;1例出现腹腔间隔室综合征,均在1周后死亡.随访期间,1例出现Ⅰ型内漏,再次行腔内治疗;1例假性动脉瘤复发再次破裂,放弃治疗.结论 长鞘联合大球囊阻断技术在破裂腹主动脉瘤腔内治疗是安全有效的治疗方式.     

高外科风险腹主动脉瘤腔内修复术的近远期结果

目的 探讨高外科风险腹主动脉瘤患者接受腔内修复术治疗的近远期结果.方法 1997年7月至2011年7月,120例因肾下腹主动脉瘤行腔内修复术治疗的高外科风险患者纳入本研究.本组患者男性96例,女性24例;年龄52～95岁,平均74岁.平均动脉瘤直径(57±8)mm.术后1、3、6、12个月及此后每年进行CT血管造影或B超随访.主要研究内容是手术病死率及远期生存率,次要研究内容是二次手术率、动脉瘤体术后的变化以及支架的通畅率.结果 全身麻醉83例,局部麻醉37例.术后Ⅰ型内漏5例,Ⅱ型内漏25例,Ⅲ型内漏1例,技术成功率95％.手术病死率2.5％.随访6～144个月,平均(36±3)个月.术后1年生存率为92％,3年生存率为75％,5年生存率为43％.术后3年支架的一、二期通畅率分别为97％和100％.5年二次手术率为10％ (12/120),手术原因为:7例内漏,2例支架断裂,2例支架移位,1例支架内血栓形成.结论 高外科风险腹主动脉瘤患者接受腔内修复术治疗的近远期结果满意,证实该技术适用于这类人群.     

八十岁以上高龄腹主动脉瘤患者的外科治疗

目的探讨八十岁以上高龄腹主动脉瘤患者的传统手术及腔内治疗的疗效。方法回顾性分析20例年龄在80～90岁腹主动脉瘤患者的外科治疗经验,其中12例接受传统手术,8例行腔内治疗。结果20例患者围手术期有2例死亡,均为手术组患者。腔内组的手术及术后并发症情况均显著优于手术组。随访3～69个月,2例手术组患者失访,手术组和腔内组各有2例远期死亡。手术组和腔内组的累计生存率分别为6／10和6／8。结论对于八十岁以上高龄腹主动脉瘤患者的外科治疗可行,在合适病例首选腔内治疗。     

30例腹主动脉瘤的外科诊疗结果分析

目的 交流腹主动脉瘤的诊断和外科治疗方法。方法 对1991年2月至2002年7月我院外科治疗的30例肾下型腹主动脉瘤的临床资料进行回顾性分析。结果 数字减影血管造影术诊断1例．MR1诊断2例。其余27例均经CT确诊。该30例中．腹主动脉瘤破裂6例．行急诊手术，死亡2例(死亡率33.3％)；24例未破裂者中．22例行腹主动脉瘤切除和原位人造血管移植术．术后死亡2例(死亡率9.1％)．另2例行腹主动脉瘤腔内人造血管移植术。结论 及早术前诊断．恰当地选择手术时机、手术方式及正确的围手术期处理是提高手术成功率，减少术后并发症和死亡率的关键。     

破裂性腹主动脉瘤的治疗

目的探讨破裂性腹主动脉瘤急诊救治的治疗经验。方法回顾性研究2002年5月-2013年7月救治的36例破裂性腹主动脉瘤患者的临床资料。其中25例合并高血压病,21例合并慢性阻塞性肺疾病。33例采取急诊开腹主动脉人工血管置换术;3例采取主动脉覆膜支架腔内修复术,其中1例中转开腹手术治疗。结果术后33例存活,另外3例死亡,死亡原因包括1例失血性休克和心功能衰竭,1例术中心跳骤停,1例术后多器官功能衰竭,围手术期病死率为8．3％。术后随访3～61个月,未发生人工血管感染等手术相关并发症及死亡病例。结论积极的手术治疗是提高破裂性腹主动脉瘤患者救治成功率的关键,早期明确诊断,手术中快速有效控制近端瘤颈血流,完善围手术期治疗能有效降低病死率。     

胸主动脉瘤外科治疗新进展

西方发达国家有关主动脉瘤的流行病学调查发现 ,近年发病率有逐渐增多趋势 ,其原因可能与人均期望寿命延长和诊断水平提高有关。值得注意的是我国香港地区的主动脉瘤发病率也有大幅度攀升 ,1 998年已成为香港居民第十大死亡原因[1] 。随着我国全民健康素质与人均期望寿命提高 ,可以预见主动脉瘤也将成为我国心脏大血管外科的常见危急重症与多发病。近十年来 ,随着手术经验积累、改进策略、完善围术期处理和应用新技术 ,以往手术风险大、住院死亡率和术后并发症高的主动脉弓动脉瘤和急性主动脉夹层分离的外科治疗结局已有长足进步 ,不乏住院…     

破裂性腹主动脉瘤的腔内治疗进展

破裂性腹主动脉瘤(RAAA)是血管外科的急症之一,病死率可高达90％.RAAA易被误诊,计算机断层扫描血管造影(CTA)影像技术既可确诊RAAA,又可对破裂血管进行三维重建,对治疗RAAA具有指导意义,是指南推荐的诊断方法.随着早期相关随机对照试验结果的公布,腹主动脉瘤腔内修复术(EVAR)在RAAA治疗中的应用已经发...     

腹主动脉瘤破裂的外科治疗：附12例报告

目的:探讨腹主动脉瘤破裂（RAAA）的诊断和治疗方法。方法: 回顾分析7年间收治的12例腹主动脉瘤破裂者的临床资料。主要临床表现有：腹痛和/或腰背痛,血压下降或休克, 腹部可触及搏动性肿块。所有患者经CT 检查确诊，7例患者采用传统开腹性手术，1例行腔内支架型人工血管植入术，另外4例未行手术治疗。结果:8例手术治疗者围手术期病死率为62.5％（5例）。死亡原因：循环衰竭2 例,急性肾衰竭1 例,多器官功能障碍综合征2 例。未手术4例全部死亡。结论:破裂腹主动脉瘤外科手术治疗病死率高。早期诊断，适当复苏，紧急外科手术，缩短手术时间，肾动脉下方阻断，是降低病死率的关键。腔内修复治疗是降低病死率的有效途径。     

Epidemiology and Outcome of Aortic Aneurysms in Hong Kong

Abstract The objective of this study was to determine epidemiology and mortality statistics for abdominal aortic aneurysms (AAAs) in Hong Kong. Data from three sources were obtained and analyzed: (1) Hong Kong Hospital Authority discharge statistics for 1999 and 2000; (2) a survey on aortic aneurysms in public hospitals conducted by the Working Group of Vascular Surgery; and (3) the Department of Surgery, University of Hong Kong Medical Center aortic aneurysm database. The disease pattern, distribution, and operative mortality were determined. The annual incidence of AAA in Hong Kong is 13.7 per 100,000 population and 105 per 100,000 for those aged 65 and above. About 10% of the AAAs that presented were ruptured. The mean age of the AAA patients was 74 years, with 84% of them over age 65. The operative repair rate for AAAs was low, being only 8% for intact aneurysms and 54% for ruptured ones. Overall, 45% of all aneurysm repairs were performed for a ruptured AAA. There is diverse practice between major vascular centers and smaller regional hospitals. The territory-wide operative mortality rates for intact and ruptured aneurysms were 10% (range 4–24%) and 70% (range 38––100%), respectively. There was no gender bias in the rupture and operative rates. The overall mortality was 17% for intact AAAs and 78% for ruptured AAAs. The average length of hospital stay was 19 days for elective AAA surgery and 13 days for ruptured AAAs. The number of operations in high-volume centers is increasing with a concomitant decrease in operative mortality. There are no definitive data to indicate that the incidence of AAAs is rising, but a trend toward an increasing number of operations in referral centers is noted. The low repair rates for intact AAAs and the high proportion of repairs for ruptured aneurysms suggest that AAAs are undertreated in Hong Kong.     

Abdominal aortic aneurysm. Change in diagnosis and therapy

The improved diagnostic approach using computerised tomography and ultrasound investigation resulted recently in a remarkable increase of early diagnosed abdominal aortic aneurysm. Simultaneously in the last decennium the number of elective interventions has been increased 4-6 times. As a result of simplification and standardisation of the operative technique (dissection resp. inlay-technique) the operative mortality for elective surgery has decreased to 1-3%. Statistical datas proved a significant increase of life expectancy for operated patients. Interventions for ruptured abdominal aortic aneurysms are still loaded with a high risk (mortality rate 40-75%). Both elective and emergency vascular repairs should be done by well trained vascular surgeons and should not be a challenge for general surgeons to do sporadic vascular surgery.     

Anaesthesia for abdominal vascular surgery

Abdominal vascular surgery is required for aneurysmal and symptomatic occlusive disease of the aorta. Abdominal aortic aneurysms account for more than 8,500 deaths per year in England and Wales. Most deaths occur as a result of rupture of the abdominal aortic aneurysm, which has an overall mortality of 80%. These deaths are potentially preventable because elective repair of the abdominal aorta can be performed with an operative mortality of less than 7%. This article reviews the current indications and anaesthetic practices for open and endovascular abdominal aortic aneurysm repair.     

Outcomes after ruptured abdominal aortic aneurysms: the "halo effect" of trauma center designation

BACKGROUND: Trauma centers have an array of services available around the clock that help reduce mortality in injured patients. Having such services available can benefit patients other than those who are injured. We set out to determine whether patients hospitalized with ruptured abdominal aortic aneurysms experience lower morbidity and mortality at regional trauma centers than at other acute care hospitals. STUDY DESIGN: We conducted a retrospective cohort study with the exposure being care at a trauma center and outcomes either mortality or organ failure. We evaluated all patients 40 to 84 years of age with a diagnosis of a ruptured abdominal aortic aneurysm who underwent operation during 2001 in 20 US states with organized systems of trauma care. We determined the relative risk of either death or organ failure at regional trauma centers compared with nondesignated centers. RESULTS: Of 2,450 patients hospitalized for ruptured abdominal aortic aneurysm, 867 (35%) hospitalizations occurred at regional trauma centers. At trauma centers, 41.4% of patients died before hospital discharge, compared with 45.2% of patients at nondesignated hospitals (odds ratio [OR], 0.85; 95% CI, 0.71-1.02). After adjusting for payor, hospital beds, annual hospital admissions, annual inpatient operations, affiliation with a vascular surgery fellowship, and comorbid illnesses, the likelihood of death or organ failure was lower at trauma centers (OR, 0.72; 95% CI, 0.55-0.93). CONCLUSIONS: Care at regional trauma centers after operative repair of ruptured abdominal aortic aneurysm is associated with improved outcomes. We postulate that these benefits reflect the ability of both vascular and general surgeons to immediately mobilize resources for care of the patient requiring urgent operative intervention. The beneficial effects of trauma center designation might extend beyond caring for the critically injured.     

Ruptured abdominal aortic aneurysm: factors influencing operative mortality

Of fifty-eight consecutive patients surgically treated for aneurysm of the abdominal aorta, twenty were emergency cases following the rupture. Associated diseases were found in 85 per cent of patients; hypertension being the most common. Fifty per cent of patients were in shock on admission. The duration between rupture and operation was three hrs to two weeks with the average of 115.5 hrs. In six patients, the diagnosis of abdominal aortic aneurysm was known for over six months. The operative mortality rate in case of ruptured abdominal aortic aneurysm was 45 per cent. The most important determinants of survival were the incidence of shock on admission, the incidence of associated disease, the known duration of the aneurysm, and the time interval from rupture to admission. The intraoperative factors most influencing survival were the type of rupture, intraoperative hypotension, and total blood loss. Comparison of the mortality rate in elective surgery of abdominal aortic aneurysms (5.3 per cent) with that in ruptured aneurysms (45.0 per cent) suggests the necessity for early elective operations whenever abdominal aortic aneurysms are diagnosed.     

Ruptured abdominal aortic aneurysms: remote aortic occlusion for the general surgeon

Endovascular abdominal aortic aneurysm repair has completely transformed the treatment of elective aneurysmal disease, but endovascular surgeons have been slow to adopt these techniques for ruptured aneurysms. There are endovascular skills and management techniques that are valuable to both vascular and general surgeons in the emergent setting. An endovascular approach to this disease process does not preclude open repair, and remote aortic occlusion can serve as an integral adjunct for general surgeons approaching a ruptured abdominal aortic aneurysm.     

Ruptured abdominal aortic aneurysm: Factors influencing operative mortality

Of fifty-eight consecutive patients surgically treated for aneurysm of the abdominal aorta, twenty were emergency cases following the rupture. Associated diseases were found in 85 per cent of patients; hypertension being the most common. Fifty per cent of patients were in shock on admission. The duration between rupture and operation was three hrs to two weeks with the average of 115.5 hrs. In six patients, the diagnosis of abdominal aortic aneurysm was known for over six months. The operative mortality rate in case of ruptured abdominal aortic aneurysm was 45 per cent. The most important determinants of survival were the incidence of shock on admission, the incidence of associated disease, the known duration of the aneurysm, and the time interval from rupture to admission. The intraoperative factors most influencing survival were the type of rupture, intraoperative hypotension, and total blood loss. Comparison of the mortality rate in elective surgery of abdominal aortic aneurysms (5.3 per cent) with that in ruptured aneurysms (45.0 per cent) suggests the necessity for early elective operations whenever abdominal aortic aneurysms are diagnosed. Presented at the Fifteenth Annual Meeting of the Japanese Association for Cardiovascular Surgery, Kanazawa, Japan, May 17–18, 1985.     

Clamp before you cut: Proximal control of ruptured abdominal aortic aneurysms using endovascular balloon occlusion--Case reports

While the mortality rate for elective abdominal aortic aneurysm (AAA) repair has declined over the last several decades, the rate for ruptured abdominal aortic aneurysm (RAAA) has unfortunately remained disturbingly high. Undiagnosed aneurysms may present with little warning until abdominal pain, syncope, and hypotension signify rupture. Fifty percent of patients with ruptured aneurysms die before reaching a medical facility, and their survival is highly dependent on hemodynamic stability at presentation. The degree of rupture containment and comorbid status of the patient determine hemodynamic stability. Endovascular stent grafting has significantly improved perioperative morbidity and mortality rates for elective AAA repair, and some of the same endovascular techniques can be used to obtain proximal control in patients presenting with RAAA. We describe 3 consecutive cases of RAAA where proximal control was obtained using a percutaneously placed, transfemoral aortic occlusion balloon before induction of anesthesia.     

Extended use of endovascular aneurysm sealing for ruptured abdominal aortic aneurysms

Endovascular repair of abdominal aortic aneurysms (EVAR) is now an established treatment modality for suitable patients presenting with aneurysm rupture. EVAR for ruptured aneurysms reduces transfusion, mechanical ventilation, intensive care. and hospital stay when compared with open surgery. In the emergency setting, however, EVAR is limited by low applicability due to adverse clinical or anatomical characteristics and increased need for reintervention. In addition, ongoing bleeding from aortic side branches post-EVAR can cause hemodynamic instability, larger hematomas, and abdominal compartment syndrome. Endovascular aneurysm sealing, based on polymer filling of the aneurysm, has the potential to overcome some of the limitations of EVAR for ruptured aneurysms and to improve outcomes. Recent literature suggests that endovascular aneurysm sealing can be performed with early mortality similar to that of EVAR for ruptured aortic aneurysms, but experience is limited to a few centers and a small number of patients. The addition of chimney grafts can increase the applicability of endovascular aneurysm sealing in order to treat short-neck and juxtarenal aneurysms as an alternative to fenestrated endografts. Further evaluation of the technique, with larger longitudinal studies, is necessary before advocating wider implementation of endovascular aneurysm sealing in the emergency setting.     

Measure what matters: institutional outcome data are superior to the use of surrogate markers to define "center of excellence" for abdominal aortic aneurysm repair

Outcome analysis is increasingly being used to develop health-care policy and direct patient referral. For example, the Leapfrog Group health-care quality initiative has proposed "evidence-based hospital" referral criteria for specific procedures including elective abdominal aortic aneurysm repair (AAA-R). These criteria include an annual hospital AAA operative volume exceeding 50 cases and provision of intensive care unit (ICU) care by board-certified intensivists. Outcomes after AAA-R are reportedly influenced by presentation (intact vs. ruptured), operative approach (endovascular vs. open, transperitoneal vs. retroperitoneal), surgeon subspecialty, case volume (hospital and surgeon), and provision of postoperative care by an intensivist. The purpose of this study was to compare our single-center results with those of high-volume centers to assess the validity of the concept that surrogate markers, such as case volume or intensivist involvement, can be used to estimate procedural outcome. A retrospective review was performed of AAA-Rs at one low-volume academic medical center from January 1994 to March 2005. Demographic data, aneurysm diameter and location, operative indications, and repair approach were documented. Postoperative complications, mortality rates, and hospital and ICU length of stay (LOS) were noted and compared to established benchmarks. During the study period, 270 patients underwent AAA-R (annual mean = 27 hospital cases and 13.4 cases/attending vascular surgeon). ICU care was provided by a dedicated vascular surgery service without routine intensivist involvement. Open, elective, infrarenal AAA-R was performed in 161 patients (60%), with a 2.5% hospital mortality rate (30-day, 3.1%). Thirty-three (12%) patients underwent elective endovascular aneurysm repair (EVAR), with no mortality. Both ICU (3.7 vs. 1.4 days, p = 0.03) and hospital (9.2 vs. 2.8 days, p = 0.002) LOS were significantly reduced after EVAR compared to open repair. Hospital LOS was significantly lower after open retroperitoneal repair compared to transperitoneal repair (6.1 vs. 10.3 days, p = 0.001). Thirty-five patients (13%) underwent ruptured AAA-R, with only 34.3% mortality (in-hospital and 30-day). Forty-one patients (15%) underwent repair of complex aortic aneurysms, with 14.1% mortality. There are increasing societal and economic pressures to direct patient referrals to "centers of excellence" for specific surgical procedures. Although our institution meets neither of the Leapfrog Group's proposed criteria, our mortality and LOS for both intact and ruptured infrarenal AAA-R are equivalent or superior to published benchmarks for high-volume hospitals. Individual institutional outcome results such as these suggest that patient referral and care should be based upon actual, carefully verified outcome data rather than utilization of surrogate markers such as case volume and subspecialist involvement in postoperative care.