介入治疗脾动脉-肠系膜上动脉干起源脾动脉瘤1例

患者女,49岁,体检发现脾动脉瘤9个月,查体及实验室检查未见异常。影像学检查：腹部CTA（图1A）示变异的脾动脉起源于脾动脉一肠系膜上动脉干,脾动脉起始部动脉瘤形成,约20mm×24mm。经肠系膜上动脉造影（图1B）证实诊断后行介入治疗。将2．7F微导管引入脾动脉瘤颈以及远端部位。经左肱动脉穿刺。置入8F动脉鞘．待导丝（加硬钢丝）进入肠系膜上动脉后,沿导丝释放覆膜支架（直径6mm。长40mm）,覆盖脾动脉一肠系膜上动脉干开口。     

Association between surgical repair of aortic aneurysms and the diagnosis of intracranial aneurysms

ObjectiveAortic aneurysms (AAs) and intracranial aneurysms (IAs) share several clinical risk factors, a genetic predisposition, and molecular signaling pathways. Nonetheless, associations between IAs and AAs remain to be thoroughly validated in large-scale studies. In addition, no effective medical therapies exist for unruptured IAs or AAs.MethodsData for this nationwide, population-based, retrospective, cohort study described herein were obtained from the National Health Insurance Research Database in Taiwan. The study outcomes assessed were (1) the cumulative incidence of IAs, which was compared between AA and patients without an AA and (2) the cumulative incidence of IAs in patients with AAs during the 13-year follow-up period, which was further compared among those who underwent open surgical repair (OSR), endovascular aneurysm repair or nonsurgical treatment (NST).ResultsOur analyses included 20,280 patients with an AA and 20,280 propensity score-matched patients without an AA. Compared with the patients without an AA, patients with AA exhibited a significantly increased risk of an IA diagnosis (adjusted hazard ratio [HR], 3.395; P < .001). Furthermore, 6308 patients with AAs were treated with surgical intervention and another 6308 propensity score-matched patients with AAs were not. Patients with an AA who underwent OSR had a significantly lower risk of being diagnosed with an IA than patients with an AA who underwent endovascular aneurysm repair or NST (adjusted HR, 0.491 [P < .001] and adjusted HR, 0.473 [P < .001], respectively).ConclusionsWe demonstrated an association between IAs and AAs, even after adjusting for several comorbidities. We also found that OSR was associated with fewer recognized IAs than NST.     

急性肠系膜上动脉闭塞的诊断与治疗

目的 探讨急性肠系膜上动脉闭塞的诊断与治疗.方法 对2000-2007年收治的15例急性肠系膜上动脉闭塞患者的临床资料进行回顾性分析.结果 本组15例患者中肠系膜上动脉栓塞11例,肠系膜上动脉血栓形成4例.入院后均行急诊剖腹探查术,其中2例行肠系膜上动脉取栓术,11例行肠系膜上动脉取栓加坏死肠管切除术,2例放弃手术.术后均行肝素等抗凝治疗.4例死亡,总病死率为27%.结论 对于有器质性心脏病的患者,如突然出现腹部疼痛,应警惕肠系膜上动脉闭塞的可能.早期诊断、早期行肠系膜上动脉取栓术是提高治愈率的关键.     

Long-term results after open repair of inflammatory infrarenal aortic aneurysms

Objective

The objective of this study was to investigate the long-term outcome after open repair of inflammatory infrarenal aortic aneurysms.

Successfully-treated asymptomatic celiac artery aneurysm: A case report

BackgroundCeliac artery aneurysm is a rare vascular lesion. It is frequently discovered after rupture, which leads to death in most cases. We present a case of an asymptomatic celiac artery aneurysm discovered in a 72-year-old female during an evaluation for high grade fever and general fatigue.Case presentationThe patient visited our department with complaints of fever and general fatigue. The patient’s medical history included type 2 diabetes mellitus with poor control and hypertension. Blood culture and urine culture that were submitted at arrival presented E. Coli. Then, she was diagnosed with bacteremia by urinary tract infection. Transesophageal echocardiography revealed no vegetation at her valves. Computed tomography was performed for investigating her urological abnormalities, revealing a 28 × 30 mm aneurysm at the trunk of the celiac artery. Blood and urine cultures submitted at arrival were positive for E. coli. Surgical repair performed after the improvement of her urinary tract infection revealed a non-infective aneurysm; thus, aneurysm closure and prosthetic grafting were conducted.ConclusionClinician awareness regarding this rare entity and discovery efforts to discover the splanchnic aneurysm before rupturing are imperative.     

Laparoscopic resection of splenic artery aneurysms

Background Laparoscopic techniques used to manage asymptomatic splenic artery aneurysms have been reported infrequently.Methods A laparoscopic splenic artery aneurysm resection was attempted for six consecutive patients.Results One patient underwent conversion to laparotomy because of a tear in the splenic vein. Among the five successful laparoscopic splenic artery aneurysm resections, the mean estimated blood loss was 37 ± 12.6 ml, the mean operative time was 187.6 ± 79.2 min, and the mean postoperative length of hospital stay was 1.8 ± 1.3 days. The mean time to a clear liquid diet was 5.3 ± 0.5 h, and the mean time to a regular diet was 1 ± 0 day. The mean duration of narcotic analgesic use was 5.4 ± 1.5 days, and the mean time to resumption of regular activities was 12.7 ± 1.6 days.Conclusions These cases illustrate the benefit of a laparoscopic approach with brief hospitalizations, early resumption of diet and regular activity, and minimal use of postoperative narcotic analgesics.     

Endovascular repair of traumatic superior mesenteric artery to splenic vein fistula

Traumatic mesenteric arterioportal fistulas (APF) are rare but serious and life-threatening. This article reports the case of a 24-year-old female who suffered a gunshot wound to the abdomen and subsequently developed a superior mesenteric artery (SMA) pseudoaneurysm and APF, which caused secondary right heart failure and pulmonary hypertension. The patient underwent a successful endovascular stent-graft exclusion of the pseudoaneurysm/APF. The patient was asymptomatic 18 months post procedure and leading an active life with a normal arterial flow in the SMA confirmed by duplex ultrasonography.     

Different laparoscopic treatment modalities for splenic artery aneurysms: about 3 cases with review of the literature

Introduction: The first laparoscopic treatment of splenic artery aneurysm (SAA) was performed in 1993. Since then, many papers have been published mentioning different laparoscopic treatment modalities, including splenectomy, aneurysmectomy, ligation or even occlusion.

Patients and methods: An updated literature review of the English medical literature using the following MeSH, ‘Lapaorscopic splenic artery aneurysm’, ‘laparoscopic aneurysectomy’, ‘Laparoscopic Splenic artery Aneurysm Ligation’ and ‘Laparoscopic Splenic artery aneurysm excision’ was done. Also three cases performed at our institutions are discussed, in terms of techniques, morbidity, mortality and postoperative outcomes.

Results: About eight case series and 16 case reports were retrieved from the literature. Different techniques were described by the authors, including splenectomy, aneurysmectomy, splenic aneurysm ligation or even occlusion. Few morbidity cases were reported and none of the authors has mentioned a single mortality case. In our three cases, the postoperative course was uneventful, with good long-term results.

Conclusions: Despite the variations in the adopted operative techniques, the laparoscopic approach seems to be harmless. However, no treatment algorithm or consensus has been published.     

脾动脉瘤的手术及微创治疗

目的 探讨脾动脉瘤的治疗方法及中远期疗效.方法 1999-2011年收治18例脾动脉瘤患者,对18例的治疗方法及预后等临床资料进行回顾性分析.结果 18例患者中男7例,女11例.平均年龄53.8±7.3岁.8例患者无临床症状于体检中发现,7例表现为左上腹疼痛,3例因动脉瘤破裂于急诊首诊.14例经三维血管造影(3DCTA)、3例经数字减影血管造影(DSA)、1例经磁共振血管造影(MRA)确诊.手术治疗11例,其中脾动脉瘤破裂行急诊手术3例,择期性手术8例.手术包括脾动脉瘤及脾切除4例,同时切除胰尾5例,脾动脉瘤切除、断端吻合1例,脾动脉瘤切除加脾及结肠脾区切除1例.另外,行脾动脉瘤介入栓塞治疗3例.本组中,4例无临床症状、且瘤体直径＜2 cm者行随访观察中.围手术期无死亡.随访16例平均3.2年.失访2例,1例于术后4年死于脑溢血.结论 脾动脉瘤发病率低,症状多隐匿,脾动脉瘤破裂多有致死的危险.开腹手术及腔内微创治疗预后良好.     

Evolution of open aneurysmorrhaphy for management of sac expansion after endovascular repair of abdominal aortic aneurysms

ObjectiveWe evaluated the perioperative and mid-term clinical outcomes of open aneurysmorrhaphy (OA) for the treatment of sac expansion after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms.MethodsOA involves sac exposure without dissection of the proximal or distal neck, sacotomy and ligation of back-bleeding vessels, preservation of the prior stent graft, and tight closure of the sac around the stent graft. We performed a retrospective review of all patients who had undergone OA for nonruptured sac expansion after standard EVAR at our institution between January 2015 and June 2021. The primary end points were 30-day mortality and aneurysm-related death. The secondary end points were postoperative complications, overall survival, freedom from reintervention, and sac regrowth rate.ResultsA total of 28 patients had undergone OA. Their mean age was 76.9 ± 6.7 years. The median sac diameter at OA was 79 mm (interquartile range [IQR], 76-92 mm). The median duration from the index EVAR to OA was 82 months (IQR, 72-104 months). Preoperative computed tomography angiography confirmed a type II endoleak (EL) in 20 patients, 1 of whom had had a coexisting type Ia EL; a type IIIb EL was identified in 1 patient. Concomitant endovascular procedures had been performed in six patients to treat a type I or III EL or reinforce the proximal and distal seals. The OA technique has been modified since 2017, with the addition of more aggressive dissection of the sac and complete removal of the mural thrombus to further decrease the sac diameter. Postoperative complications occurred in two patients and included abdominal lymphorrhea and failed hemostasis of the common femoral artery requiring surgical repair in one patient each. The 30-day mortality was 0%. During the median follow-up of 36 months (IQR, 14-51 months), the overall survival was 92.7% and 86.9% at 12 and 36 months, respectively, without any aneurysm-related death. In the late (2017-2021) treatment group, the median sac diameter immediately after OA was smaller than that in the early (2015-2016) treatment group (early group: median, 50 mm; IQR, 39-57 mm; vs later group: median, 41 mm; IQR, 32-47 mm; P = .083). Furthermore, in the late group, the sac regrowth rate was lower (early group: median, 0.36 mm/mo; IQR, 0.23-0.83 mm/mo; vs late group: median, 0 mm/mo; IQR, 0-0.11 mm/mo; P = .0075) and the freedom from reintervention rate was higher (late group: 94.7% at both 12 and 36 months, respectively; early group: 71.4% and 53.6% at 12 and 36 months, respectively; log-rank P = .070).ConclusionsOur results have shown that OA for the management of post-EVAR sac expansion is feasible with acceptable mid-term outcomes. Aggressive dissection and tight plication of the sac might be imperative for better mid-term outcomes after OA.     

Outcomes of open repair of postdissection abdominal aortic aneurysms

BackgroundEvidence to guide management of postdissection abdominal aortic aneurysms (PDAAA) is lacking. This study describes the outcomes of open repair of PDAAA.MethodsA retrospective cohort study was conducted of all consecutive patients treated with open repair for PDAAA after a Stanford type A or type B thoracic aortic dissection between January 2006 and December 2017 in two vascular referral centers. Preceding type B dissection treatment could include conservative or surgical management. Primary outcomes were 30-day mortality, complication rates, survival, and reintervention-free survival. Survival and reintervention-free survival were analyzed using the Kaplan-Meier method. Reintervention was defined as any endovascular or surgical intervention after the index procedure.ResultsIncluded were 36 patients (27 men [75%]) with a median age of 64 years (range, 35-81 years). The 30-day mortality was 2.7%. The median follow-up was 16 months (range, 0-88 months). The postoperative course was uneventful in 21 patients (58%). The most frequent complications were postoperative bleeding requiring repeat laparotomy (n = 4), pneumonia (n = 3), congestive heart failure (n = 2), new-onset atrial fibrillation (n = 2), mesenteric ischemia requiring left hemicolectomy (n=1), and ischemic cerebrovascular accident (n = 1). Renal failure requiring hemodialysis developed in one patient. The overall survival at 1 year was 88.8%. Reintervention-free survival was 95.5% after 1 year and 88.6% after 2 years.ConclusionsOpen repair of PDAAA can be performed with a low mortality rate and an acceptable complication rate, comparable with elective open repair of abdominal aortic aneurysms without dissection.     

肠系膜上动脉狭窄的血管腔内治疗

目的探讨介入治疗肠系膜上动脉狭窄的安全性及临床疗效。方法对12例肠系膜上动脉狭窄的患者行选择性肠系膜上动脉造影,然后行球囊扩张或支架植入治疗,评价疗效。结果 12例肠系膜上动脉狭窄的患者技术成功率100%,其中单纯球囊扩张2例,球囊扩张+内支架植入术10例。对所有患者随访6~24个月,平均16个月,其中10例无明显症状,2例有腹痛症状,经再次腔内治疗,症状得到明显改善。随访中所有患者均未出现肠坏死、死亡等严重并发症。结论血管腔内介入治疗肠系膜上动脉狭窄是一种安全、有效的方法。     

覆膜支架腔内隔绝和开腹手术治疗腹主动脉瘤破裂疗效比较

目的比较开腹手术和腔内隔绝术治疗腹主动脉瘤破裂的手术效果。方法 2000年3月-2011年7月,收治48例腹主动脉瘤破裂患者,其中40例行腹动脉瘤切除、人工血管移植术治疗(开腹组),8例行覆膜支架腔内隔绝术治疗(腔内隔绝组)。两组患者性别、年龄、瘤颈长度≤2 cm构成比、瘤颈成角≥60°构成比、髂外动脉严重扭曲构成比、术前收缩压、术前合并症组间比较差异无统计学意义(P>0.05),具有可比性。术后对两组患者输血量、手术时间、重症监护时间、术后并发症、二期手术率、术后24 h内死亡率和术后30 d内死亡率进行比较。结果两组术后24 h死亡率、术后30 d死亡率以及非移植物相关并发症发生率比较差异均无统计学意义(P>0.05);但组间手术时间、输血量、重症监护时间、二期手术率及移植物相关并发症发生率比较差异均有统计学意义(P<0.05)。结论腔内隔绝术对解剖条件良好的腹主动脉瘤破裂患者是一种可行的手术方式,在输血量、手术时间、重症监护时间方面与传统开腹手术相比具有明显优势。     

经导管弹簧圈栓塞治疗脾动脉瘤

目的探讨经导管弹簧圈栓塞治疗脾动脉瘤的临床应用价值。方法回顾性分析接受经导管弹簧圈栓塞治疗的18例脾动脉瘤患者的资料,其中真性脾动脉瘤14例,假性脾动脉瘤4例;近端型6例,中间型4例,脾门型8例。根据患者脾动脉造影情况,选择普通弹簧圈、微弹簧圈或机械可脱式弹簧圈进行栓塞。术后1周及1、3、9个月行CT增强或CTA复查,随后每月行电话随访。结果对18例均顺利完成手术,11例采用隔绝旷置术,4例采用瘤腔填塞术,3例采用隔绝旷置术+瘤腔填塞术。术后12例出现栓塞后综合征,其中8例出现不同程度的脾梗死,梗死体积约10%~35%;余4例为轻微并发症。随访中无瘤体增大、破裂或复发及相关并发症。结论经导管弹簧圈栓塞治疗脾动脉瘤简单可行、安全有效。     

肠系膜上动脉夹层15例诊治分析

目的 探讨肠系膜上动脉夹层的临床诊治路径.方法 分析2006年2月至2010年7月收治的15例肠系膜上动脉夹层患者的临床资料.男13例,女2例.年龄43～63岁,平均(53±8)岁.除1例有明确的外伤史,余无明确诱因.所有患者均经腹部增强CT扫描检查明确诊断.治疗方法包括腔内支架治疗、保守治疗及开放手术治疗.结果 腔内支架治疗成功5例,未成功而转保守治疗9例.1例因疑有严重肠缺血的患者接受开放手术,术中行肠系膜上动脉夹层开窗,恢复远端肠系膜上动脉血供.15例中13例患者得到随访,随访率为86.7％.随访时间12 ～60个月,平均(28±14)个月.在随访期内无腹痛复发及慢性肠缺血症状.保守治疗的患者CT随访无夹层瘤样扩张,腔内治疗成功的患者内支架均通畅.结论 腔内治疗肠系膜上动脉夹层的成功率不高;对于症状缓解的患者及无症状的患者,可在长期随访检测下进行保守治疗;症状不缓解或出现肠缺血坏死征象时应尽早行开放手术治疗.     

Perioperative and long-term outcomes after open conversion of endovascular aneurysm repair versus primary open aortic repair

BackgroundThe use of endovascular abdominal aortic aneurysm repair (EVAR) has superseded that of open aneurysm repair (OAR) as the procedure of choice for abdominal aortic aneurysm repair. However, significant rates of late reintervention and aneurysm rupture have been reported after EVAR, resulting in the need for conversion to OAR (C-OAR). To assess the relative effects of C-OAR on patients, we compared the outcomes of these patients to those of patients who had undergone P-OAR.MethodsThe data from all patients who had undergone C-OAR and P-OAR in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database from 2003 to 2018 were queried. Multivariable logistic regression and Kaplan-Meier survival and Cox proportional hazard regression analyses were used to assess the perioperative long-term outcomes.ResultsA total of 4763 patients were included (91.4%, P-OAR; 8.6%, C-OAR). C-OAR was associated with a significant increase in the odds of perioperative mortality (odds ratio, 1.7; 95% confidence interval [CI], 1.1-2.7; P = .027) and renal complications (odds ratio, 1.5; 95% CI, 1.1-2; P = .004) vs P-OAR. At 5 years, conversion was associated with a higher risk of mortality (hazard ratio [HR], 1.5; 95% CI, 1.3-1.9; P < .001), aneurysmal rupture (HR, 1.9; 95% CI, 1.2-3.1; P = .007), and reintervention (HR, 1.4; 95% CI, 1.05-1.97; P = .022) compared with P-OAR. These results also persisted at 10 years, with conversion associated with a higher risk of mortality (HR, 1.5; 95% CI, 1.2-1.8; P < .001), rupture (HR, 1.8; 95% CI, 1.1-2.8; P = .018), and reintervention (HR, 1.5; 95% CI, 1.1-2.1; P = .010).ConclusionsThe results from the present study have demonstrated that C-OAR is associated with a significantly higher risk of perioperative morbidity and mortality compared with P-OAR. We found a significant increase in mortality, aneurysm rupture, and reintervention at 5 and 10 years of follow-up.