应用一体式分叉支架型人工血管腔内治疗腹主动脉瘤42例

目的总结应用一体式分又支架型人工血管治疗腹主动脉瘤初步经验。方法本组42例，其中腹主动脉瘤39例，腹主动脉假性动脉瘤1例，Ⅲ型夹层动脉瘤1例，降主动脉瘤合并腹主动脉瘤1例。除均在腹主动脉放置一体式分又支架型人工血管外，1例降主动脉瘤合并腹主动脉瘤者共放置5枚支架型人工血管，其中4枚直型支架用于隔绝降主动脉瘤；1例Ⅲ型夹层动脉瘤者，降主动脉近侧破口用直型支架型人工血管封堵；1例因一侧髂外动脉闭塞需先经腹膜外切口行人工血管搭桥后才能放置一体式分叉支架。结果平均手术时间50min。1例死亡，8例附加近侧短的覆膜支架，1例附加远侧Cuff，1例近侧和远侧均加Cuff。8例术后有少量内漏，1周后内漏均消失。5例封堵了双侧髂内动脉，20例封堵了单侧髂内动脉，但均未导致臀肌坏死或疼痛等并发症。2例瘤颈与瘤体呈90度角也获得成功。结论一体式分又支架型人工血管可以达到隔绝腹主动脉瘤的作用，且操作更快捷。     

Ⅲ型夹层动脉瘤介入治疗误堵颈动脉的处理

目的 总结Ⅲ型夹层动脉瘤介入治疗误堵左颈总动脉的处理和经验教训.方法 4例Ⅲ型夹层动脉瘤患者行支架型人工血管封堵降主动脉内膜破口时不慎误堵塞左颈总动脉.4例患者均为男性,年龄37～45岁,平均年龄41岁.1例因存在内漏加Cuff时将第一个支架推向近侧导致左颈总动脉和左锁骨下动脉堵塞,经球囊拖向下方后解决;1例放置支架时支架前跳堵塞左颈总动脉和左锁骨下动脉.立即从股动脉进抓捕器抓住从左上肢肱动脉进入升主动脉的刻度猪尾导管将支架拖向远侧后恢复左颈总动脉和左锁骨下动脉血流;1例因定位误差导致支架堵塞2/3左颈总动脉和左锁骨下动脉,立即显露左颈总动脉分叉经颈外动脉置入左颈总动脉支架(chimney技术)后左颈总动脉血运完全恢复;1例是在心外科误将前端无裸支架的支架型人工血管当成有裸支架而将一半的无名动脉、左颈总动脉和左锁骨下动脉封堵,经正中开胸行升主动脉双颈动脉及左腋动脉人工血管搭桥后缓解.结果 4例患者均成功封堵Ⅲ型主动脉夹层的近侧内膜破口,无明显内漏,无脑梗死和左上肢缺血表现.结论 介入治疗Ⅲ型主动脉夹层误堵颈动脉后需立即通过手术或介入手段解决以避免发生脑缺血并发症.     

支架型人工血管临床应用的初步经验

目的探讨支架型人工血管治疗各类动脉瘤的临床效果。方法本组包括夹层动脉瘤 4 8例 ;腹主动脉瘤 13例 ;降主动脉、左锁骨下动脉、肾下和肾上腹主动脉假性动脉瘤分别为 4例、1例、2例和 1例 ;左、右髂动脉瘤各 1例。对夹层动脉瘤和假性动脉瘤均行破口封堵术 ,真性腹主动脉瘤行隔绝术。结果本组均获技术成功。围手术期死亡 2例。 5例夹层动脉瘤术后近侧有少量残余漏 ,但 4例半年后近侧渗漏消失 ,9例残存远侧破口少量返流。腹主动脉瘤 6例术后即时有轻度内漏 ,3个月后 5例内漏消失。结论支架型人工血管治疗夹层动脉瘤、假性动脉瘤和真性动脉瘤手术微创、安全 ,但其远期疗效需进一步观察。     

腔内修复联合辅助技术治疗累及主动脉弓的Stanford B型夹层动脉瘤

目的 探讨主动脉腔内修复手术联合辅助技术治疗累及主动脉弓部的Stanford B型主动脉夹层动脉瘤.方法 分析腔内治疗累及主动脉弓部,破口邻近左锁骨下动脉或位于其近端的46例StanfordB型主动脉夹层动脉瘤的临床资料.腔内封堵左锁骨下动脉43例;PDA封堵器封堵左锁骨下动脉6例次;颈部动脉搭桥术9例次;“烟囱”技术重建左颈总动脉8例次;“开窗”技术封堵夹层破口,同时保留主动脉弓部所有分支动脉1例次.结果 患者术后均存活,随访时间(25±16)个月.未发生严重神经系统并发症.10例发生左锁骨下动脉Ⅱ型内漏,其中6例通过PDA封堵器隔绝,2例保守治疗后自愈;9例发生左上肢缺血症状,其中8例行保守治疗,另1例症状严重,行颈部动脉搭桥术重建左锁骨下动脉.随访中,所有人工血管和分支动脉支架均保持通畅,降主动脉真腔直径显著扩大,假腔直径逐渐缩小.结论 对累及主动脉弓部,破口邻近左锁骨下动脉或位于其近端的StanfordB型主动脉夹层,腔内治疗联合PDA封堵器、颈部动脉搭桥术、“烟囱”技术或“开窗”技术是安全有效的治疗方法.     

腔内隔绝治疗特殊类型主动脉夹层动脉瘤和复杂型腹主动脉瘤

目的探讨基底节区脑出血合并StanfordB型主动脉夹层动脉瘤、肾移植术后患者合并StanfordB型主动脉夹层动脉瘤以及复杂型腹主动脉瘤进行腔内隔绝术的可行性。方法对4例特殊类型的动脉瘤行腔内隔绝治疗,1例为基底节区脑出血合并StanfordB型主动脉夹层动脉瘤,1例为肾移植术后合并StanfordB型主动脉夹层动脉瘤,2例为瘤颈成角大于70°,瘤颈长1.6cm,髂动脉严重扭曲。结果 2例主动脉夹层动脉瘤患者术后未发生内漏,术中应用小剂量肝素,减少造影剂,建立稳定的低血压,有效地保证了脑和移植肾血流灌注,防止了脑部再出血和移植肾的功能损害;2例腹主动脉瘤患者,通过拉紧两端导丝克服血管扭曲的方法使带膜支架顺利释放,带膜支架成角严重时在成角处加放裸支架。其中1例瘤颈发生内漏,支架0.4cm移位,降压治疗1周后复查螺旋CT血管成像(CTA)内漏基本消失,1例髂外动脉带膜支架成角未及时加放裸支架,术后因成角处血流缓慢出现血栓形成,急诊行股—股搭桥。4例患者均痊愈出院。结论应用腔内隔绝治疗脑出血和肾移植后合并主动脉夹层动脉瘤、复杂型腹主动脉瘤是可行的。     

腔内修复术治疗胸腹主动脉夹层动脉瘤

目的 介绍血管内支架技术治疗胸腹主动脉夹层动脉瘤的经验。方法 对2000年10月－2001年6月间6例胸腹主动脉夹层动脉瘤的治疗经过进行回顾性分析。结果 6例均为男性,年龄42－72岁。Standford A型胸腹主动脉夹层动脉瘤1例,B型5例。其中5例经行腔内人工血管支架修复成功,1例中转腹主动脉夹层开窗手术。术后1例发生髂外动脉夹层破裂,行腹主动脉夹层开窗人工血管移植术;1例术后3d因严重心肌梗塞抢救无效死亡。5例随访1－9个月,情况良好。结论 腔内人工血管治疗主动脉夹层动脉瘤简化了手术操作,减小了手术风险。腹主动脉夹层开窗手术是治疗主动脉夹层的辅助手段。     

“烟囱”技术在Ⅲ型夹层动脉瘤和腹主动脉瘤腔内修复术中的应用

目的 总结“烟囱”技术在主动脉瘤腔内修复术中的应用体会和一期效果.方法 在30例主动脉瘤腔内修复术中使用“烟囱”技术增加近端覆膜支架锚定区,其中25例DebakeyⅢ型夹层动脉瘤使用“烟囱”支架保留左锁骨下动脉(23例)或左颈总动脉(3例),肾下腹主动脉瘤使用“烟囱”支架保留肾动脉(5例).结果 所有病例均顺利完成操作,放置“烟囱”支架的分支动脉术中造影均通畅.其中2例夹层动脉瘤(8％)和1例腹主动脉瘤残留(20％)少量Ⅰ型内漏,1例夹层动脉瘤左锁骨下动脉“烟囱”病例术后5d猝死,考虑为远侧破口所致夹层动脉瘤破裂.其余22例夹层动脉瘤和4例肾下腹主动脉瘤均无内漏.随访28例(90.3％),随访1～19个月,平均(6±5)个月.随访期超声或CTA示“烟囱”血管血流均通畅.1例腹主动脉瘤仍有内漏,2例夹层内漏病例随访中(尚未行CTA),其他病例瘤腔血栓形成.结论 “烟囱”技术能够有效的延长覆膜支架在主动脉瘤腔内修复术中的近端锚定区并保持重要分支动脉通畅.     

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目的 探讨支架型人工血管治疗主动脉夹层的临床效果。方法 2001年3月至2003年9月间，应用支架型人工血管治疗Ⅲ型夹层44例和Ⅰ型主动脉夹层1例。45例主动脉夹层共应用56个支架型人工血管行近侧内膜破口封堵，1例同时行远侧内膜破口手术关闭，1例远侧破口以分叉的支架型人工血管封闭。结果 所有病人均获得技术成功。围手术期死亡2例，1例术后12h后死于脑出血，1例术后10d死于假腔破裂；1例手术后半年死于细菌性心内膜炎。结论 支架型人工血管行Ⅲ型主动脉夹层和破口在降主动脉的Ⅰ型主动脉夹层破口封堵术较传统手术安全，其远期疗效需进一步观察。     

血管、淋巴管

支架型人工血管腔内治疗复杂主动脉瘤；Stanford B型主动脉夹层腔内修复后转为StanfordA型10例分析；胸主动脉夹层合并腹主夹层动脉瘤的一期腔内治疗；血管损伤的腔内治疗体会；四肢骨骼肌血管畸形的分类与治疗方法的研究     

复杂主动脉病变的腔内血管外科治疗

目的 探讨复杂主动脉病变的腔内血管外科治疗方法。方法 对21例合并有内脏动脉缺血等复杂的主动脉病变,双球管定位下经锁骨上动脉到股动脉交换导丝以确保真腔内植入带膜支架,对真腔完全被假腔压闭的患者采取真腔内加压推进以通过导丝,用超长带膜支架来封堵大破口治疗夹层合并巨大假性动脉瘤形成,对夹层合并腹主动脉瘤患者采取血管腔内技术联合开腹手术等方法。结果 术后内漏3例,其中2例7 d后停止,1例漏血持续存在。3例主动脉创伤术后完全康复,余18例复杂主动脉夹层术后即时造影示瘘口已被完整覆盖,假腔无血漏入,内脏动脉等恢复真腔供血。18例中6例合并肠管缺血,3例合并肾动脉缺血,3例肠管缺血、肾动脉缺血,2例腹主动脉真腔完全被假腔压迫,以及2例合并下肢缺血术后均逐渐恢复,无脏器及肢体缺血坏死发生。2例合并腹主动脉瘤夹层行支架型人工血管封闭夹层破口后行开腹手术切除腹主动脉瘤、人工血管置换。16例随访5～36个月,平均22.3月,1例内漏持续存在,但假腔未继续加大,其余患者存活良好。结论 对复杂的主动脉病变的治疗,通过对腔内血管外科技术进行改进,并适当结合传统手术方法,使某些过去被认为不能够治疗的复杂主动脉病变可得以成功治疗。     

Surgical treatment of the thoracoabdominal aortic aneurysms with Marfan's syndrome

We experienced two cases of the thoracoabdominal aortic aneurysms with Marfan's syndrome. Case 1; The 31 year-old-woman was operated upon by Crawford's procedure, which includes reconstruction of renal arteries, superior mesenteric artery, and celiac artery using temporary shunt. Although she had been well for three years after the operation before she developed acute aortic dissection, she could not tolerate the Bentall's procedure on it. Case 2; The 37 year-old woman was operated upon for dissecting aneurysm (DeBakey IIIb). The procedure included replacement of the descending and abdominal aorta by Dacron graft. Four years after the operation, enlargement of residual false lumen had been observed, which caused its dehiscence just proximal to the abdominal aortic anastomosis. The Crawford's procedure, which includes reconstruction of renal arteries, superior mesenteric artery, and celiac artery using temporary shunt was employed for repair of the remaining thoracoabdominal aortic aneurysm. She is well now 5 months after surgery. We conclude that cardiovascular changes in patients with Marfan's syndrome must be observed carefully because of its high recurrent rate after initial surgery. The operation at proper time and a careful observation of cardiovascular changes will improve the prognosis.     

Surgical treatment of fusiform thoracoabdominal aortic aneurysm with Marfan's syndrome. A report on reconstruction of 4 major abdominal visceral branches

A fusiform thoracoabdominal aortic aneurysm involving celiac, superior mesenteric and renal arteries was successfully replaced in a 53-year-old female with Marfan's syndrome who also had annuloaortic ectasia, dissecting aneurysm of descending aorta and bilateral subclavian arterial aneurysms. Exposure of the aneurysm was obtained with a thoracoabdominal incision by reflecting the abdominal viscera to the right. First the limbs of a 24 X 12mm dacron bifurcated prosthesis were attached to common iliac arteries in an end-to-side fashion. Then renal arteries were anastomosed end-to-end to the branches previously attached to the body of the prosthesis. With the temporary bypass from left subclavian to left limb of the dacron graft, reconstruction of the celiac and superior mesenteric arteries was performed by direct suture of orifices to the opening made in the graft. Proximal anastomosis between descending aorta and the graft was made in an end-to-end fashion. The dissecting lesion of the proximal descending aorta was wrapped by dacron mesh. The immediate postoperative course was uneventful except transient hepatitis and pneumonia. The patient was discharged 49 days after operation. One month later, however, she died suddenly. Autopsy could not reveal the exact cause of death. Retrograde revascularization combined with Crawford's method was useful in shortening the occlusion time.     

Complex Thoracic Aortic Aneurysm: A Combined Open and Endovascular Approach

The authors wish to describe a combined open and endovascular approach to repair a complex thoracic aortic aneurysm. A 72-year-old man with chronic obstructive pulmonary disease, aortic valvular insufficiency and diffuse thoracic aortic aneurysm underwent aortic valve and ascending aorta replacement by a Bentall-procedure and replacement of arch aneurysm using the elephant trunk technique, performed in a first procedure. During the second procedure, endovascular stenting of the descending thoracic aorta was done. Only a few similar case reports have been presented. Endovascular repair after an elephant trunk procedure for complex thoracic aortic aneurysms is an elegant approach to deal with such mega aortas. Further research is necessary to compare open and endovascular repair and to determine long-term follow-up with regard to endoleaks and mortality.     

Complex thoracic aortic aneurysm: a combined open and endovascular approach

The authors wish to describe a combined open and endovascular approach to repair a complex thoracic aortic aneurysm. A 72-year-old man with chronic obstructive pulmonary disease, aortic valvular insufficiency and diffuse thoracic aortic aneurysm underwent aortic valve and ascending aorta replacement by a Bentall-procedure and replacement of arch aneurysm using the elephant trunk technique, performed in a first procedure. During the second procedure, endovascular stenting of the descending thoracic aorta was done. Only a few similar case reports have been presented. Endovascular repair after an elephant trunk procedure for complex thoracic aortic aneurysms is an elegant approach to deal with such mega aortas. Further research is necessary to compare open and endovascular repair and to determine long-term follow-up with regard to endoleaks and mortality.     

A case of ascending aortic dissection after aortic valve replacement in congenital bicuspid aortic valve]

Congenital bicuspid aortic valve is a risk factor of aortic dissection, but the case is rare in Japan. Several reports described ascending aortic aneurysm after aortic valve replacement. In these reports, most of aneurysms were false aneurysm, but the cases of ascending aortic dissection were rare. In this case, dissecting aneurysm of the ascending aorta occurred 4 years after aortic valve replacement, which was performed with mechanical prosthesis because of infective endocarditis, and it was repaired successfully by the modified Cabrol's method. This case was congenital bicuspid aortic valve, and had already been complicated with moderate aortic dilatation in the ascending aorta. In patients of congenital bicuspid aortic valve with aortic dilatation, consideration of complete replacement of the ascending aorta with aortic valve replacement is important.     

Pararenal aortic aneurysms: definition, classification, directions for surgery

The formidable impact derived by the endovascular correction (Evar) of abdominal aorta aneurysms (AAA), has risen its classification aspects. The topographical criteria has assumed importance in decisional diagnostic-therapeutic strategy especially in cases of so called pararenal aneurysms (PRAA). DEFINITION: PRAA defines aneurysm being involved underenal juxtarenal aorta (JRA), or more rarely, suprarenal aorta with normal aortic diameter at level of celiac (JRA), or more rarely, suprarenal aorta with normal aortic diameter at level of celiac trunk. CLASSIFICATION: The morphologic-topographic aspect is considered in function of selection or eligibility of patients to Evar or standard open surgery, in the need of a suprarenal clamping for the tailoring of proximal anastomosis or anchorage of endoprotesis. Various specific classifications for these aneurysms have been proposed (Schumacher, 1997; Wolf, 2000; Ayari, 2001) that considers: 1. Aneurysm collar: short/long/tortuous, 2. Relations with renal arteries, 3. Relations with the left renal vein. DIRECTIONS FOR SURGICAL TREATMENT: The choice between the technical solution to prefer either open or endovascular surgery will have to consider a series of additional variables to the standard direction common to every AAA based on dimensions and morphology. Priority will have to be given to evaluating, using shared morphologic-topographical classification criteria, real incidence of PRAA-JRA (3%-20% in literature review); greater post opening mortality (1.3%-15.3%); dimensions (AAA with diameter > or = 5.5 cm in operating risk assessment of single patient, in clinical evolution and increase in the time of the lesion); in common occurrence in AAA of steno-obstructive lesions of renal arteries and involvement of same ones in the aneurysm collar in need of reconstruction and suprarenal aortic clamping.     

不同内径腹主动脉瘤腔内血流状况分析

目的　观察不同内径腹主动脉瘤腔内血流情况。方法　应用二维彩色多普勒超声观察不同内径和形状腹主动脉瘤患者 (2 0例 )和通过牛颈外静脉移植法 (3例 )及补片法 (3例 )制作不同内径和形状的腹主动脉瘤模型的动脉瘤腔内血流。结果　在人体中 ,动脉瘤内径≤ 3 .0cm有 5例 ,其中 4例为层流 ,动脉瘤形态为梭形。动脉瘤内径 >3 .0cm有 15例 ,其中 14例出现湍流。 3例牛颈静脉移植法建立的模型 ,当内径≤ 1.5cm时 ,血流表现为层流 ,动脉瘤形态为梭形。内径 >1.5cm时 ,动脉瘤腔内出现湍流和逆流。 3例牛颈静脉补片法建立的模型 ,在动脉瘤腔内近凸起部位出现湍流和逆流。结论　随着动脉瘤内径的增大和形状的改变 ,瘤腔内的血流更为复杂 ,可能会对动脉瘤的生长、破裂及血栓形成产生进一步的影响。     

Total graft replacement of the thoracoabdominal aorta with reconstruction of visceral branches, intercostal and lumbar arteries in expanding chronic dissecting aneurysms of the thoracoabdominal aorta

Four patients with expanding chronic dissecting thoracoabdominal aneurysm underwent total replacement of the thoracoabdominal aorta with reconstruction of all visceral branches, intercostal and lumbar arteries with the aid of femoro-femoral bypass. During aortic cross-clamping, selective celiac and both renal arteries perfusion was performed to prevent the organ ischemia. Somatosensory evoked potentials monitoring or spinal cord evoked potentials monitoring was also performed to detect the spinal cord ischemia. Surgical technique employed in this series was direct anastomosis of onlay patch graft to the normal true lumen from which visceral branches and intercostal and lumbar arteries arise. The celiac artery and left renal artery arise from the false lumen in some cases were reconstructed with graft interposition or direct anastomosis to an opening made in the onlay patch graft. All patients survived the operation, and are leading normal life late in the postoperative period except one who developed partial paraplegia. Total graft replacement of the thoracoabdominal aorta may be a valid technique for the treatment of expanding aneurysms of the dissecting thoracoabdominal aorta.     

Surgical treatment of aneurysms of unpaired visceral branches of the abdominal aorta

Aneurysms of unpaired visceral branches of the abdominal aorta are rare diseases but they are dangerous for life. Russian Research Center of Surgery RAMS has an experience of diagnosis and surgical treatment of 23 patients with aneurysms of the celiac trunk (2), superior mesenteric artery (4), inferior mesenteric artery (1), hepatic artery (4), splenic artery (7), gastroduodenal artery (2), inferior pancreatoduodenal artery (1), multiple aneurysms of celiac trunk and superior mesenteric artery (2). 21 of 23 patients were operated. 20 patients were discharged with complete recovery. 1 (4.8%) patient died due to gastroduodenal bleeding 4 months after surgery. The results show that patients with aneurysms of unpaired visceral branches of abdominal aorta require surgical treatment.