离体肾动脉瘤切除和自体肾移植术治疗复杂肾动脉瘤

目的 探讨手助腹腔镜法活体取肾、离体肾动脉瘤切除、肾动脉重建和自体肾移植技术治疗复杂性肾动脉瘤的安全性和可行性.方法 2006年10月收治1例42岁复杂性肾动脉瘤男性患者.术前彩超、CT及DSA检查显示左肾动脉瘤3.4 cm×4.3 cm×4.5cm大小,瘤内有部分血栓形成,位于左肾动脉主干分叉部,累及5支分支动脉,邻近肾门.患者有高血压病史,药物控制不佳.术中采用手助腹腔镜法活体取肾成功后,立即对离体肾脏采用4℃肾脏保存液灌注,低温保护肾脏.体外进行肾动脉瘤切除:切取自体右髂内动脉体外行肾动脉重建,最后将肾脏异位移植至右侧髂窝.结果 患者手术成功,围手术期未出现并发症.术后.肾功能正常:彩超复查显示右侧髂窝移植肾动脉及其分支血流通畅无狭窄,肾静脉血流通畅,输尿管无狭窄.术后13个月随访,血压恢复正常,肾功能正常.结论 离体肾动脉瘤切除和自体.肾移植术治疗复杂性肾动脉瘤微创、安全、可行.     

后腹腔镜取肾、离体肾动脉瘤切除及自体肾移植治疗复杂性肾动脉瘤1例并文献复习

目的：总结复杂性肾动脉瘤1例的诊治经验。
方法:报告采用后腹腔镜取肾、离体肾动脉瘤切除、肾动脉重建和自体肾移植治疗复杂性肾动脉瘤1例的治疗经过及结果，并复习文献。患者，男，27岁。术前彩超、CT及CTA示：动脉瘤体4.5 cm×4.0 cm×3.0 cm大小，靠近肾门，位于肾动脉主干远端分叉部，累及6根分支。采用后腹腔镜切取右肾后，离体肾脏采用4 ℃低温肾脏保存液灌注、离体行肾动脉瘤切除及自体大隐静脉肾动脉重建，然后通过原取肾切口将肾脏移植于右髂窝。
结果:手术顺利，时间为6.5 h，失血约50 mL，肾热、冷缺血时间分别为4 min和2.5 h。围手术期未出现并发症，术后肾功能正常。术后1个月CTA及2周和3个月彩超复查显示右髂窝移植形态正常，肾动脉及其分支血流通畅无狭窄，肾静脉血流通畅，输尿管无狭窄。
结论:后腹腔镜取肾、离体肾动脉瘤切除、肾动脉成形和自体肾移植用于治疗远段和/或累及分支的复杂性肾动脉瘤，微创、安全、有效、可行。

     

离体肾肿瘤切除、肾重建和原位自体肾移植技术治疗复杂性肾错构瘤的临床应用

目的:探讨离体肾肿瘤切除、肾重建技术应用于复杂肾错构瘤保留肾单位手术的安全性和可行性。方法:双源CT三维血管成像(CTA)确诊左侧复杂肾错构瘤2例,其中1例为左肾上极巨大错构瘤及肾窦错构瘤,1例为左肾窦内错构瘤。均实施手术切除病变肾脏,在离体后给予UW液灌注和低温保护肾脏,于体外实施肾错构瘤切除及肾实质重建,随后将重建肾脏原位移植于左侧腹膜后肾床。结果:手术均获成功,围手术期无严重并发症发生。术后2周复查肾彩色多普勒提示左腹膜后移植肾动脉及其分支血流通畅,肾实质血流灌注良好。术后4个月双源CT示左腹膜后移植肾动脉及其分支血流通畅无狭窄,肾静脉回流通畅,输尿管无狭窄。结论:离体肾肿瘤切除、肾重建和原位自体肾移植技术治疗复杂性肾错构瘤安全可行,并为治疗复杂性肾脏外科疾病提供了可行途径。     

移植肾动脉瘤五例报告

目的 探讨移植肾动脉瘤(RAA)的病因、诊断及治疗. 方法 1998年8月至2004年12月共行同种异体肾移植手术1251例,发生RAA 5例(0.4%).5例均为男性,平均年龄43岁,移植肾血管吻合方式均为移植肾动脉一髂内动脉端端吻合.患者主要临床表现为进行性肾功能减退,突发少尿或无尿,顽固性高血压及肾区疼痛,均经彩色多普勒超声、数字减影血管造影检查确诊为动脉瘤,动脉瘤大小1.8 cm×2.0 cm×2.0 cm～4.0 cm×4.0 cm×5.0 cm. 结果 移植肾动脉吻合口动脉瘤2例,1例发现动脉瘤后1个月内移植肾功能丧失,行移植肾切除术,术后规律透析治疗,随访1年后行二次肾移植;1例移植肾失功后1周内行对侧髂窝二次肾移植手术,保留原移植肾,术后随访2年肾功能正常.RAA合并近端移植肾动脉狭窄2例,1例行吻合口球囊扩张并放置支架后,以弹簧螺圈栓塞动脉瘤,术后随访1年肾功能稳定;1例行移植肾切除、二次.肾移植术,术后随访3年肾功能正常.吻合口髂内动脉侧粥样硬化斑块导致髂内动脉狭窄、移植肾动脉侧动脉瘤1例,行移植肾切除术,术后2 d因脑干栓塞死亡. 结论 移植肾动脉-髂内动脉端端吻合易诱发血管并发症,RAA治疗应谨慎采用开放手术切除,可选择近期行二次肾移植和血管内介入治疗.     

移植肾假性动脉瘤的诊断和治疗四例报告

目的 总结移植肾假性动脉瘤的诊治体会.方法 首次接受肾移植者4例,其供肾动脉均为单支,肾动脉无损伤,也未行动脉修补成形术.供肾动脉均与受者的髂外动脉行端侧吻合.术中发现受者髂外动脉有粥样斑块或动脉分层者2例.术后4例均未出现移植肾周感染,亦未行移植肾穿刺活检或其他有创检查.依据临床表现、彩色多普勒超声检查、多层螺旋CT血管成像和数字减影血管造影诊断移植肾假性动脉瘤.结果 分别在术后1.5个月、2个月、5个月和7个月诊断移植肾假性动脉瘤,其临床表现缺乏特异性,3例经数字减影血管造影、1例经多层螺旋CT血管成像确诊.1例移植肾假性动脉瘤突发破裂,急诊切除假性动脉瘤和移植肾;1例因瘤体短期迅速增大,行带膜支架置入及栓塞术;2例行移植肾动脉瘤切除及动脉裂口修补术.结论 移植肾假性动脉瘤是肾移植术后的少见并发症,其临床表现缺乏特异性,多层螺旋CT血管成像和数字减影血管造影有助于本病的诊断.对于移植肾假性动脉瘤的治疗,可选择手术切除或介入栓塞术,关键在于是否保留移植肾,并需考虑移植肾血管重建方式.     

肾移植术后肾外型假性动脉瘤2例

目的:探讨肾移植术后肾外型假性动脉瘤诊治方法。方法:对2例肾移植术后肾外型假性动脉瘤患者资料进行回顾性分析。结果:1例栓塞后动脉瘤逐渐缩小。4 年后复查彩超,示左髂内动脉瘤为4.8 cm×4.1cm×4.8 cm,动脉瘤内部回声不均,有少许的液性暗区,无血流信号。1 例因瘤口无法修补,移植肾缺血,行动脉瘤及移植肾切除。结论:磁共振血管造影有助于本病的诊断。肾外型假性动脉瘤一旦确诊应尽早处理。手术治疗对保留肾脏最为理想,但由于再次手术发生动脉瘤的血管壁一般水肿严重,无法修补或重建,大多数行动脉瘤及移植肾切除。     

14例亲属活体供肾动脉变异的血管重建

目的 探讨亲属活体供肾动脉变异的血管重建方法.方法 在104例亲属活体供肾移植中,有14例供肾动脉变异.供肾动脉变异的分类和血管重建方法分别为:(1)单支动脉较早分支型2例,取肾时分支受损,分别用受者髂内动脉及其分支、腹壁下动脉离体重建受损动脉.(2)双支动脉型10例,4例用受者髂内动脉及其分支离体重建血管,3例用受者腹壁下动脉与较细分支于体内吻合,1例较短肾动脉与较长肾动脉端侧吻合,1例较细副.肾动脉与主肾动脉端侧吻合,1例双支分别与髂外动脉端侧吻合.(3)3支动脉型2例,1例用受者髂内动脉及分支离体重建血管,1例结扎细小分支后,将较细的副肾动脉与主肾动脉端侧吻合.14例血管重建后,分别将供肾动脉较粗支和/或髂内动脉主干端与受者髂外动脉端侧吻合.结果 术后各支动脉血流通畅,移植.肾血液供应丰富、均匀.12例肾功能早期恢复正常,其中1例术后第14天发生急性排斥反应.1例术后即发生急性排斥反应;1例血肌酐下降缓慢.随访至2008年7月,除1例动脉粥样硬化较重的受者(三支动脉)下极动脉栓塞,血肌酐升高并稳定在170μmol/L外,其余患者动脉血流通畅,血液供应丰富、均匀.结论 供肾动脉变异时,利用所得供肾动脉的自身条件重建血管,或用受者髂内动脉及分支或腹壁下动脉重建血管,可获得较好的移植肾功能.受者动脉粥样硬化较重,同时有较细肾动脉支做重建吻合时,应注意该支动脉发生栓塞的可能.     

探讨肾动脉多支畸形的供肾在体外血管重建中的方式及在肾移植中的应用

目的探讨。肾动脉多支畸形的供。肾在体外血管重建中的方式及其在肾移植中的应用。方法对5例肾动脉多支畸形供肾的修整采取截取受者同侧髂内动脉的方法，依据供肾动脉的分支数而保留髂内动脉的分支数；在体外将供肾动脉各分支与髂内动脉大分支的开口进行端端吻合，然后将髂内动脉主干与受者髂外动脉行端侧吻合。将肾动脉重建后的供肾应用于双侧肾动脉瘤患者的自体肾移植术1例、亲属活体供肾肾移植术3例和尸体肾移植术1例。结果术后5例受者均未发生外科并发症。1例术后发生短暂的急性。肾小管坏死，但48h后进人多尿期，肾功能恢复顺利。术后随访10-36个月，受者移植。肾功能全部正常，肾动脉及分支未发生血栓或闭塞。结论采用受者的髂内动脉体外重建供。肾动脉的方法，可有效修复肾动脉3支以上以及。肾动脉过短的供肾，是一种安全可行的血管重建的方法，血管并发症较低，可有效应用于肾移植。     

腹腔镜手术治疗肾动脉瘤1例报告并文献复习

目的:探讨腹腔镜术治疗肾动脉瘤的可行性与方法。方法:报告1例59岁女性患者,因"反复高血压10年,检查发现肾动脉瘤1周"入院。CTA示右肾动脉瘤,直径2cm,肾动脉主干发出两支二级动脉分支,动脉瘤位于其中一根二级分支近主干处。患者左侧卧位,建立气腹,游离肾脏及血管,分离动脉瘤体,用哈叭狗钳分别阻断主干及两根二级分支,用剪刀将动脉瘤完整切除。4-0血管缝线缝合动脉破口,2-0可吸收线缝合肾周筋膜,局部放置一引流管。结果:手术成功,手术时间125min,其中热缺血时间28min,血管缝合时间8min,术中出血50ml,患者术后24小时开始进食半流质,48小时开始下床行走。术后3天起患者血压较术前入院时170/100mmhg明显下降,波动于124～145/70～85mmhg。术后7天CT复查示右肾动脉未见狭窄,右肾小部分缺血表现,出院。结论:腹腔镜下肾动脉瘤切除手术可行,熟练的操作与精细的缝合是其关键。     

复杂性肾动脉瘤诊治

目的 探讨复杂性肾动脉瘤(RAA)的特点及诊治方法.方法 1999年3月至2008年9月收治复杂性RAA患者5例.女4例,男1例.平均年龄35(20～54)岁.腰痛伴血尿2例、腹痛伴休克i例、高血压1例、查体发现1例.RAA直径平均3.5(0.5～9.0)cm.单侧3例、双侧2例.5例均经数字减影血管造影确诊.保守治疗1例、肾动脉栓塞后肾切除1例、超选择性肾动脉栓塞1例、覆膜支架介入治疗1例、肾分支动脉结扎1例.结果 1例孤立肾多发动脉瘤破裂出血者保守治疗5 d死亡;1例肾上极1.5 cm动脉瘤,超选择性肾动脉栓塞后随访10个月未见复发;1例直径9.0 cm肾动脉瘤经肾动脉栓塞后行肾切除,随访12个月未见复发;1例肾内3.0 cm动脉瘤行覆膜支架介入治疗,随访12个月未见复发;1例右肾2.5 cm动脉瘤行右肾分支动脉结扎,10个月后发现左肾1.3 cm动脉瘤.随访24个月左肾RAA无变化,右肾RAA无复发.结论 直径＜2 cmRAA可密切观察,复杂性RAA治疗应根据患者一般状况、症状,动脉瘤大小、数目、部位、肾功能、有无并发症等选择手术或介入治疗.     

Laparoscopic Nephrectomy,Ex Vivo Repair,and Autotransplantation for a Renal Artery Aneurysm: Report of a Case

A 57-year-old woman was hospitalized with a left renal artery aneurysm (RAA). The aneurysm measured 35 mm in diameter and was located at the renal artery bifurcation. We performed a laparoscopic nephrectomy using a retroperitoneal approach and performed an ex vivo repair of the renal artery. The reconstructed kidney was then autotransplanted at the left iliac fossa. The patient's postoperative course was uneventful. A laparoscopic nephrectomy and ex vivo repair are both considered to be effective for treating complex RAA.     

Renal autotransplantation combined with direct pyelocystostomy for a doubled renal artery aneurysm of a stone forming kidney

A 35-yr-old female patient presented with recurrent left-sided calcium oxalate nephrolithiasis in combination with equilateral doubled renal artery aneurysm. Approximately two-thirds of the cumulative renal function were scintigraphically calculated in favour of the affected kidney. After a left-sided nephrectomy, "workbench surgery" with resection of both aneurysms was performed. The renal artery was reconstructed with contralateral internal-iliac artery graft. To allow passage of renal calculi, the kidney was transplanted in the right iliac fossa combined with a wide pyelocystostomy. The patient recovered uneventfully and presented with good physical health and regular serum creatinine 1 yr postoperatively.     

Bilateral renal artery aneurysms: in-situ and extracorporeal repair.

Renal artery aneurysms are uncommon, but when they do occur they are frequently associated with hypertension which may be amenable to surgery. Complex arterial abnormalities which formerly would have been treated by nephrectomy may now be reconstructed with preservation of the kidney. This is illustrated by a patient with renovascular hypertension and bilateral renal artery aneurysms, in whom arteriography and renal vein renin ratios were used as a guide to surgery performed in two stages. An in-situ repair was performed on one side. On the other side, where the aneurysm involved the three main branches of the renal artery, an extracorporeal repair was performed using continuous cold perfusion, substitution of the pathological segment with the patient's internal iliac artery, and autotransplantation to the iliac fossa. Both kidneys were retained and the hypertension was cured.     

BILATERAL RENAL ARTERY ANEURYSMS: IN-SITU AND EXTRACORPOREAL REPAIR

Renal artery aneurysms are uncommon, but when they do occur they are frequently associated with hypertension which may be amenable to surgery. Complex arterial abnormalities which formerly would have been treated by nephrectomy may now be reconstructed with preservation of the kidney. This is illustrated by a patient with renovascular hypertension and bilateral renal artery aneurysms, in whom arteriography and renal vein renin ratios were used as a guide to surgery performed in two stages. An in-situ repair was performed on one side. On the other side, where the aneurysm involved the three main branches of the renal artery, an extracorporeal repair was performed using continuous cold perfusion, substitution of the pathological segment with the patient's internal iliac artery, and autotransplantation to the iliac fossa. Both kidneys were retained and the hypertension was cured.     

Laparoscopic hybrid techniques for ectopic or accessory renal arteries debranching in complex endovascular aneurysm repair

The aim of this study was to report an assisted or totally laparoscopic approach for renal revascularization in patients with congenital renal vascular anomalies during endovascular abdominal aneurysm repair (EVAR). In three patients with an ectopic main or a large accessory renal artery (>3mm) arising from the aneurysm, laparoscopic exposure of the target renal artery and the ipsilateral iliac bifurcation was performed. In two patients a small incision was made over the area between the iliac bifurcation and the renal target vessel in order to facilitate the anastomotic procedure. In the third patient a totally laparoscopic bypass between a big left inferior renal polar artery and the left common femoral artery was carried out. In all patients the aneurysm was successfully excluded using an endovascular graft. Technical success was achieved in all three patients. The mean total operative time was 126 min (range 110-152 min). The mean hospital length of stay (HLS) was 3.5 days. Renal function of the patients remained unchanged. All bypasses were found to be patent and endoleaks was not observed at 6-month follow-up. Laparoscopic assisted or totally laparoscopic renal revascularization may increase the applicability of EVAR in complex abdominal aortic aneurysms.     

Ex situ surgical repair of complex lesions of the renal artery

Forty one patients underwent ex situ repair of complex renal artery lesions. This series includes 22 males and 19 females, 10 children and 31 adults. Ages of the patients were comprised between 17 months and 70 years. The operated lesions were: --aneurysms of the renal artery and/or of its branches with or without associated stenosis: 16 cases; --spontaneous dissection of the renal artery with extension to the branches: 7 cases; --extensive dysplasia extended to distal branches: 16 cases; --dysplasia of the artery with segmental lesion of the kidney: 2 cases; --reoperation on the renal artery: 2 cases. In all cases, the kidney was exteriorized after transsection of its vessels. It was cooled by perfusion of cold Eurocollins solution. After repair, the kidney was reimplanted either in the lumbar (16 cases) or in the iliac fossa (27 cases). An arterial substitute was used in 32 cases: 26 arterial and 6 venous autografts. No mortality was observed in this series. Two postoperative thromboses occurred leading to kidney loss (4.6%). Segmental thrombosis leading to partial atrophy of the kidney occurred in 3 cases (7%). During the late follow-up, one iterative stenosis was observed and required nephrectomy; two fusiform dilations of venous autografts were also observed. In all other cases (35 patients, 85.3%), repair of the lesion was successful. Ex situ repair must be reserved to: 1) lesions involving several branches of the artery whose repair requires prolonged renal circulatory arrest and 2) lesions profoundly situated in the renal sinus, especially aneurysms, whose repair is difficult by conventional in situ surgery.     

Use of the gastroduodenal artery in right renal artery revascularization

Of 15 patients having revascularization of the right renal artery with the use of the hepatic circulation from May 1984 through March 1987 at the Massachusetts General Hospital, eight patients had this accomplished with end-to-end anastomosis of the gastroduodenal artery and right renal artery. Operative indications were acute azotemic renal failure (three patients), poorly controlled renovascular hypertension (four patients), and staged repair of bilateral renal artery disease (one patient). All revascularizations were successful in restoring renal function or rendering hypertension manageable and were assessed by means of renal flow scans, celiac angiography, or return of function in those patients with a solitary, functioning kidney. All patients survived the operation with one late death caused by myocardial infarction after abdominal aortic aneurysm repair. The gastroduodenal artery may be used as the source for arterial inflow in revascularization of the right renal artery by end-to-end anastomosis in approximately 50% of instances, conferring the advantage of the use of only one anastomosis and obviating the long-term possibility of vein graft failure.     

Renal perfusion with the Biomedicus pump during resection of an abdominal aortic aneurysm.

Renal artery perfusion is usually unnecessary during resection of an abdominal aortic aneurysm, because most of these aneurysms are situated below the renal arteries. The authors report the interesting case of a patient with a solitary functioning kidney, who had undergone previous bypass grafting from the right iliac artery to the right renal artery and in whom the kidney was perfused with the Biomedicus pump during the repair of an abdominal aortic aneurysm. This technique may be useful in special situations in which any period of renal ischemia might be hazardous to renal function.     

肾移植术后伤口淋巴漏和淋巴囊肿分析

目的：探讨尸肾移植术后发生伤口淋巴漏和髂窝淋巴囊肿的原因及其防治方法。方法：统计489例尸肾移植患者，对其中发生术后长时间伤口淋巴漏或症状性髂窝淋巴囊肿的患者进行回顾性分析。结果：尸肾移植术后发生长时间伤口淋巴漏8例，症状性髂窝淋巴囊肿7例。治疗方法包括体外引流、硬化剂治疗及腹腔内引流术等。结论：肾移植手术应防止操作粗暴，以减少受者淋巴管的损伤和移植肾淋巴液漏出；对术后长时间伤口淋巴漏和出现症状的髂窝淋巴囊肿，应给予积极处理。