内漏对腹主动脉瘤腔内隔绝术后瘤腔内压力的影响

目的 探讨内漏状态下腹主动脉瘤(AAA)腔内隔绝术(EVE)后瘤腔内压力的变化。方法 通过建立犬AAA EVE后内漏模型，测定内漏存在前后瘤腔内压力的变化。结果 内漏状态下瘤腔内平均动脉压明显升高，而内漏封闭后压力显著下降，且曲线平直。结论 瘤腔内压力曲线可作为评估EVE后瘤壁所受负荷的变化，也可作为判断内漏存在的方法之一。     

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中内漏动物模型的建立

目的：建立近似人体的腹主动脉瘤（AAA）腔内隔绝术（EVE）后内漏的实验动物模型。方法：采用6只犬 ，以牛颈静脉间置法或前壁补片的方法形成保留腰动脉的肾下型AAA，经髂动脉行AAA EVE，术中采用修剪人造血管和改变支架附着点的方法形成内漏。结果：血管造影示6只犬动脉瘤形态良好，5只犬形成了即时性内漏，内漏来自近端返流，也有近端返流。结论：通过移植物释放位置的变化可以模拟出与人体EVE后相似的即时性内漏，以供血流动力学和治疗研究。     

腔内隔绝术治疗瘤颈扭曲大于60°的腹主动脉瘤

目的　探讨腔内隔绝术 (EVE)治疗瘤颈扭曲大于 6 0°腹主动脉瘤 (AAA)的安全性和可行性。从而扩大治疗AAA的适用范围。方法　对瘤颈扭曲大于 6 0°的AAA通过技术改进 (术中对瘤颈进行捆扎或置入Cuff) ,然后实施EVE。结果　对瘤颈扭曲大于 6 0°的AAA成功地实施了EVE ,术后复查彩超、CTA、MRA证实 :瘤体被完全隔绝 ,支架无移位、扭曲及内漏现象。结论　EVE是一种治疗瘤颈扭曲大于 6 0°的AAA简便可行的方法 ,其主要特点是安全、微创、简捷 ,特别适于合并多种并存病的年老体弱患者。     

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。     

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。     

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。     

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。     

主动脉弓上病变的双烟囱法腔内隔绝术

血管腔内隔绝术(endovascular exclusion,EVE)已经成为治疗主动脉夹层病主动脉瘤等主动脉扩张性疾病的成熟微创方法,可明显降低手术并发症和病死率,改善患者预后[1,2].但当病变累及主动脉弓上分支时,传统EVE由于无法保留分支血供而无法实施,而杂交手术、移植物开窗和分支技术也各有局限和缺陷.本文通过1例累及主动脉弓的EVE后I型内漏的治疗,介绍一种用于主动脉弓上病变治疗的双烟囱法EVE技术.     

Endovascular stent-graft in abdominal aortic aneurysms: the relationship between patent vessels that arise from the aneurysmal sac and early endoleak

PURPOSE: To determine the association of patent sac branch vessels (lumbar and inferior mesenteric arteries [IMAs]) with early endoleak rate after stent-graft repair of abdominal aortic aneurysm (AAA). MATERIALS AND METHODS: Pre- and postoperative computed tomographic (CT) angiograms in 158 patients who underwent stent-graft AAA repair were retrospectively reviewed to determine the preoperative patency of IMAs and other sac branch vessels (feeders) and presence or absence of immediate postoperative endoleak. Relationships of early endoleak rate with total branch vessel, IMA, and lumbar artery patency and graft type were evaluated. RESULTS: There was a significant association between patency of sac feeders and rate of early endoleak, especially type 2. As total patent feeders increased from zero to three to four to six, total endoleak rate increased from 6% (one of 17) to 35% (30 of 86); type 2 endoleak rate, from 0% to 25%. IMA patency was significantly associated with total early endoleak rate. Increasing lumbar artery patency also was associated with significantly higher total and type 2 endoleak rates: With zero to three lumbar arteries, the total endoleak rate was 17% and type 2 endoleak rate was 13%, as compared with 60% and 50%, respectively, with more than six patent lumbar arteries. CONCLUSION: Sac branch vessel patency is associated with significantly higher early total and type 2 endoleak rates after stent-graft repair of AAAs; thus, patent sac branches play an important role in the pathogenesis of endoleaks.     

Aortic side branch embolization before endovascular aneurysm repair: incidence of type II endoleak

PURPOSE: To assess the feasibility of embolization of aortic side branches and its impact on the incidence of type II endoleak after endovascular aneurysm repair. MATERIALS AND METHODS: Endovascular aneurysm repair was performed in 74 patients. Aortic side branch vessels were evaluated on the preoperative angiogram and computed tomography (CT) and, where embolization of lumbar and inferior mesenteric vessels was considered technically possible, this was attempted prior to endovascular repair. Follow-up CT was used to assess the presence of type II endoleak. RESULTS: Seventy-two patients were followed up for longer than 1 month. Embolization was attempted in 25 cases, successfully in 10, with partial success in 11, and failure in four. Twenty patients with successful or partly successful preoperative embolization were discharged and followed-up. Four (20%) had demonstrable type II endoleak during follow-up, with two of these persisting at latest follow-up. Of 43 patients without previous embolization, there were 10 (23.3%) type II endoleaks during the follow-up period, four of these persisting. In cases with type II endoleak, mean sac diameter change was -0.5 mm in the cases with previous embolization and +3.1 mm without. The mean period to onset of type II endoleak was 6.9 months without, and 15.3 months with, previous embolization. CONCLUSION: Although the cohort size is below a level that would confer significance, the trend of these findings is such as to suggest a lack of influence of aortic side branch embolization on the incidence of type II endoleak during the follow-up period.     

Comparison of Type II Endoleak Embolizations: Embolization of Endoleak Nidus Only versus Embolization of Endoleak Nidus and Branch Vessels

Purpose

To compare outcomes of type II endoleak embolization involving embolization of the endoleak nidus only vs embolization of the endoleak nidus and branch vessels in patients treated with endovascular repair of abdominal aortic aneurysms.

64层螺旋CT血管成像技术在主动脉病变腔内支架隔绝术后随访中的临床应用价值

目的 探讨64层MSCTA技术在主动脉病变腔内支架隔绝术后随访中的临床应用价值.方法 30例主动脉夹层(AD)及5例腹主动脉瘤(AAA)患者腔内支架隔绝术后接受了44次64层MSCTA检查.35例患者的图像后处理及分析采用MPR、MIP及VR技术.在全面观察分析图像的基础上,重点观察AD及AAA的转归及并发症发生情况.结果 (1)30例AD患者中,28例假腔内大量血栓形成,2例少最血栓形成.5例AAA患者支架外瘤体完全血栓化.(2)1例无名动脉受累的AD患者,术后3次CTA随访发现无名动脉内血栓形成.1例肠系膜上动脉内血栓形成患者术后15 d随访CTA发现血栓未溶解,3个月后再次复查则发现血栓溶解.1例术后随访发现右髂外动脉出现内膜撕裂.5例AAA患者中,1例右髂内动脉闭塞,1例右髂总动脉远端支架内血栓柃塞.(3)14例AD患者有内漏发生,其中Ⅰ型内漏8例、Ⅲ型内漏6例,1例Ⅲ型内漏3个月后再次复查,内漏消失.结论 64层MSCTA以其快速、无创、准确性高等优点,结合多种后处理方法可以对腔内隔绝术的疗效作出较为客观的评价,已成为主动脉病变腔内支架隔绝术后随访首选的影像检查方法之一.     

Treatment of a large type II endoleak via extraperitoneal dissection and embolization of a collateral vessel using ethylene vinyl alcohol copolymer (Onyx)

Type II endoleak is defined as persistent blood flow and pressure within an aneurysmal sac after endovascular deployment of a stent graft from patent aortic branches. This paper describes the simultaneous deployment of an endoluminal graft, with limited extraperitoneal dissection of a collateral vessel and use of an ethylene vinyl alcohol copolymer, Onyx, to obliterate a large type II endoleak.     

Transarterial Embolization of Type II Endoleaks after EVAR: The Role of Ethylene Vinyl Alcohol Copolymer (Onyx)

Purpose

To determine the feasibility and efficacy of transarterial endoleak embolization using the liquid embolic agent ethylene vinyl alcohol copolymer (Onyx).

Methods

Over a 7-year period eleven patients (6 women, 5 men; mean age 68 years, range 37–83 years) underwent transarterial embolization of a type II endoleak after endovascular aortic aneurysm repair using the liquid embolic agent Onyx. Two patients (18 %) had a simple type II endoleak with only one artery in communication with the aneurysm sac, whereas 9 patients (82 %) had a complex type II endoleak with multiple communicating vessels. We retrospectively analyzed the technical and clinical success of transarterial type II endoleak embolization with Onyx. Complete embolization of the nidus was defined as technical success. Embolization was considered clinically successful when volume of the aneurysm sac was stable or decreased on follow-up CT scans.

Result

Mean follow-up time was 26.0 (range 6–50) months. Clinical success was achieved in 8 of 11 patients (73 %). Transarterial nidus embolization with Onyx was technically successful in 6 of 11 patients (55 %). In three cases the nidus was embolized without direct catheterization from a more distal access through the network of collateral vessels.

Conclusion

Onyx is a favorable embolic agent for transarterial endoleak embolization. To achieve the best clinical results, complete occlusion of the nidus is mandatory.     

The fate of infrarenal abdominal aortic aneurysms after stent grafting: influence of thrombosis at side branch ostia

PURPOSE: To evaluate the effect of postoperative thrombosis of the side branch ostia on the shrinkage of endoluminally treated abdominal aortic aneurysms with patent side branch vessels. MATERIALS AND METHODS: Thirty-three patients were followed up with serial computed tomography (CT). Special attention was paid to presence or absence of retrograde enhancement of the side branch ostia after the covering of the patent side branch vessels by the stent graft and aneurysm diameter change on postoperative CT. Preoperative CT was also reviewed to assess the number of patent side branch vessels, degree of aneurysm wall calcification, and thickness of the mural thrombus. The patients with type 2 endoleak were excluded from this evaluation. The patients were divided into 2 groups, the nonthrombosed and thrombosed groups, based on presence or absence of retrograde enhancement of the side branch ostia as depicted on all postoperative CT. RESULTS: Type 1 endoleak was not seen in all patients. Preoperative diameter of the aneurysm was 4.75 +/- 0.18 cm in the thrombosed group (n = 12) and 4.98 +/- 0.35 cm in the nonthrombosed group (n = 8). There were no significant differences in follow-up periods, preoperative diameter of the aneurysm, number of patent side branch vessels, degrees of aneurysm wall calcification, and thickness of the mural thrombus between the 2 groups. The mean diameter of the aneurysm in the nonthrombosed group did not change at 3 and 6 months then first decreased at 12 months after the stent grafting. However, in the thrombosed group, the mean diameter of the aneurysm had decreased at 3 months after stent grafting. Thereafter, the aneurysms continuously shrank. CONCLUSIONS: Postoperative thrombosis of the side branch ostia may predict favorable shrinkage of endoluminally treated aneurysms.     

Predictive Value of Preprocedural Computed Tomography Angiography for the Technical Success of Transarterial Embolization of Type II Endoleaks Arising from the Lumbar Arteries

PurposeTo evaluate the ability of preprocedural computed tomography angiography (CTA) to predict the technical success of embolization of type II endoleak arising from a lumbar artery after endovascular aortic repair (EVAR).Materials and MethodsAll patients at a single academic institution who underwent angiography with possible embolization for a post-EVAR lumbar-supplied type II endoleak from 2009 to 2018 were retrospectively reviewed. Patients who did not undergo CTA before the procedure were excluded. CTAs were reviewed for the ability to trace the entire course of a feeding vessel from the internal iliac artery (IIA) to the lumbar artery at the site of the endoleak. Procedural imaging was reviewed for technical success, defined as the catheterization and embolization of the aneurysm sac through a lumbar artery.ResultsFifty-seven angiograms with a type II endoleak and suspected feeding lumbar artery were identified. On CTA acquired before the procedure, the arterial path supplying this lumbar artery could be traced from the IIA to the aneurysm sac in 18 (32%) patients. Embolization was technically successful in 16 of these 18 (89%) procedures compared with 10 of 39 (26%) procedures in which the supplying artery could not be traced using CTA (P < .001).ConclusionsA potential catheter path from the IIA through the iliolumbar and lumbar arteries to the aneurysm sac can be traced on preprocedural CTA in the minority of lumbar-supplied type II endoleaks. The ability to trace these inflow vessels may predict technical success during embolization. The low rate of technical success when the feeding vessel could not be traced using CTA suggests that these patients should be considered for percutaneous or transcaval sac puncture.     

Predictive factors, morphologic effects, and proposed treatment paradigm for type II endoleaks after repair of infrarenal abdominal aortic aneurysms

PURPOSE: To evaluate the predictive factors and outcome of type II endoleaks after endovascular repair of infrarenal abdominal aortic aneurysms with use of a Zenith endograft. MATERIALS AND METHODS: Patients classified at high risk were enrolled in a prospective study and evaluated with serial cross-sectional imaging techniques. The effect of a type II endoleak on sac behavior and associated factors were analyzed. Type II endoleaks were categorized as absent, persistent, or transient, and the morphologic effects were determined. Logistic regression and classification tree were used to predict which patients may be at risk for persistent type II endoleaks. RESULTS: A total of 273 patients were enrolled. Patients were excluded in the absence of a minimum of 6 months digital data or the presence of endoleak not classified as type II. Two hundred four patients met inclusion criteria, with a median follow-up period of 24 months (range, 6-60 months). Early type II endoleak was detected in 35 patients (17%), which resolved spontaneously in 17 cases. There were 18 patients with persistent endoleak, 17 patients with transient type II endoleak, and 169 patients with no endoleak. Aneurysm enlargement was detected in seven patients with persistent endoleak (39%), no patients with transient type II endoleak, and one patient with no endoleak. No variables were predictive of the development of persistent endoleak. The relative risk of aneurysmal growth was 77 with persistent endoleak. Successfully treated persistent endoleaks were not associated with any growth. CONCLUSIONS: Persistent endoleaks are associated with sac growth. Transient type II endoleaks have a benign course and do not require treatment. Successful treatment of persistent endoleak ameliorates the risk of growth.