u-PA和明胶酶A、B蛋白在人腹主动脉瘤组织中表达的研究

目的 探讨尿激酶型纤溶酶原活化物(u-PA)和明胶酶A、B在腹主动脉瘤(AAA)组织中蛋白的表达和产生的来源。方法 用u-PA和明胶酶A(MMP-2)、明胶酶B(MMP-9)的单克隆抗体,以免疫组织化学SABC方法在10例AAA组织和10例正常腹主动脉组织的切片上控测u-PA和MMP-2、MMP-9抗原(蛋白)。结果 u-PA和MMP-9蛋白在AAA组织中主要浸润于中层和外膜巨噬细胞表达,在正常腹主动脉组织中无表达,MMP-2蛋白在AAA组织中主要由中层平滑肌细胞表达,在正常腹主动脉组织中无表达。结论 由巨噬细胞产生的u-PA直接激活,并调节MMP-2和MMP-9的活性,在AAA的形成、扩张和破裂中起着关键性的作用。     

Natural history of patients with abdominal aortic aneurysm

Factors determining the outcome for patients with abdominal aortic aneurysm (AAA) were analysed in a retrospective population-based study of 187 consecutively diagnosed AAAs at one hospital during a 9-year period. All aneurysms were diagnosed by ultrasound, and those cases that were not primarily operated upon, were followed by repeat ultrasound examinations. An expansion rate of more than 0.4 cm/year was seen in 27% of the aneurysms and a tendency towards a higher rate of expansion could be seen with larger lesions. The overall cumulative rupture rate was 12% at 5 years. For patients with small (less than 5 cm) aneurysms it was 2.5% at 7 years, and no aneurysm could definitively be shown to be smaller than 5 cm at the time of rupture. The rupture risk was significantly higher (28% at 3 years) for larger aneurysms (greater than or equal to 5 cm). The only reliable predictor for rupture was aneurysm size. The overall cumulative survival was 51% at 5 years. Patients with large aneurysms did not have a significantly shorter survival although a tendency for this to be the case was found. There was a significant difference between the proportion of deaths caused by aneurysm rupture in patients with small aneurysms when compared to those with large aneurysms, 5.5 and 53%, respectively. The expansion rate for AAA was highly individual and aneurysm diameter was the only recognisable predictor of rupture. The rupture rate for AAAs smaller than 5 cm was lower than previously reported.     

Anaesthesia for patients with an abdominal aortic aneurysm

The intraoperative anaesthetic management of patients with an abdominal aortic aneurysm (AAA) remains a challenge to the anaesthetist. The immediate operative morbidity/mortality of elective patients has in recent decades been lowered. Long-term results are influenced above all by the presence of concomitant cardiovascular disease engaging all vital functions: heart, brain and kidneys. Many of the AAA patients are also obese and heavy smokers and have diabetes. The AAA patient presenting as an emergency with a ruptured or leaking aneurysm has a very high mortality which has not changed much even with the introduction of more sophisticated anaesthetic regimens or monitoring devices. Patients are operated on either during general anaesthesia alone or in combination with spinal/epidural anaesthesia. There are pros and cons with both methods. Potential complications although seldom occurring with epidural blockade following heparinization must be borne in mind. Long-term results have not been dependent on the method chosen, but epidural analgesia might make the post-operative period smoother and allow earlier mobilization of patients. In the last 10 years abdominal aortic aneurysms have also been repaired with endoluminal surgical techniques using stents. Primarily these methods were intended for patients considered too sick to undergo open repair. In principle the patients can be operated on under local analgesia with sedation. Endoluminal surgery has not reduced operating time or overall costs owing to the necessary follow-up of patients with for example angiography. The long-term results are identical to those of the older methods, probably because of a continuation of the underlying cardiovascular disease. However, newer methods are evolving and the surgical skills are improving.     

Coronary artery disease in patients with abdominal aortic aneurysm

Selective coronary angiography to determine the prevalence of coronary artery disease (CAD) has been performed in patients with abdominal aortic aneurysm (AAA). Thirty patients in this series consisted of 26 men and 4 women with an age range of 48-87 years (mean +/- SD: 67.5 +/- 8.2 years). As the atherosclerotic risk factors, cigarette smoking was present in 19 patients (63.3%), hypertension was in 18 (60%), hypercholesteremia was in 10 (33.3%), and diabetes mellitus was in 2 (6.7%). Cerebral vascular disease was present in 11 patients (36.7%). Regarding CAD, angina pectoris or old myocardial infarction was found in 9 patients (30%), and abnormal electrocardiography (ECG) was in 16 patients (53.3%). Coronary angiography prior to operation of AAA was performed to 22 patients (73.3%), and 15 patients (68.2%) among them had significant coronary artery stenosis, and 9 patients underwent myocardial revascularization (4 CABG, 5 PTCA). CAD was frequently complicated both in patients without symptoms or ECG abnormalities and in less than 65-year patients. In order to prevent fatal myocardial infarction, we recommend routine coronary angiography to patients with AAA. And if necessary, myocardial revascularization must be indicated prior to aneurysmectomy.     

Abnormal levels of urokinase plasminogen activator protein and tissue plasminogen activator activity in human aortic aneurysms.

OBJECTIVE: To measure the concentrations and activities of plasminogen activators and plasminogen activator inhibitors in human abdominal aneurysms. DESIGN: Laboratory study. SETTING: University hospital, Sweden. MATERIAL: Biopsy specimens from 12 abdominal aortic aneurysms and 8 normal aortas (controls). INTRERVENTIONS: Tissues were homogenised and eluted. The supernatants were assayed for antigens of tissue and urokinase plasminogen activator and plasminogen activator inhibitor 1 and 2. The activities of tissue plasminogen activator and plasminogen activator inhibitor-1 were assayed by ELISA. Frozen sections were immunostained for tissue and urokinase plasminogen activators and for plasminogen activator inhibitor-1. MAIN OUTCOME MEASURES: Concentrations and activities of these activators and inhibitors. RESULTS: The concentration of urokinase plasminogen activator antigen was higher in aneurysmal walls than in normal aortas; it was detected immunohistochemically in aneurysmal but not in normal aortas. The concentration (and the detection immunohistochemically) of tissue plasminogen activator was equal in aneurysmal and normal aortas, but its activity was reduced in the aneurysmal wall. Plasminogen activator inhibitor-1 did not differ significantly between the groups. CONCLUSIONS: Urokinase plasminogen activator may be responsible for the digestion of the media of the aorta and the development of an aneurysm. Reduced activity of tissue plasminogen activator may be responsible for thrombosis in the aneurysm.     

腹主动脉瘤的诊治体会

目的 探讨腹主动脉瘤的诊断,手术时机,手术方式的选择,人工血管的应用。方法 回顾性分析了7例腹主动脉瘤诊治的临床资料。结果 DeBaKeyl型^[1]胸腹主动脉瘤患者在手术前动脉瘤突然破裂死亡。其余6例主动脉瘤均行动脉瘤阻断、切开,人工血管置换术。其中1例亚铃状胸腹主动脉瘤分期行手术治疗。无手术并发症,均痊愈出院。结论 手术是治疗腹主动脉瘤的有效方法,及时明确诊断,选择合理的术式和人造血管是手术成功的关键,而围手术期的正确处理则是治疗成功的重要保证。     

Management of cholelithiasis in patients with abdominal aortic aneurysm.

Gallstones were detected in 42 of 865 patients with abdominal aortic aneurysm (4.9%). Eighteen patients underwent concomitant aneurysm resection and cholecystectomy. Eleven patients had aneurysmectomy without cholecystectomy. Thirteen patients underwent cholecystectomy alone. There were no significant increases in operative mortality, duration of operation, or length of hospital stay when cholecystectomy was added to aneurysm resection. However, there was one instance of prosthetic infection which occurred in a patient who did not have his graft retroperitonealized prior to cholecystectomy, and who also underwent gastrostomy and drainage of the liver bed. There have been no graft complications in the remaining 17 consecutive patients who had their graft retroperitonealized prior to cholecystectomy. Nine of 11 patients who underwent aneurysmectomy without cholecystectomy experienced an episode of acute cholecystitis during a mean follow-up period of 2.9 years. Two of these episodes occurred in the immediate postoperative period and one patient died of biliary sepsis. On the basis of these findings, concomitant aneurysmectomy and cholecystectomy is advised in those patients with cholelithiasis undergoing aortic aneurysm resection providing no contraindications exist.     

Hypotensive resuscitation in patients with ruptured abdominal aortic aneurysm.

BACKGROUND: The technique of hypotensive resuscitation in haemorrhagic shock involves resuscitation to below normotensive blood pressures achieving the minimum perfusion pressure that will adequately perfuse vital organs until definitive arrest of haemorrhage. AIM: To summarise the evidence for the use of hypotensive resuscitation in patients with uncontrolled haemorrhagic shock and ruptured abdominal aortic aneurysm (AAA). METHODS: A MEDLINE (1966-2004) and Cochrane library search for articles relating to hypotensive resuscitation was undertaken; see text for further details. RESULTS: Several animal studies exist using an abdominal aortotomy model of ruptured AAA. These have demonstrated improved tissue perfusion, decreased blood loss and improved survival associated with hypotensive resuscitation compared with aggressive resuscitation. There are several human studies advocating delayed rather than immediate resuscitation in trauma patients but careful review of the literature reveals no prospective studies of hypotensive resuscitation in patients with ruptured AAA. CONCLUSIONS: Animal studies demonstrate superiority of hypotensive resuscitation over aggressive resuscitation but further research is required to assess its efficacy in patients with ruptured AAA.     

EndoSuture aneurysm repair versus fenestrated aneurysm repair in patients with short neck abdominal aortic aneurysm

ObjectiveThe aim of this study was to compare midterm results of EndoAnchors in EndoSuture aneurysm repair (ESAR) versus fenestrated endovascular aneurysm repair (FEVAR) in short neck abdominal aortic aneurysm (AAA).MethodsAll patients who underwent an ESAR procedure for a short neck AAA at our center between September 2017 and May 2020 were considered for analysis. To form the control group, preoperative computed tomography angiography of patients who underwent FEVAR for juxtarenal AAA between April 2012 and May 2020 were reviewed and patients who met short neck criteria selected. A propensity-matched score on neck length and neck diameter was calculated, resulting in 18 matched pairs. AAA shrinkage, type Ia endoleaks (EL), AAA-related reinterventions, and AAA-related deaths were compared.ResultsThe median AAA diameter was 54 mm (interquartile range [IQR], 52-61 mm) versus 58 mm (IQR, 53-63 mm) with a median neck length of 8 mm (IQR, 6-12 mm) vs 10 mm (IQR, 6-13 mm) in ESAR and FEVAR patients, respectively. Technical success was 100% in both groups. Procedural success was 94% in the ESAR group versus 100% in the FEVAR group. The median procedure duration was 138 mm (IQR, 113-182 mm) vs 240 mm (IQR, 199-293 mm) ( P < .001) and the median length of stay was 2 days (IQR, 2-3 days) vs 7 days (IQR, 6-7 days) (P < .001) in ESAR and FEVAR patients, respectively. No major hospital complications were observed in ESAR patients compared with two in FEVAR patients (11%) with one transient acute kidney injury and one transient paraplegia. The median follow-up was 23 months (IQR, 19-33 months) vs 36 months (IQR, 22-57 months) with 67% versus 61% AAA shrinkage in the ESAR and FEVAR groups, respectively (P = .73). No type Ia EL, proximal neck-related reinterventions, or AAA-related deaths were observed in either group. No AAA-related reintervention was observed in the ESAR group versus three reinterventions in the FEVAR group (P = .23).ConclusionsESAR seems to be a safe technique with no major postoperative complications or reinterventions observed during follow-up. It seems to offer similar midterm results as FEVAR in terms of type Ia EL, aneurysm shrinkage, and aneurysm-related mortality. ESAR seems to be a good off-the-shelf alternative to FEVAR in case of technical constraints.     

基质金属蛋白酶在腹主动脉瘤组织中的表达

目的探查基质金属蛋白酶类（MMPs）在腹主动脉瘤（AAA）组织中产生的源泉。方法采用间质胶原酶（MMP-1）和明胶酶以MMP-9）的mRNA探针在20例AAA组织及4例正常人腹主动脉组织的切片上行原位杂交实验结果MMP-1及MMP-9在巨噬细胞、平滑肌细胞和淋巴细胞均有表达,其中巨噬细胞的MMPs表达强烈。结论MMPs在AAA的形成和扩张中发挥重要作用,炎性细胞是产生MMPS的主要源泉,并影响问质细胞的MMPS表达。     

骨保护素在腹主动脉瘤中的表达及作用

目的：探讨骨保护素（OPG）的表达在腹主动脉瘤（AAA）形成中的作用。方法：收集20例AAA组织和6例正常腹主动脉组织,用补片法构建兔AAA动物模型（18只AAA模型动物分别于造模后7,21,35 d取材,以6只假手术兔为对照）。用免疫组化法检测OPG在人AAA组织与正常腹主动脉组织中的表达;Western blot和RT-PCR法检测上述组织以及动物模型AAA组织中OPG、基质金属蛋白酶9（MMP-9）蛋白及mRNA的表达;末端转移酶标记（TUNEL）法观察动物模型AAA组织中膜血管平滑肌细胞（VSMC）的凋亡情况。结果：免疫组化显示,人AAA组织中OPG蛋白表达量较正常腹主动脉组织增加,且随AAA直径的增大而增加,在破裂性AAA组织中表达量最高。Western blot和RT-PCR结果显示,OPG与MMP-9蛋白及mRNA的表达在人AAA组织及动物模型AAA组织组均较各自的对照组明显升高（P<0.05）,且两者的蛋白与mRNA表达水平均随瘤体直径的增加或造模时间的延长而逐渐增加。TUNEL染色显示模型组VSMC凋亡细胞较对照组明显增加,且随造模时间延长有增加趋势（P<0.05）。结论：OPG表达水平与AAA的发生发展密切相关,机制可能与其促进MMP的表达和诱导VSMC凋亡有关。

     

Renal function in patients with abdominal aortic aneurysm. Comparison with hypertensive patients

AIMS: Renal dysfunction occurs occasionally after the repair of abdominal aortic aneurysm (AAA), and preoperative renal function is considered as one of the potential causes. The present study was designed to evaluate and compare renal function and risk factors of AAA patients with those of hypertensive patients. METHODS: We prospectively examined 95 patients with AAA and 72 patients with essential hypertension (HT) without other cardiovascular diseases (CVD). Renal function, urinary albumin excretion (UAE) and renal scintigraphy were compared. Kidney size was calculated using ultrasonography. RESULTS: Serum creatinine and creatinine clearance in AAA patients was worse than in HT patients. Smoking status was more apparent in AAA patients. Renal artery stenosis occurred in 8 patients with AAA. Renal scintigraphy showed normal function in 19%, hypofunction in 69% and severe dysfunction in 12% of the AAA patients, and normal function in 42% and hypofunction in 58% of the HT patients (p < 0.0001). Multivariate linear regression analysis showed that renal function was related to age, UAE, CVD, smoking status and kidney size for all patients, UAE, CVD, smoking status and kidney size for AAA patients, and age and kidney size for HT patients. CONCLUSION: Renal function of AAA patients was worse than HT patients without other CVD. The risk factors for renal dysfunction were different between AAA and HT patients. These preoperative conditions may relate to the postoperative renal dysfunction seen in AAA patients.     

Ten-year outcome of patients with very small abdominal aortic aneurysm

BACKGROUND: The long-term fate of very small abdominal aortic aneurysms (AAA) is not well known. METHODS: Forty-one patients with asymptomatic small AAA (range 25 to 40 mm) underwent ultrasonographic surveillance. RESULTS: The median follow-up period was 7.3 years. The median linear aneurysm expansion rate was 2.0 mm/year (range 0 to 8.4). Three patients experienced aneurysm rupture (7.3%) which resulted in 1 patient'death. Thirteen patients underwent aneurysm repair (31.7%) and 1 patient died postoperatively (7.7%). The survival rate at 10-year follow-up was 59.0%. The survival rate free from aneurysm rupture and repair at 10-year follow-up was 69.9%. The median time for occurrence of aneurysm rupture was 4.9 years (range 1.8 to 10.5) and the need for aneurysm repair was 4.5 years (range 1.4 to 10.4). CONCLUSIONS: The fate of very small AAA is to slowly enlarge in size, sometimes threatening the patient's life. These observations underline the importance of continuous surveillance and the potential benefits of any medical treatment in this patient population.     

Two patients with horseshoe kidney and ruptured abdominal aortic aneurysm

Renal anomalies present a challenge to surgeons who repair aortic aneurysms; horseshoe kidneys occur in 1 out of 400 people in the general population. The degree of fusion, accessory blood supply and ureteric anomalies all affect the approach to aneurysm repair in the elective or emergency setting. The authors report two patients with ruptured abdominal aortic aneurysms, who were found at operation to have a horseshoe kidney. In both cases a thick renal isthmus was found crossing the aorta between the inferior mesenteric artery and the bifurcation. The kidney was preserved intact, accessory blood supply was controlled from inside the aorta and the aneurysm was repaired with a Dacron graft. One patient underwent ureterolysis; although renal failure subsequently developed, it was likely related to prolonged preoperative hypotension. The other patient recovered without complications.     

Surgical outcome in patients with concomitant-infected abdominal aortic aneurysm and spondylitis

The coexistence of infected abdominal aortic aneurysms and spondylitis is rare but challenging. The etiology of the infection is frequently unknown. The aim of this study was to review the outcome of surgical repair of this complex disease. From 2004 to 2006, six patients were identified who underwent surgical repair of concomitant infected abdominal aortic aneurysm and spondylitis. Diagnosis, treatment and intermediate-term results are presented. The clinical manifestation included the signs of ongoing systemic infection, neurological deficit and abdominal or back pain. Computed tomography revealed abdominal aortic aneurysms associated with polysegmental spondylitis. Patients underwent radical debridement and aortic replacement with cryopreserved aortic allografts or silver-coated prostheses followed by antibiotic treatment. Only one patient received a simultaneous anterior vertebral stabilization. Greater omentum was placed in the abscess cavity. Intensive care unit and hospital stay averaged 3.0 and 28.0 days, respectively. Organisms were identified in all but one patient. Over a follow-up period of 4.4 years, four patients are alive and showing freedom from infection, and two patients had died unrelated at seven and eight months. In conclusion, surgical repair of infected aortic aneurysms with resection of infected tissues and implantation of a homograft or a silver-coated prosthesis achieved favorable results in this sick patient group. Simultaneous vertebral stabilization is rarely necessary.