破裂腹主动脉瘤的外科治疗及预后

目的探讨破裂腹主动脉瘤的诊断、治疗方法及影响预后的因素。方法回顾性分析1999年4月至2005年12月期间我院收治的23例肾动脉下破裂腹主动脉瘤患者的临床资料，其中男15例，女8例；年龄35～78岁，平均65岁。自知有腹主动脉瘤者7例，有腹部搏动性包块者6例，术前行急诊彩超和（或）CT检查确诊15例。所有患者均行急诊手术治疗。根据术中情况采取肾动脉下腹主动脉钳夹阻断或腹主动脉腔内球囊阻断，控制出血后行人造血管移植术。结果手术后30d内死亡9例（39％），死亡原因为出血性休克所致的急性肾功能衰竭4例、多器官功能衰竭3例、呼吸循环衰竭2例。结论手术治疗是对破裂腹主动脉瘤的有效治疗，根据术中情况采取不同的方法阻断破裂口近端腹主动脉以控制出血是手术的关键。急性心脑血管疾病、急性肾功能衰竭及肺部并发症是术后的主要并发症及死亡原因。     

腹主动脉瘤破裂的临床分析(附6例报告)

目的探讨腹主动脉瘤破裂的诊断和治疗方法。方法我院从1999年10月至2004年1月期间经手术治疗腹主动脉瘤破裂6例。结果1例患者因术后失血性休克而死亡;5例患者随访4年,1例术后2年死于心肌梗死,余4例存活。结论腹主动脉瘤应早期诊断、早期治疗,一旦破裂应迅速诊断、急诊手术,手术时应注意阻断腹主动脉的方法以及防止术后下肢缺血。     

腹主动脉瘤破裂的外科治疗：附12例报告

目的:探讨腹主动脉瘤破裂（RAAA）的诊断和治疗方法。方法: 回顾分析7年间收治的12例腹主动脉瘤破裂者的临床资料。主要临床表现有：腹痛和/或腰背痛,血压下降或休克, 腹部可触及搏动性肿块。所有患者经CT 检查确诊，7例患者采用传统开腹性手术，1例行腔内支架型人工血管植入术，另外4例未行手术治疗。结果:8例手术治疗者围手术期病死率为62.5％（5例）。死亡原因：循环衰竭2 例,急性肾衰竭1 例,多器官功能障碍综合征2 例。未手术4例全部死亡。结论:破裂腹主动脉瘤外科手术治疗病死率高。早期诊断，适当复苏，紧急外科手术，缩短手术时间，肾动脉下方阻断，是降低病死率的关键。腔内修复治疗是降低病死率的有效途径。     

腹主动脉瘤破裂的急救体会（附2例报告并文献复习）

目的探讨对腹主动脉瘤破裂的诊断及急救措施。方法回顾分析2007年1月至2010年3月收治的2例腹主动脉瘤破裂患者抢救过程。结果1例患者治愈出院,1例术后因大量失血导致弥散性血管内凝血（DIC）及多器官功能衰竭而死亡,存活率为50％。结论急诊手术是救治腹主动脉瘤破裂患者的最有效方法。早期诊断,适时复苏,急诊外科手术,是降低病死率的关键。     

胸、腹主动脉瘤腔内隔绝术的临床应用

美国主动脉瘤列疾病死亡的第十三位,在老龄人口中,主动脉瘤破裂是更为常见的死亡原因,在死于腹主动脉瘤破裂的患者中,83%年龄大于65岁.胸、腹主动脉瘤在西方国家发病率高于我国,但随着我国的人口老龄化和饮食结构的改变,胸、腹主动脉瘤在我国的发病率逐年上升.胸、腹主动脉瘤一旦形成,其自然病程是瘤体逐渐增大直到破裂,除非患者在瘤体破裂前因其它原因死亡.Bickerstaff等报道,胸主动脉瘤(thoracic aortic aneurysm,TAA)诊断后的5年生存率为13%,其中动脉瘤破裂致死者占70%.Estes报道腹主动脉瘤(abdominal aortic aneurysm,AAA)诊断后的5年生存率为19%,10年生存率为0,其中63%的患者死于动脉瘤破裂.外科手术是预防胸、腹主动脉瘤破裂的唯一有效方法.传统的手术方法为经胸或经腹行主动脉瘤切开或切除,人工血管主动脉重建术.手术指征动脉瘤横径大于5cm或每年直径增加0.5cm以上,以及有压迫周围脏器等伴随症     

30例腹主动脉瘤的外科诊疗结果分析

目的 交流腹主动脉瘤的诊断和外科治疗方法。方法 对1991年2月至2002年7月我院外科治疗的30例肾下型腹主动脉瘤的临床资料进行回顾性分析。结果 数字减影血管造影术诊断1例．MR1诊断2例。其余27例均经CT确诊。该30例中．腹主动脉瘤破裂6例．行急诊手术，死亡2例(死亡率33.3％)；24例未破裂者中．22例行腹主动脉瘤切除和原位人造血管移植术．术后死亡2例(死亡率9.1％)．另2例行腹主动脉瘤腔内人造血管移植术。结论 及早术前诊断．恰当地选择手术时机、手术方式及正确的围手术期处理是提高手术成功率，减少术后并发症和死亡率的关键。     

腹主动脉瘤33例诊断和手术治疗体会

目的探讨腹主动脉瘤的诊断和手术治疗经验。方法1996年6月至2004年12月间,诊断和手术治疗腹主动脉瘤33例,其中胸腹主动脉瘤1例。均采用动脉瘤切除人造血管移植术。结果腹主动脉瘤破裂急诊手术7例,2例死亡。择期手术26例,无一例死亡。结论术前诊断和掌握手术时机是提高手术成功的关键。应用16排螺旋CT主动脉造影(sixteen-detector row computed tomography aortic angiography,16排螺旋CTA)在腹主动脉瘤诊断中具有无创、安全、快速、方便等优点,具有应用价值。对有手术指征的腹主动脉瘤应积极手术治疗,提高传统手术技术使腹主动脉瘤手术更为安全。     

腹主动脉瘤破裂18例救治体会

１８例腹主动脉瘤破裂，１６例经手术治疗。手术方法主要为腹主动脉瘤切除人造血管植入术，围手术期死亡６例（３７５％）。为提高病人生存率，一旦腹主动脉瘤诊断成立，应积极行择期手术治疗。腹主动脉瘤破裂后，正确及时的诊断尤为重要。手术时应注意阻断腹主动脉的方法以及防止术后下肢缺血     

胸、腹主动脉瘤破裂围手术期脏器功能评估与保护

目的 探讨影响胸、腹主动脉瘤破裂手术死亡的因素,对胸、腹主动脉瘤及其破裂患者围手术期重要脏器功能进行评估和保护,降低手术死亡率.方法 回顾性分析手术治疗22 例胸、腹主动脉瘤破裂患者的临床资料,数据采用单变量分析.同期完成48 例胸、腹主动脉瘤手术.结果 胸、腹主动脉瘤破裂与非破裂手术死亡率分别为31.8%和2.1%.年龄跃75 岁、心电图提示心肌缺血程度、血红蛋白约90 g/L 和肌酐逸150 umol/L 可作为预测胸、腹主动脉瘤破裂手术死亡的指标.结论 围手术期对胸、腹主动脉瘤及破裂患者的主要脏器功能进行评估和保护,加速患者康复,减少并发症的发生,降低手术死亡率.     

肾下型腹主动脉瘤的外科治疗

目的总结26例肾下型腹主动脉瘤的手术治疗经验。方法回顾性分析近5年多来手术治疗26例肾下型腹主动脉瘤的临床资料，全组26例，术前均经影像检查证实诊断。行择期手术21例，破裂型腹主动脉瘤急诊手术5例。26例均行腹主动脉瘤切除，人工血管重建术。结果围手术期死亡2例，均为急症手术患者，总病死率7．7％，急诊手术病死率40．0％。随访时间1-5年。术后1，3，5年生存率分别为96％，88％，75％。死亡原因均与腹主动脉瘤和手术无关。结论CTA检查是诊断腹主动脉瘤的可靠方法。手术治疗仍是治疗腹主动脉瘤的重要方法。瘤体直径不是决定手术的唯一指征。影响手术的危险因素主要是高龄、严重的心肺疾病和肾功能不全。     

破裂腹主动脉瘤的外科治疗

目的探讨急诊腹主动脉瘤切除人工血管移植术治疗破裂腹主动脉瘤的经验。方法总结1999年4月至2005年4月外科手术治疗破裂腹主动脉瘤20例，采用钳夹阻断膈下腹主动脉或Foley氏球囊管腔内阻断瘤颈上腹主动脉后行急诊腹主动脉瘤切除人工血管移植术，应用分叉型人工血管12例，直型人工血管8例。结果急诊腹主动脉瘤切除人工血管移植手术30d围手术期死亡率40％（8例），死亡原因包括急性肾功能衰竭4例，多器官功能衰竭2例，呼吸循环衰竭2例。存活12例，术后合并症包括急性肾功能不全、肺部感染、凝血机制障碍和腹泻等共11例，均经治疗后痊愈。随访观察6～60个月，无人工血管血栓形成和感染等并发症以及随访期死亡发生。结论破裂腹主动脉瘤外科手术治疗死亡率仍然很高，早期确定诊断，紧急外科手术治疗，术后加强围手术期管理是降低破裂腹主动脉瘤死亡率的关键。     

院内发生的腹主动脉瘤破裂诊治

目的 总结5例院内发生的腹主动脉瘤破裂的救治经验.方法 对2006年1月～2009年12月我院5例院内发生的腹主动脉瘤破裂患者的临床资料进行回顾性分析.结果 1例因出血性休克所致急性呼吸循环衰竭死亡;其余4例患者采用开腹手术救治,行肾动脉下腹主动脉阻断,采用自体血液回输,行急诊腹主动脉瘤切除人造血管移植术,4例手术成功,随访6～38个月,无并发症发生.结论 手术治疗腹主动脉瘤破裂是有效治疗方法,对于非腹部疾病引起的住院腹主动脉瘤患者特别是有明确诱因患者,采取术前降低血压并紧急外科手术治疗是降低破裂腹主动脉瘤死亡率的关键.     

破裂性腹主动脉瘤的治疗

目的探讨破裂性腹主动脉瘤急诊救治的治疗经验。方法回顾性研究2002年5月-2013年7月救治的36例破裂性腹主动脉瘤患者的临床资料。其中25例合并高血压病,21例合并慢性阻塞性肺疾病。33例采取急诊开腹主动脉人工血管置换术;3例采取主动脉覆膜支架腔内修复术,其中1例中转开腹手术治疗。结果术后33例存活,另外3例死亡,死亡原因包括1例失血性休克和心功能衰竭,1例术中心跳骤停,1例术后多器官功能衰竭,围手术期病死率为8．3％。术后随访3～61个月,未发生人工血管感染等手术相关并发症及死亡病例。结论积极的手术治疗是提高破裂性腹主动脉瘤患者救治成功率的关键,早期明确诊断,手术中快速有效控制近端瘤颈血流,完善围手术期治疗能有效降低病死率。     

腹主动脉瘤破裂的处理及预后分析

目的探讨腹主动脉瘤破裂的处理及影响预后的主要因素。方法回顾性分析12年间收治的42例腹主动脉瘤破裂的临床资料。85．7％的患者术前行影像学检查确诊。36例行手术治疗,其中35例行腹主动脉瘤切除人工血管植入术,术中80％采用肾动脉下腹主动脉阻断, 14．3％采用膈下腹主动脉阻断,5．7％采用Foley尿管球囊阻断（2例）;1例行覆膜支架腔内隔绝术。结果围手术期死亡率45．24％。单因素统计分析表明在围手术期死亡者年龄（72．1±1．0）岁、合并疾病13例和术前收缩压（82±53）mm Hg;存活者年龄（61．5±17．0）岁、合并症7例、术前收缩压（82±28）mm Hg,之间差异有统计学意义（P〈0．05）,而性别、术前Hb、肌酐、瘤体直径和手术失血量则无显著差异（P〉0．05）。结论手术是治疗破裂腹主动脉瘤的惟一有效方法,高龄、合并其他疾病和休克提示预后不良。     

Impact of delay on survival in patients with ruptured abdominal aortic aneurysm

Rupture of the abdominal aortic aneurysm (RAAA) is a common surgical emergency. Surgical treatment of this condition carries a high morbidity and mortality rate. For successful outcome, an early diagnosis and prompt treatment are essential. However, recently, some centers have reported better results in patients whose surgery had been delayed because of interhospital transfer. Delay in treatment sometimes occurs as patients are transferred from one institution to another where specialized vascular care is available. This retrospective study sought to determine the effect of delay in treatment on the mortality of patients with RAAA repair.The time from arrival at the emergency room to surgery and operative time were obtained from the case notes of 45 consecutive patients with RAAA. Patients' physiology scores on admission were calculated using V-POSSUM for the RAAA model.Thirty-five patients were diagnosed with RAAA in the emergency room and were transferred to surgery. These patients were divided into two groups: patients who had surgery within 1 hour (n = 23) and those in whom surgery was delayed for up to 4 hours (n = 12).There was no significant difference in physiology score between the two groups (p = .12). The time to surgery and operative time with death as the outcome were plotted on a logistic regression model that showed that the delay in surgical treatment increases the mortality rate following RAAA repair (p = .041). Furthermore, a long operative time was associated with a higher surgical mortality rate (p = .029).Delay to surgery and a long operation increase the mortality rate following RAAA repair. However, delay to surgery alone did not influence the mortality rate.     

Clamp before you cut: Proximal control of ruptured abdominal aortic aneurysms using endovascular balloon occlusion--Case reports

While the mortality rate for elective abdominal aortic aneurysm (AAA) repair has declined over the last several decades, the rate for ruptured abdominal aortic aneurysm (RAAA) has unfortunately remained disturbingly high. Undiagnosed aneurysms may present with little warning until abdominal pain, syncope, and hypotension signify rupture. Fifty percent of patients with ruptured aneurysms die before reaching a medical facility, and their survival is highly dependent on hemodynamic stability at presentation. The degree of rupture containment and comorbid status of the patient determine hemodynamic stability. Endovascular stent grafting has significantly improved perioperative morbidity and mortality rates for elective AAA repair, and some of the same endovascular techniques can be used to obtain proximal control in patients presenting with RAAA. We describe 3 consecutive cases of RAAA where proximal control was obtained using a percutaneously placed, transfemoral aortic occlusion balloon before induction of anesthesia.     

The post-operative mortality of ruptured abdominal aortic aneurysm repair.

INTRODUCTION: Late peri-operative death after ruptured abdominal aortic aneurysm (RAAA) repair is usually due to multiple-organ failure. The aim of this study was to identify any factors that are associated with mortality in this group of patients. METHODS: A retrospective case-note review of a single decade's operative experience of RAAA repair in a single centre. Only those patients with confirmed rupture at laparotomy were included. Sixty-three pre- intra- and post-operative variables were recorded where possible for each patient who survived surgery and the initial 24-hours post-operatively. Multi-variate analysis was performed using stepwise logistic regression. The P-POSSUM, RAAA-POSSUM, RAAA-POSSUM (physiology only), V-POSSUM, and V-POSSUM (physiology only) models were all compared to determine how each performed in these patients. RESULTS: Two hundred and twenty-three cases of confirmed RAAA were identified, of whom 139 survived the operation and initial 24-hours post-operatively. In-hospital mortality in this group of patients was 32.4%. Variables significantly associated with mortality after multi-variate analysis, were low intra-operative systolic blood pressure, the presence of a consultant anaesthetist at the initial operation and the development of cardiac, renal or gastro-intestinal complications. All POSSUM models except the V-POSSUM and P-POSSUM (physiology only) models demonstrated no significant lack of fit in this dataset. DISCUSSION: Factors associated with delayed peri-operative death after RAAA are not the same as those previously found to be associated with overall peri-operative mortality after RAAA repair.     

Ruptured abdominal aortic aneurysms: clinical presentation in Auckland 1993-1997

Background : Rupture of an abdominal aortic aneurysm (RAAA) carries a reported mortality rate in the range of 32–95%. Survival requires prompt diagnosis and surgical management. The presenting features, however, are varied, often insidious and potentially misleading with Osler noting nearly 100 years ago that a correct premortem diagnosis was achieved in only 33% of cases. The present study aims to review our present accuracy in diagnosing this condition and outline demographic and presenting features of patients with RAAA. Methods : A review was undertaken of hospital and Coroner’s files of all patients residing in the Auckland Coronial region who had RAAA between 1 January 1993 and 31 December 1997. Results : Three hundred and twenty‐nine cases of RAAA were identified, and they occurred most commonly in the 8th decade. The male:female ratio was 3:1 and at least 73% of patients were Caucasian. The overall mortality was 71%. Nearly half underwent surgery and the hospital averaged mortality rate was 46%. No patient survived without surgery. Classic presenting features of RAAA were absent in many cases. Abdominal pain, back pain and a palpable mass occurred in only 49%, 36% and 18% of patients, respectively. Other common presenting symptoms included vomiting, general malaise and pelvic or hip pain. Forty‐three patients (16%) were initially misdiagnosed. Conclusions : Although our ability to correctly diagnose a RAAA has improved since Osler’s time, the initial misdiagnosis rate of 16% leaves no room for complacency. Ruptured abdominal aortic aneurysms must be included in the differential diagnosis of any patient over the age of 55 years who presents with shock, even if the pain is non‐specific or atypical.