Simultaneous abdominal aortic replacement and thoracic stent-graft placement for multiple aortic aneurysms: report of a case

Patients with aneurysmal disease involving both the thoracic and abdominal aorta have historically required simultaneous or sequential conventional operations. Staged operations were generally preferred, but we experienced that a patient had rupture of the second aneurysm after he finished initial treatment for the first aneurysm. We have implemented simultaneous operation using thoracic stent-graft placement. A 78-year-old male who had multiple aortic aneurysm involving both the thoracic and abdominal aorta underwent conventional abdominal aortic replacement with endovascular stent-graft placement into the distal arch of the thoracic aorta under fluoroscopic guidance. The stent-graft was composed of two units of self-expanding stainless-steel Z stent covered with an thin wall woven Dacron graft. Postoperative aortography showed no stent migration and no endoleak. Simultaneous abdominal aortic replacement and deployment of a thoracic stent-graft may be a valuable treatment option for these patients. However, careful long term follow up is necessary to prove the value and the effects of the endovascular treatment.     

腹主动脉瘤的血管腔内治疗

目的 探讨腹主动脉瘤(AAA)血管腔内治疗后的短期临床效果.方法 回顾性分析2009年4月～2010年7月我科收治的8例AAA患者的临床资料.结果 患者均接受血管腔内治疗,手术成功率7/8,死亡1人.5例植入分叉型支架,2例植入直型支架,1例支架释放不成功.1例术后第2天右髂动脉支架折叠成角,远端血栓形成,给予局部溶栓成功后第3天血栓再次形成,急诊行左股－右股动脉旁路转流术.1例术后第2天出现急性肾功能不全,2个月后出现结肠缺血表现,给予对症治疗后好转.1例术中主体支架释放不成功,急诊行开腹手术,取出支架,行AAA修补术,术后第2天因呼吸循环衰竭死亡.随访1～16个月,中位随访时间5个月,至最后一次随访(死亡)时止,无内漏发生,无支架明显移位及动脉瘤腔内血栓形成.结论 AAA血管腔内治疗后的短期临床疗效满意,远期疗效有待进一步随访.     

Emergency stent-graft placement for hemorrhage control in acute thoracic aortic rupture

Objective: To report mid-term results of stent-graft (SG) implantation in acute thoracic aortic rupture as alternative to conventional open surgery with its associated high morbidity and mortality rates. Methods: Out of a series of 69 patients undergoing thoracic aortic SG implantation since 1998, 24 (mean age 57±19 years, range 20–85-years-old) patients were treated on an emergency basis for hemorrhage control. The indication for SG placement was acute traumatic aortic rupture in 15 patients, type B dissection with contained rupture in 3 patients, penetrating aortic ulcer with periaortic hematoma in 3 patients, and thoracic aortic aneurysm rupture in 3 patients. Preoperative assessment was done by computed tomography (CT) scanning and echography. Patients were treated in the angiography suite by implantation of Excluder (n=18), Talent (n=4), Corvita (n=1), and Vanguard (n=1) self-expanding grafts. Local anesthesia was the most frequently used anaesthesiologic technique. Results: Technical success rate of SG deployment was 100%. The early postoperative mortality was 12.5% (3 of 24). One patient suffered temporary paraplegia (4%). There was no intervention-related mortality during the mean follow-up of 34.1 months. Two secondary endoleaks were successfully treated with additional SG placement at 2 and 12 months postoperative, respectively. Conclusions: Emergency SG repair to control hemorrhage in patients with an acute thoracic aortic rupture is a less-invasive attractive and rational treatment option, especially if associated lesions or co-morbidity may interfere with the surgical outcome. Long-term follow-up results will be helpful to clarify procedure durability bounded by material failure and postoperative aneurysm or aortic wall remodelling.     

Endoluminal stent-graft placement in patients with acute aortic dissection type B

Objectives: This study was performed to evaluate the feasibility, safety and effectiveness of endovascular stent-grafting in treating Stanford type B acute aortic dissection. We describe our first clinical experiences and initial results with stent-grafting across the primary entry tear in patients with acute aortic dissection type B. Methods: Between March 2000 and August 2001, nine patients with acute type B dissection were treated endoluminally by stent-graft implantation. There were seven male and two female patients with a mean age of 63 years (between 48 and 85 years). In all nine patients aortic dissection was diagnosed by multislice computed tomography (CT) angiography. All nine patients had a maximal aortic diameter of 5.5 cm or more and recurrent pain, one patient showed hemoptysis. This patient with signs of a contained rupture was treated under emergency condition, the eight remaining patients were in hemodynamic stabile condition at the time of intervention. The GORE^® Excluder stent-graft system was used in eight patients (mean 1.8 stents/patient) and the TALENT^® stent-graft system in one patient, which were introduced transfemorally. Results: The primary entry tear could be sealed successfully in all nine patients. Complete thrombosis of the false thoracic aortic lumen was obtained in two patients, in the remaining seven patients the false lumen was obliterated in the area of the thoracic aorta but perfused via re-entries in the abdominal region. No severe intraoperative complications occurred. One patient developed bilateral incomplete paraplegia with motor and sensory deficits affecting completely the right leg and partially the left leg, 14 h after intervention. A cerebrospinal fluid drainage was initiated by inserting a lumbar catheter. All nine patients, including the patient with the transient paraplegia, could be discharged from the hospital in excellent condition and without remaining neurologic deficits. Control CT scans showed a reduction of the false lumen from 2.34±0.58 to 0.7±0.44 cm and an increase of the true lumen from 1.56±0.5 to 4.10±0.6 cm in the thoracic aortic region. Mean ICU stay was 1.8 days, mean postoperative hospital stay was 7.6 days. Conclusions: Stent-grafting of acute type B dissections may represent a very effective and promising new method by closure of the primary entry tear, thereby minimizing the risk of rupture of the thoracic aorta and optimizing distal perfusion by decompression of the true lumen.     

Endovascular repair of a ruptured thoracic aortic dissection with a right sided aortic arch: A case report

BackgroundEmergency treatment of complex aortic pathology is challenging in the setting of a right-sided aortic arch. We report the successful treatment of a ruptured thoracic aortic aneurysm (TAA) in the setting of a Stanford type B aortic dissection (TBAD) and right-sided aortic arch.Presentation of caseThe patient is a 66-year-old male with chronic kidney disease (CKD) admitted with right sided chest pain and hypotension. Computed tomography angiography (CTA) revealed a 5 cm ruptured TAA in the setting of a TBAD and right-sided aortic arch. The TBAD began just distal to the right common carotid artery and involved the origin of the left subclavian artery (SCA). Using a totally percutaneous approach, a conformable Gore^® TAG^® thoracic endoprosthesis was placed in proximal descending thoracic aorta covering the left SCA. Aside from progression of his pre-existing CKD, the patient had an uneventful recovery. CTA one-month post-procedure revealed a type IB endoleak with degeneration of the distal descending thoracic aorta. To exclude the endoleak, the repair was extended distally using a Medtronic Valiant^® thoracic stent graft. The left subclavian artery was subsequently coil embolized to treat an additional retrograde endoleak. The patient has done well with no further evidence of endoleak or aneurysm expansion.ConclusionRight-sided aortic arch presents challenges in the emergency setting. CTA and post-processing reconstructions are very helpful. While the endoleaks prompted additional interventions, the end result was excellent. This case displays the importance of careful attention to detail and follow-up in these complicated patients.     

Endovascular repair for a descending thoracic aortic aneurysm with a stent-graft covering the celiac artery: Report of two cases

An adequate landing zone for fixation and sealing is necessary for endovascular aneurysm repair (EVAR). This report presents two cases of a successful EVAR for thoracic aortic aneurysms (TAA) with a stent-graft covering the celiac artery (CA) to secure a distal landing zone. Case 1 was a 61-year-old man with a chronic traumatic descending TAA 12 mm away from the CA. Case 2 was a 79-year-old man with a descending TAA proximal to the CA. Preoperative angiography and computed tomography (CT) scan revealed a normal visceral blood flow including the peripancreatic arteries. Endovascular aneurysm repair with coverage of the CA was performed in both cases. Angiography after the EVAR demonstrated good blood flow to the CA branches via the peripancreatic arteries and a CT scan showed thrombosed aneurysms. Both patients were discharged without any abdominal symptoms. Endovascular aneurysm repair with a stent-graft covering the CA may therefore be an acceptable endovascular approach in treating selected TAA patients with a limited distal landing zone.     

Simultaneous operations for abdominal aortic aneurysm and liver cancer complicated by severe ischemic heart disease: report of a case

We performed successful simultaneous operations for an abdominal aortic aneurysm (AAA) and liver cancer in a patient complicated by severe ischemic heart disease. A 59-year-old man with a history of liver dysfunction presented with acute epigastric pain. Abdominal computed tomography findings of ascites and a liver tumor indicated a diagnosis of ruptured hepatocellular carcinoma. He had a concomitant 65-mm AAA and a 48-mm right common iliac aneurysm. Elective surgery was scheduled because of his good general condition. Although triple-vessel disease was detected preoperatively, there were no graftable coronary arteries. The aneurysms were repaired first to utilize intra-aortic balloon pumping (IABP) during resection of the liver cancer, followed by left lateral segmentectomy. Perioperative hemodynamics were maintained by administering catecholamines and vasodilators, without the need for IABP. The patient was discharged on the 21st postoperative day without any complications, and no recurrence of liver cancer has been found in the 5 months since his operation.     

手术治疗腹主动脉瘤205例远期疗效分析

目的评价手术治疗肾下型腹主动脉瘤的围手术期和远期效果。方法回顾性分析205例肾下型腹主动脉瘤切除术的临床资料,总结围手术期并发症和远期生存率,评价手术治疗腹主动脉瘤的安全性和远期疗效。结果30 d围手术期死亡率为1．0％;手术时间3-6 h,平均(3．8±1．4)h;ICU恢复时间中位数为16 h。围术期主要并发症包括心功能不全18例,呼吸功能不全10例,急性心肌梗塞2例,急性脑梗塞2例,急性肾功能衰竭4例;寿命表分析1、3、5年生存率分别为96．2％,83．1％,75．8％,随访中未发现与人工血管移植有关的死亡病例和并发症。结论手术仍是腹主动脉瘤的标准治疗方法。术前全身系统风险的评估和围手术期的谨慎管理在提高手术治疗效果中起重要作用。     

巨大和长段胸主动脉瘤的血管腔内修复术治疗

目的探讨巨大和长段胸主动脉瘤行带膜支架主动脉腔内修复治疗的可行性。方法对3例10．6～28．0cm长真性胸主动脉瘤的男性患者,采用多个带膜支架相连接成一条长段支架型人工血管,行主动脉腔内修复治疗。对瘤体全长28．0cm、最大直径7．3cm的病例,采用4个长度为130mm的不同直径的带膜支架相连接覆盖胸主动脉;另2例分别用2枚、3枚带膜支架治疗。2例术中先行颈总动脉-颈总动脉和颈总动脉-锁骨下动脉旁路术。结果3例手术过程顺利,术后恢复良好。2例术后无内漏,分别随访1,2个月,瘤腔内血栓形成;1例在支架连接处有少量内漏,术后1年消失,瘤腔内血栓形成。1例术后出现短暂脑缺血表现,1个月后消失。结论采用多个带膜支架相连接对巨大和长段胸主动脉瘤行主动脉腔内修复治疗,安全、微创,疗效良好,远期效果有待观察。     

分次阻断胸腹主动脉重建术13例

目的 总结胸腹主动脉瘤（TAA）分次主动脉阻断法胸腹主动脉重建的经验,探讨该手术方式对降低手术病死率、减少严重并发症－肾衰、截瘫等的作用。方法 运用改良的Crawford法行胸腹主动脉分支重建术13例。其中男性9例,女性4例。TAA分型为I型1例,Ⅱ型1例,Ⅲ型2例,Ⅳ型3例（Crawford分型）;主动脉夹层Debakey I型1例,主动脉夹层DebakeyⅢ4例（其中2例为动脉瘤破裂急诊手术病例）;主动脉缩窄1例。结果 13例手术均成功完成,1例于手术即将结束时因心脏意外死亡,手术病死率为7．7％（1／13）。本组病例手术并发症：急性坏死性胰腺炎1例,ARDS 1例,胸腔出血2例,截瘫、急性肾功能衰竭发生率各为7．7％。结论 分次主动脉阻断法行胸腹主动脉重建术降低了手术病死率及凶险并发症发生率,减少了脏器的缺血性损伤,是常温全身麻醉下行主动脉置换较为合理的方式。     

Adverse outcome following transfemoral endovascular stent-graft repair of an abdominal aortic aneurysm in a patient with severe liver dysfunction: Report of a case

We describe herein the case of a patient with severe liver failure in whom an abdominal aortic aneurysm (AAA) extending to the right iliac artery was diagnosed. Because the risk of performing a standard open repair was considered too high in this patient, the aneurysm was uneventfully repaired using a tech-nique of transfemoral endovascular stent-grafting with femorofemoral bypass and occlusion of the left common and right internal iliac arteries. Unfortunately, multiorgan failure associated with adult respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC) suddenly developed on postoperative day (POD) 2 and the patient died on POD 9. Thus, although endovascular stent-grafting is generally assumed to be less invasive and therefore feasible for high-risk patients, patients with severe liver dysfunction may not be suitable candidates. Received: August 4, 1999 / Accepted: March 24, 2000     

150例Stanford B型主动脉夹层动脉瘤腔内手术回顾

目的：总结150例Stanford B型主动脉夹层动脉瘤的腔内手术治疗经验。方法：术前对病人进行多种影像学检查，以获得主动脉夹层动脉瘤的有关解剖学资料。术中在DSA监视下对150例Stanford B型主动脉夹层动脉瘤施行了人工血管内支架安置术。术后1周和术后1年，作螺旋CT以观察手术疗效及有无内漏、移位和人工血管内支架塌陷等术后并发症。结果：148例(98．6％)获临床成功。围手术期内，1例(0．67％)死亡，1例(0．67％)发生脑梗死。术后截瘫发生率为零。26例(17．3％)发生内漏。结论：与传统手术相比，腔内治疗Stanford B型主动脉夹层动脉瘤具有创伤小、严重并发症少、住院时间较短的优势。近期和中期疗效令人满意，但远期疗效还有待于更长的随访。     

腹主动脉瘤开放手术围手术期并发症分析

目的 探讨腹主动脉瘤(abdominal aortic aneurysm,AAA)开放手术并发症的治疗和预防.方法 1991年1月到2009年8月手术治疗AAA329例,对围手术期并发症进行回顾性分析.结果 患者均顺利完成手术治疗,30 d围手术期死亡率为0.91%.围手术期主要并发症发生率为19.1%(63/329),包括心功能不全21例,呼吸功能不全15例,心肌梗死6例,肾功能衰竭5例,心律失常6例,脑梗死2例,下肢动脉栓塞2例,伤口裂开2例,腹壁切口疝1例,皮下血肿1例,下肢深静脉血栓2例.均给以对症治疗,1例患者死于急性心肌梗死,1例术后6 h出现肾功能衰竭,经20 d透析治疗后死亡,1例术后6 h死于频发室早和室颤,其余患者恢复良好.结论 心脏并发症及呼吸功能不全是AAA开放手术后最常见的并发症,术前全面评估、术中精细操作、术后严密监护并及时处理相应并发症是提高疗效的关键.     

腹主动脉瘤开放手术围手术期并发症分析

目的 探讨腹主动脉瘤(abdominal aortic aneurysm,AAA)开放手术并发症的治疗和预防.方法 1991年1月到2009年8月手术治疗AAA329例,对围手术期并发症进行回顾性分析.结果 患者均顺利完成手术治疗,30 d围手术期死亡率为0.91%.围手术期主要并发症发生率为19.1%(63/329),包括心功能不全21例,呼吸功能不全15例,心肌梗死6例,肾功能衰竭5例,心律失常6例,脑梗死2例,下肢动脉栓塞2例,伤口裂开2例,腹壁切口疝1例,皮下血肿1例,下肢深静脉血栓2例.均给以对症治疗,1例患者死于急性心肌梗死,1例术后6 h出现肾功能衰竭,经20 d透析治疗后死亡,1例术后6 h死于频发室早和室颤,其余患者恢复良好.结论 心脏并发症及呼吸功能不全是AAA开放手术后最常见的并发症,术前全面评估、术中精细操作、术后严密监护并及时处理相应并发症是提高疗效的关键.     

Hybrid procedures as a combined endovascular and open approach for pararenal and thoracoabdominal aortic pathologies

OBJECTIVES: to report our experience with hybrid vascular procedures in patients with pararenal and thoracoabdominal aortic pathologies. METHODS: 68 patients were treated for thoracoabdominal aortic pathologies between October 1999 and February 2004; 19 patients (16 men; mean age 68, range 40-79) with high risk for open thoracoabdominal repair were considered to be candidates for combined endovascular and open repair. Aortic pathologies included five thoracoabdominal Crawford I aneurysms, one postdissection expanding aneurysm, three symptomatic plaque ruptures (Crawford IV), five combined thoracic descending and infrarenal aneurysms with a healthy visceral segment, three juxtarenal or para-anastomotic aneurysms, and two patients with simultaneous open aortic arch replacement and a rendezvous maneuver for thoracic endografting. Commercially available endografts were implanted with standardized endovascular techniques after revascularization of visceral and renal arteries. RESULTS: Technical success was 95%. One patient developed a proximal type I endoleak after chronic expanding type B dissection and currently is waiting conversion. Nine patients underwent elective, five emergency and five urgent (within 24 h) repair. 17 operations were performed simultaneously, and 2 as a staged procedure. Postoperative complications include two retroperitoneal hemorrhages, and one patient required long-term ventilation with preexisting subglottic tracheal stenosis. Thirty-day mortality was 17% (one multiple organ failure, one secondary rupture after open aortic arch repair, one myocardial infarction). Paraplegia or acute renal failure were not observed. Total survival rate was to 83% with a mean follow-up of 30 months. CONCLUSIONS: Midterm results of combined endovascular and open procedures in the thoracoabdominal aorta are encouraging in selected high risk patients. Staged interventions may reduce morbidity.     

自制国产化支架-移植物腔内治疗腹主动脉瘤的实验研究

目的 探讨自制国产化支架、移植物在治疗犬腹主动脉瘤中的作用。方法 以国产镍钛合金丝纺织成网状管型支架,外套以国产真丝涤纶交织人造血管,装入导鞘制成支架-移植物系统;用胰蛋白酶灌注犬肾下腹主动脉段形成动脉瘤模型;用血管腔内技术将支架-移植物置入腹主动脉内,隔绝血流分别于第1周、1个月、3个月和6个月末观察通畅度及新生内膜生长。结果 20条模型犬接受手术,成功19条,支架置入后能充分展开并恢复形状,1个月末,支架内表面90%被新生内膜覆盖,3个月末几达100%,6个月末,79%的支架保持通畅,无移位、内漏等并发症。结论 自制国产化支架、移植物有良好的生物相容性和较高的通畅率,可用于腹主动脉瘤的治疗。     

Simultaneous total arch replacement and abdominal aortic surgery

It is common to encounter patients with coexisting aortic arch aneurysm and abdominal aortic lesions. We conducted simultaneous total arch replacement and abdominal aortic surgery in 3 patients having such lesions. Mean operative time was 511 minutes and no in-hospital mortality occurred. Postoperative respiratory failure was observed in an 80-year-old patient who recovered and all three patients were discharged in good condition. No other postoperative complication was seen. Simultaneous total arch replacement and abdominal aortic surgery may thus offer advantages to patients with such double aortic lesions if it can be conducted safely.     

外科手术在肾下腹主动脉瘤治疗中的地位(附187例手术经验)

目的：就肾下型腹主动脉瘤的治疗经验，讨论外科手术的实用性和前途。方法：回顾分析1992年1月至2004年2月择期行肾下型腹主动脉瘤切除术187例，将其结果与经腔内治疗者作比较。结果：围手术期死亡1例(0．54％)，死亡原因是术后6h出现频发室性早搏、室颤，诱发大面积心肌梗死。手术时间平均为3．8h；出血量平均470ml．输血量445ml。ICU内恢复时间为12～24h。围手术期并发症包括心力衰竭17例，呼吸衰竭8例，急性心肌梗死2例，急性脑梗死1例，急性肾功能衰竭3例，无术后严重出血或失血性休克发生，也无下肢动脉栓塞发生。术后1、3、5年生存率分别为97．0％、84．6％及78.3％，随访期间病人死亡者的原因与腹主动脉瘤和手术无关。经腔内治疗手术目前仍有较高的中、远期并发症。结论：瘤体直径不能作为手术适应证的唯一指标。术前同时应确切评价全身重要脏器功能。影响腹主动脉瘤手术的危险因素主要是高龄、严重心、肺疾患及肾功能不全等。迄今，经腹手术仍是治疗腹主动脉瘤的主要方法。     

腔内支架人工血管治疗主动脉弓部动脉瘤

目的 探讨腔内支架人工血管治疗主动脉弓部动脉瘤的基本方法。方法 采用国产腔内支架人工血管治疗主动脉弓部动脉瘤患者46例,其中主动脉瘤累及主动脉弓中部23例(50％),单纯累及弓降部22例(48％),累及胸降主动脉1例(2％)。选择支架直径是夹层破裂口或瘤口近端相应部位主动脉直径宽的1．15～1．20倍。支架近端直径34～38mm,长度90～120mm。支架材料为国产形状记忆镍钛合金。结果 支架释放成功45例(98％),无远端动脉并发症发生。支架释放后即刻封闭瘤口或破裂口43例(96％),早期内漏2例(4％)。夹层真腔全部恢复正常。急性期患者中转手术1例,死亡2例。术后43例患者获随访,随访时间1～23个月,远期内漏3例(7％),但所有随访患者均恢复正常生活。结论 腔内支架人工血管可用于主动脉弓部动脉瘤的治疗,其治疗的长期效果还需进一步观察。