腔内隔绝术治疗腹主动脉瘤

目的探讨腹主动脉瘤（ＡＡＡ）腔内隔绝术的手术指征、手术方法、操作要点和存在的问题。方法１例高龄男性和多病并存的ＡＡＡ患者在全麻和选择性动脉造影动态监控下,用１１．０ｃｍ×２．６ｃｍ的内支撑－涤纶血管复合体,对ＡＡＡ进行了腔内隔绝术。结果术后１周和２０天分别行彩超和螺旋ＣＴ复查显示：复合体内径为２．２～２．４ｃｍ,通畅,无移位和扭曲。复合体壁外原ＡＡＡ腔内充满血栓,未探及通畅的腰动脉和肠系膜下动脉,ＡＡＡ外径无变化。复合体近端与ＡＡＡ颈前壁之间有一微裂隙,但对ＡＡＡ体影响不大。随访６个月,患者腹部搏动性肿块及左下肢间歇性跛行消失。结论ＡＡＡ腔内隔绝术避免了传统ＡＡＡ手术的各种缺点,而具简便、微创和疗效确实的优点,有良好的应用价值。     

腹主动脉瘤腔内手术治疗进展

我国血管外科事业在近五十年里取得了前所未有的发展 ,这是广大血管外科专业人员共同努力的结果。进入 2 1世纪后 ,血管外科将得到更加迅速的发展。本专题特邀国内在此领域有突出贡献的专家 ,就目前血管外科的现状与发展趋势作一讲座 ,希望这一方小小的论坛 ,能对血管外科新技术的推广起一点的推动作用 ,并能吸引更多的有志青年加入到血管外科专业医师的队伍中来     

腹主动脉瘤腔内治疗

腹主动脉瘤(Abdominal Aortic Aneurysm,简称AAA)是最常见的动脉瘤,90%腹主动脉瘤是动脉粥样硬化所致,多发病于40岁以后,男女比例为10:1.腹主动脉瘤的最终结局是破裂,如前壁破裂,死亡率高达90%.手术切除动脉瘤同时重建腹主动脉血流是行之有效的传统治疗方法.目前择期手术死亡率低于5%,但对于合并心、脑、肺、肾等重要脏器疾患的高龄病人,其手术死亡率可高达40%[1],这对于患者心理和生理无疑是十分沉重的打击.寻找一种简单、有效、微创、患者易于接受的治疗方法成为20世纪末各国血管外科和放射介入科医师努力的方向.     

腹主动脉瘤的外科治疗

自１９８１年至１９９４年，作者共收治包括４７例胸腹主动脉瘤在内的腹主动脉瘤患者１７８例。年龄自４岁至７９岁，平均５２．１岁。男女比例为５∶１。４例伴主动脉－上腔静脉瘘，２例腹主动脉－十二指肠瘘，１例伴由胃癌所致的幽门梗阻，６例由大动脉瘤。腹主动脉瘤采用常规手术方法。胸腹主动脉瘤用改良的ＢｅＢａｋｅｙ法、Ｃｒａｗｆｏｒｄ法或胸腹部病变分期切除法。腹主动脉瘤手术死亡率３．８％，胸腹主动脉瘤１７．４％。     

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.     

腹主动脉瘤腔内治疗现状

1991年,Parodi等发明人工血管内支架（stent graft,SG）并用于临床成功治愈腹主动脉瘤（abdominal aortic aneurvsm,AAA）,此后腹主动脉瘤腔内治疗（endovascular abdominal aortic aneurysm repair,EVAR）取得迅速发展。由于EVAR避免了传统开腹手术创伤大和出血多的缺点,使高龄或伴有心、肺、肝、肾功能不全的患者获得积极治疗的机会。一般来讲,腔内治疗主要是指肾下型腹主动脉瘤。     

近肾腹主动脉瘤的腔内治疗技术进展

腹主动脉瘤腔内修复术目前已成为大部分肾下型腹主动脉瘤患者的首选治疗,但对于近端瘤颈较短的近肾腹主动脉瘤,需要涉及内脏分支重建,常规的腹主动脉瘤腔内修复术疗效并不满意。近年来,烟囱支架技术、开窗支架技术、分支支架技术、八爪鱼技术等创新性技术的使用为近肾腹主动脉瘤患者的腔内治疗提供了多种解决方案,本文回顾并总结当前腔内治疗技术的进展,以期对目前各种技术的应用难点加以分析思考。     

腹主动脉瘤血管腔内治疗的体会

目的 观察腹主动脉瘤血管腔内治疗的近期疗效.方法 对12例肾下型腹主动脉瘤进行分析.结果 术中出血平均245 mL,住院时间平均8.6 d,术后禁食时间平均1.5 d.白细胞、血红蛋白和血小板以及肾功能、肝功能均在正常范围;PT和APTT术后延长,1周内恢复正常.并发症包括:肺部感染1例、腹胀2例,经保守治疗好转;内漏1例,3个月后自然消失.结论 腹主动脉瘤血管腔内治疗具有安全、微创及对人体内环境干扰小的优点.     

腔内修复术与开放手术治疗腹主动脉瘤的对比分析

目的 对比分析传统开放手术与血管腔内修复术治疗腹主动脉瘤的疗效.方法 回顾性分析我科2009年至2012年经外科治疗的43例肾动脉下腹主动脉瘤患者的临床资料,行腔内治疗患者25例,行传统手术的18例,对比分析两组患者术前、术中情况,术后并发症及6个月内死亡情况.结果 两组患者在手术时间、术中失血及输血量方面,两组差异均有统计学意义（t值分别为8.377,5.124,5.043,P均＜0.001）;术后30d内并发症比较,差异有统计学意义（X2=0.09,P＜0.05）;术后6个月内死亡率比较,差异无统计学意义（x2=4.21,P＞0.05）.结论 血管腔内修复术比传统手术创伤小,手术时间短,术中失血及输血量少,术后短期并发症发生率低,但中远期死亡率无明显差别.     

Factors associated with postoperative renal dysfunction and the subsequent impact on survival after open juxtarenal abdominal aortic aneurysm repair

BackgroundRenal dysfunction is a well-described complication of open juxtarenal abdominal aortic aneurysm repair, but the associated risk factors and corresponding impact on survival are not well described.MethodsWe identified all patients not on hemodialysis undergoing open repair of nonruptured juxtarenal aneurysms in the Vascular Quality Initiative from 2003 to 2017. We used mixed-effects logistic regression to determine factors associated with in-hospital postoperative renal dysfunction, including acute kidney injury (AKI, defined as serum creatinine concentration increase >0.5 mg/dL) and new renal replacement therapy (RRT), as well as the association between postoperative renal function and perioperative mortality. Cox regression was used to determine the association between postoperative renal complications and long-term survival.ResultsWe identified 2635 open juxtarenal repairs, of which 621 (24%) were complicated by AKI. The majority of these (20% of the overall cohort) were AKI alone, but 2.2% required temporary RRT and an additional 1.7% were permanently dialysis dependent. Factors independently associated with postoperative renal dysfunction included renal-visceral ischemia time (per minute: odds ratio [OR], 1.01 [1.01-1.02]; P < .001), clamp site (above both renal arteries: OR, 1.4 [1.1-1.8; P = .02]; supraceliac: OR, 1.7 [1.1-2.5; P = .01]), statin use (OR, 1.5 [1.1-2.0]; P = .01), male sex (OR, 1.7 [1.2-2.2]; P = .002), and preoperative renal function (glomerular filtration rate [GFR] of 45-60 mL/min/1.73 m²: OR, 1.8 [1.3-2.5; P < .001]; GFR of 30-45 mL/min/1.73 m²: OR, 1.9 [1.2-2.8; P = .003]; GFR of <30 mL/min/1.73 m²: OR, 6.2 [3.1-12.2; P < .001]). When renal-visceral ischemia time was categorized, there was no difference in risk of postoperative renal dysfunction until >25 minutes, but risk increased stepwise thereafter (25-39 minutes: OR, 1.6 [1.2-2.1; P = .004]; 40+ minutes: OR, 2.6 [1.9-3.5; P < .001]). Neither mannitol nor the use of cold renal perfusion was associated with renal complications or mortality in the overall cohort, but cold renal perfusion was associated with lower risk of AKI when clamp times exceeded 25 minutes (OR, 0.4 [0.2-0.97]; P = .041). Postoperative renal dysfunction was associated with higher adjusted perioperative mortality (AKI: OR, 2.6 [1.4-5.0; P < .01]; RRT: OR, 10.5 [4.0-27.6; P < .001]) and significantly higher risk of long-term mortality (AKI: hazard ratio, 1.5 [1.0-2.1; P = .049]; RRT: hazard ratio, 5.8 [3.2-10.3; P < .001]).ConclusionsPostoperative renal dysfunction, even a mild elevation in creatinine concentration, is associated with higher perioperative and long-term mortality. Although the routine use of mannitol and cold renal perfusion was not associated with postoperative renal dysfunction after open juxtarenal repair, cold renal perfusion was associated with lower risk of AKI if clamp times exceeded 25 minutes.     

Delayed rupture of an internal iliac artery aneurysm following proximal ligation for abdominal aortic aneurysm repair

This is a report of a patient presenting with a contained rupture of an internal iliac aneurysm following proximal ligation after abdominal aortic aneurysm repair three years earlier. The patient presented with a large pelvic mass with symptoms of urgency, frequency, dysuria, tenesmus and fevers associated with anemia. Following evacuation of the aneurysm and direct suture ligation of the distal branches of the internal iliac artery, the patient's aortic graft was covered with omentum which also filled the pelvic cavity. The importance of proximal and distal control of aneurysms and/or the importance of complete luminal control of internal iliac artery aneurysms is emphasized by this case.     

The decline of open abdominal aortic aneurysm surgery among individual training programs and vascular surgery trainees

ObjectiveIn the past decade, treatment of abdominal aortic aneurysm (AAA) has dramatically shifted from open repair to an endovascular approach. The decreasing number of open AAA repairs (OAR) has raised concerns regarding future vascular surgeons' competence to perform this complex and high-risk procedure. Prior work has documented decreasing open aortic volume among surgical residents. However, these studies report average national case volume with a limited understanding of the variation in OAR exposure among training programs and trainees. We sought to evaluate the current open AAA repair trends among individual accredited vascular surgery training programs and vascular surgery residents to better evaluate trainees' exposure to OAR.MethodsWe identified elderly Medicare beneficiaries undergoing OAR and endovascular aneurysm repair (EVAR) between 2010 and 2014. Accredited vascular surgery training program hospitals were identified. OAR and EVAR volume was aggregated at the program level and the number of senior vascular surgery trainees per year at each program was captured. The training program all-payer total AAA repair volume was calculated based on the national proportion of patients undergoing AAA covered by Medicare in the Vascular Quality Initiative. Temporal trends in program and vascular surgery trainee OAR and EVAR volume were calculated.ResultsA total of 119,408 (77%) EVAR and 35,042 (23%) were identified in the Medicare database between 2010 and 2014. Of these, 21% were performed among the 111 training programs, including 22,227 (73%) EVAR and 8416 (27%) OAR. The total OAR volume among training programs decreased by 38% during the study period, from a median of 29.1 to 18.2 OAR. In 2014, 25% of programs performed fewer than 10 OARs annually. Among senior vascular surgery trainees, the median number of OAR decreased from 10.0 in 2010 to 6.4 in 2014 and approximately one-half of senior trainees had exposure to fewer than five OAR in 2014.ConclusionsExposure to OAR among vascular surgery training programs has dramatically decreased, with nearly one-half of senior trainees performing fewer than five OAR in 2014. The variable and diminishing OAR exposure among vascular surgery training program highlights growing concerns surrounding competence in complex open repairs and suggest that only a small proportion of current trainees have ample opportunity to develop confidence and proficiency in this high-risk operation.     

Large neonatal thoracoabdominal aneurysm: case report and review of the literature

We present a neonate with a large saccular aneurysm of the thoracoabdominal aorta, extending from the intrathoracic aorta to the left common iliac artery. No underlying cause could be identified. Despite an early diagnosis, the aneurysm was deemed inoperable because of the lengthy involvement and the frail aspect of all visceral arteries. A review of the literature on congenital abdominal aortic aneurysm in infants was conducted. Eleven cases of live-born infants with a congenital abdominal aortic aneurysm have previously been published. None of them involved as large a part of the thoracic and abdominal aorta as the case presented here.     

主动脉腔内修复术治疗腹主动脉瘤或夹层合并腹部恶性肿瘤

目的 观察主动脉腔内修复术（EVAR）治疗腹主动脉瘤（AAA）或腹主动脉夹层（AAD）合并腹部恶性肿瘤的价值。方法 回顾性分析17例接受EVAR治疗的AAA（n=14）/AAD（n=3）合并腹部恶性肿瘤患者,其中12例于EVAR后接受腹腔镜肿瘤切除术、1例接受开腹肿瘤切除术,4例因心肺功能欠佳仅接受药物治疗;观察EVAR治疗效果。结果 EVAR成功率为100%,术中无严重不良反应及并发症;术后1个月CTA显示支架位置良好、通畅。术后随访1~28个月,期间均未见明显并发症,亦未见AAA/AAD相关死亡病例。结论 EVAR治疗AAA/AAD合并腹部恶性肿瘤效果较佳。     

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.