胸腹主动脉置换术患者术后脊髓损伤的危险因素分析

目的:分析胸腹主动脉置换术(TAAA)患者术后脊髓损伤的危险因素。方法:回顾性分析我院自2011年7月至2018年1月,TAAA术患者204例围术期资料,根据是否发生术后脊髓损伤分为对照组与脊髓损伤组。结果:术后脊髓损伤的发生率为4.9%(10/204例)。单因素分析发现术毕血乳酸浓度与二氧化碳分压(PaCO_2)、CrawfordⅢ型、严重呼吸系统并发症、透析、脑脊液压力、术后24 h内最低HGB浓度、ICU时间、以及异体红细胞输注量与术后脊髓损伤有关。多因素Logistic回归分析表明,脑脊液压力(OR=1.350,95%CI:1.102～1.653,P=0.004)、术毕血乳酸浓度(OR=1.256,95%CI:0.996～1.583,P=0.054)与术毕PaCO_2(OR=1.112,95%CI:1.013～1.220,P=0.025)是术后脊髓损伤的独立危险因素。ROC曲线分析示脑脊液压力临界值为14.5 mmHg(1 mmHg=0.133 kPa)。结论:TAAA术患者术后脊髓损伤的发生率仍然较高。脑脊液压力、术毕血乳酸浓度与PaCO_2是TAAA术患者术后脊髓损伤的独立危险因素。     

全胸腹主动脉置换术后脊髓缺血的临床分析

目的:分析全胸腹主动脉置换术(total thoracoabdominal aortic aneurysm repair,t TAAAR)后出现脊髓缺血(spinal cord ischemia,SCI)患者的临床特点、危险因素及治疗经验。方法:回顾性分析北京安贞医院于2012年1月至2013年2月间,常温、非体外循环下行t TAAAR治疗患者的临床资料,共31例(男性20例,女性11例),平均年龄(38±12)岁。患者均为Crawford II型胸腹主动脉瘤,其中Stanford A型夹层5例,Stanford B型夹层20例,真性动脉瘤6例。结果:t TAAAR手术成功率100%,围术期病死率3.2%。术后随访1年,出现脊髓缺血7例(22.6%),经过积极的激素冲击、甘露醇脱水、脑脊液引流等治疗后,4例(12.9%)下肢轻瘫患者完全恢复,3例(9.7%)截瘫患者进一步改善。结论:脊髓缺血是t TAAAR术后严重并发症,加强围术期的脊髓保护,监测脑脊液压力,并进行积极的对症治疗,能有效减少其发生率。     

Clinical approach for thoracoabdominal aortic aneurysm repair

Thoracoabdominal aortic aneurysm repair represents a continuing challenge for the vascular surgeon. Although myocardial dysfunction and renal failure used to be worrisome problems after this procedure, adequate diagnostic evaluation and simple intraoperative maneuvers have dramatically reduced both potential complications. However, paraplegia, intraoperative coagulopathy, and respiratory failure remain continuing problems.Our approach represents a multimodality attempt to minimize the risks of this procedure. Preoperative evaluation includes functional cardiac testing and duplex carotid screening. Major occlusive lesions in either of these regions are corrected prior to thoracoabdominal aneurysm repair. Patients with renal dysfunction are not excluded from thoracoabdominal aneurysm repair; however, preoperative hydration is used and we routinely provide for a delay between preoperative angiography and surgical repair, thus minimizing the potential nephrotoxic effect of the angiogram contrast load. At the time of operation, an intrathecal catheter is inserted for monitoring cerebral spinal fluid (CSF) pressure and for drainage in order to keep the CSF pressure below 10 mmHg. CSF drainage is also continued for 3 days postoperatively. A shunt or bypass is generally used for patients with type I to type II thoracoabdominal aneurysm. An inlay technique is used for graft replacement of the aneurysm and as many intercostal arteries as possible are routinely reimplanted. No attempt is made to monitor spinal cord function during repair. In order to minimize perioperative bleeding complications, visceral ischemia time is kept to a minimum. Pharmacologic manipulation and systemic or regional cooling is used to minimize the reperfusion injury. Using this multimodality approach, the overall incidence of neurologic deficit in over 200 thoracoabdominal aneurysm repairs is 4.4%. Intraoperative mortality is 2.5% and the incidence of reoperation for bleeding is 4.8%. Thoracoabdominal aneurysm repair can be done safely and with acceptable morbidity if appropriate attention is paid to preoperative evaluation, perioperative technique, and postoperative care.     

3D Printing-guided endovascular repair of enormous twisted thoracoabdominal aortic aneurysm with branch stenosis and occlusion

A 67-year-old male patient was admitted with an enormous twisted thoracoabdominal aortic aneurysm (TAAA) with multiple branch arteries stenosis and occlusion. Three-dimensional (3D) printing technology combined with mechanics was used for developing a transparent model of lesion to simulate the segment of diseased aorta. A stent graft was deployed in the 3D model to make a physician-modified stent graft (PMSGs) on table. The locations of the opening of branches were marked twice during operation. The PMSG was successfully deployed during the surgery and repaired the TAAA, with no endoleak and all the branched arteries patency in follow-up. This technique could offer precision individualized therapy and could simplify the procedure process greatly.     

术中诱发电位监测对胸腹主动脉置换患者术后脊髓损伤的影响

目的:评价术中诱发电位监测(SEP)能否减少胸腹主动脉置换患者术后脊髓损伤的发生率。方法:回顾性分析安贞医院自2011年7月至2018年1月,择期胸腹主动脉置换术患者204例围术期资料,根据是否使用SEP将患者分为SEP组(n=69)与未监测组(n=135)。结果:10例患者术后发生脊髓损伤,其中SEP组4例,未监测组6例,脊髓损伤发生率为4.9%(10/204)。两组术后脊髓损伤发生率差异无统计学意义(P=0.736)。术中近端胸主动脉阻断期间、肋间动脉阻断期间、术毕体感与运动诱发电位阳性的患者均无人发生术后脊髓损伤。监测组4例术后脊髓损伤患者术中体感与运动诱发电位均为阴性。结论:胸腹主动脉置换术中采用SEP能发现脊髓缺血情况,但其不能降低术后脊髓损伤的发生率。应注意术中诱发电位阴性的患者术后仍有发生脊髓损伤的可能。     

Supravalvular aortic stenosis and coronary aneurysm]

A 32-year old woman, with endocarditis caused by Streptococcus mitis, and systolic murmur is presented. The Doppler examination was found a systolic gradient of 150 mmHg. Aortography showed a multiple membranous supravalvular aortic stenosis, with aneurysmal dilatation of the left main coronary artery and circumflex artery, associated with bicuspid aortic valve and mild aortic insufficiency. The patient died suddenly by cardiac arrest in stand by to cardiac surgery. Anatomic comprobation was not possible. The coronary artery anomalies associated with the supravalvular aortic stenosis syndrome are reviewed.     

Sinus of valsalva aneurysm with congenital aortic stenosis and aortic coarctation

A 52-year-old female was diagnosed with the extremely rare combination of sinus of Valsalva aneurysm, congenital unicuspid aortic valve stenosis, and coarctation of the aorta. She was successfully treated in a two-stage operation. The first operation consisted of a bypass graft to correct the coarctation. The second, performed 31 days later, included aortic valve replacement, patch closure of the aneurysm, and translocation of the right coronary artery.     

Monoparesis due to spinal cord infarction associated with thoracoabdominal aneurysm

We describe a case of acute monoparesis of a lower limb due to asymmetric spinal cord infarction in a patient with previously unrecognized thoracoabdominal aneurysm. The clinical course suggested that the likely reason for the spinal cord infarction was thromboembolism originating from the aneurysm’s mural thrombi. This rare entity should be considered when managing patients with acute mono-or paraparesis who have a thoracoabdominal aneurysm with mural thrombi because interventions aimed at preventing further embolisms could be beneficial in these patients.     

A case of Salmonella-infected thoracoabdominal aortic aneurysm making final diagnosis difficult

We report a case of thoracoabdominal aortic aneurysm (TAAA) due to Salmonella Enteritidis making final diagnosis difficult. A 63-year-old man with a history of diabetes mellitus, hypertension, and cerebral infarction was seen elsewhere for a 40 degrees C fever, vomiting, and shaking on day 1 after onset. He was diagnosed with Salmonella bacteremia and hospitalized by us for intensive care. Computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound imaging did not, however, show critical findings of aneurysm, endocarditis, or osteomyelitis, and laboratory testing suggest significant inflammatory symptoms. He did not respond to antibiotics, but had an intermittent low fever during the first hospitalization. On day 48 after onset during the second hospitalization, abdominal CT showed an aneurysm -3 cm in diameter in the thoracoabdominal aorta above the renal artery- small enough to have been missed in earlier diagnosis. Surgery and TAAA graft replacement were done on day 64. Bacterial culture of the graft showed no Salmonella growth due to long-term in vivo antibiotic exposure. He recovered without significant complications, with oral ciprofloxacin antibiotic therapy continued to the present. This case indicates the importance of an early diagnosis through continuous blood culture and imaging for Salmonella sp blood stream infection.     

Two-stage combined endovascular and surgical approach for recurrent thoracoabdominal aortic aneurysm.

PURPOSE: To present a 2-stage combined endovascular and surgical approach for recurrent thoracoabdominal aortic aneurysm (TAAA). CASE REPORT: A 78-year-old man with previous surgical repairs of infrarenal abdominal and descending thoracic aortic aneurysms was referred for dysphagia due to an enlarging 9-cm aneurysm extending from the mid thoracic to the suprarenal aorta. Because no suitable endograft was available, an open repair was attempted, but the presence of a "frozen" chest made the redo procedure extremely difficult. A 2-stage treatment was thus decided upon. First, a retrograde bifurcated bypass graft was implanted from the abdominal aortic graft to the superior mesenteric and celiac arteries. Twenty days later, the TAAA was successfully excluded with a stent-graft, during which spinal fluid drainage was performed to prevent paraplegia. At 6 months, computed tomography showed patency of the endoprosthesis and visceral grafts. At 1 year, the patient remains asymptomatic. CONCLUSIONS: This case illustrates that a 2-stage combined endovascular and surgical approach may be a safe and effective alternative to reoperation for recurrent TAAA.     

Extensive thoracoabdominal aortic aneurysm repair using deep hypothermic bypass and circulatory arrest

We sought to evaluate the safety and usefulness of deep hypothermic cardiopulmonary bypass with intervals of circulatory arrest for extensive thoracoabdominal aortic aneurysms. Between March 1994 and December 2002, 17 patients with Crawford type I and II were reviewed retrospectively. The patients were divided into two groups: group H (hypothermic circulatory arrest, n = 8) and group N (normothermic cardiopulmonary bypass, n = 9). In group H, in-hospital mortality was 12.5%, and that in group N was 11.1%. Operation times were similar between the two groups though the cardiopulmonary bypass time was significantly shorter in group N than in group H (p < 0.05). Postoperative paraplegia occurred in 1 patient of group N. Postoperative renal dysfunction occurred in none of group H except in 1 preoperative dialysis case, whilst it occurred in 6 patients of group N. Postoperative creatinine levels were significantly higher in group N than in group H. Three cases in group H required tracheostomy. Our experience with hypothermic cardiopulmonary bypass and circulatory arrest for diffuse type thoracoabdominal aortic aneurysm confirms the safety and efficacy of this technique. Although respiratory complications remain a problem, the technique is considered to be effective for renal protection.     

Contained rupture of a thoracoabdominal aortic aneurysm presenting as a back mass

Chronic contained rupture of aortic aneurysm is a rare but important subset of ruptured aneurysms, which has a presentation that is distinctly different from that of acute rupture. These aneurysms are usually small. Patients are hemodynamically stable, usually presenting with a long history of back or loin pain, with symptoms attributable to compressive or erosive effects. The resultant pseudoaneurysmal sac may cause extensive vertebral erosion, but rib erosion has rarely been described previously. Even more unusual is the presentation of the pseudoaneurysmal sac as a large back mass. We present an unusual case of contained rupture of a thoracoabdominal aortic aneurysm, which presented as a back mass, and demonstrate the radiographic and computed tomography findings. Radiographs of the chest show large posterior mediastinal mass eroding the rib. Computed tomography scans demonstrate fusiform dilatation of the thoracoabdominal aorta with positive aortic drape sign, which is highly suggestive of a contained leak. The importance of early identification of this condition lies in the imminent danger of exsanguination, if undetected.     

Endovascular exclusion of a thoracoabdominal aortic aneurysm after retrograde visceral artery revascularization

Historically, open surgical repair of thoracoabdominal aortic aneurysms has been associated with high morbidity and mortality rates. Furthermore, endovascular exclusion alone can restrict blood flow to visceral arteries. We report a case of thoracoabdominal aortic aneurysm that was repaired using a hybrid approach: surgery followed by an endovascular procedure. A 53-year-old woman was admitted to our hospital for endovascular exclusion of a thoracoabdominal aortic aneurysm that included the superior mesenteric artery and the celiac artery. Aorto-mesenteric and aorto-celiac artery bypass grafting was performed to create a landing zone for subsequent endovascular exclusion of the aneurysm, which was completed successfully 6 weeks after the bypass procedure. For thoracoabdominal aortic aneurysms that extend beyond the superior mesenteric artery and the celiac or renal arteries, a hybrid approach, consisting of limited surgical treatment followed by endovascular exclusion of the aneurysm, may yield optimal results in selected patients with serious preoperative comorbidities.     

传统及改良全胸腹主动脉替换术的临床疗效及术后并发症分析

目的探讨胸腹主动脉瘤(TAAA)患者行全胸腹主动脉替换术(tTAAAR)的临床疗效及术后并发症。方法回顾性分析2010年4月至2019年4月期间本院收治的14例行开放手术治疗的TAAA患者,11例为CrawfordⅡ型,3例为CrawfordⅢ型。男12例,女2例,年龄28～54岁,平均(36.1±7.1)岁。手术方式4例采用传统深低温体外循环tTAAAR,10例采用改良常温非体外循环tTAAAR。传统方式于深低温体外循环下建立动静脉通路进行体外转流,改良方式在常温非体外循环下建立降主动脉-髂动脉旁路循环。结果 14例患者均完成手术。降主动脉阻断时间为(22.2±9.6)min;脊髓缺血时间为(23.0±7.3)min。术后早期死亡2例,急性肾功能不全4例,双下肢截瘫3例,肺部感染4例,一过性脑功能障碍4例。1例患者术中行脾切除术,1例患者术后行气管切开术。结论开放性行tTAAAR是一种相对安全、有效的手术方式,是目前针对部分复杂TAAA的有效治疗手段。     

Dissecting aneurysm of aorta complicating aortic valvular stenosis.

Six cases of classical dissecting aneurysm of the aorta complicating aortic valvular disease in which aortic stenosis was dominant are described. In three of the cases the aortic complication occurred after the natural aortic valve had been replaced by a prosthetic valve. The longest postoperative period was four months. The factor common to all reported cases in our series was cystic medial necrosis of the aorta. The authors agree with the concept of McKusick and associates that aortic dissecting aneurysm complicating aortic valvular disease is an association other than chance and is related to cystic medial necrosis of the aorta. The latter, in turn, is a consequence of the altered hemodynamics of aortic valvular disease, particularly stenosis.     

覆膜支架腔内隔绝术治疗高龄胸腹主动脉瘤的疗效

目的：探讨主动脉腔内隔绝术治疗高龄患者胸腹动脉瘤的临床效果。方法：回顾性分析我院2004年2月至2011年7月25例实行覆膜支架腔内隔绝术的高龄胸腹主动脉瘤患者（年龄均≥65岁）的临床资料,总结手术效果,术后并发症和死亡率。结果：24例（96％）康复出院,术后并发症发生率24％（6／25）,病死率4％（1／25）,平均住院时间为（14．36±2．46）d,术后住院时间为（9．50±1．58）d。结论：覆膜支架腔内隔绝术可作为治疗高龄主动脉瘤首选方式,但须严格把握手术指征。