头臂型大动脉炎致严重脑缺血的手术治疗

目的探讨手术治疗头臂型大动脉炎所导致的严重脑缺血的疗效和经验。方法15例重症头臂型大动脉炎患者经胸行人工血管旁路术,升主动脉-双腋动脉、单颈内动脉(ICA)架桥6例,升主动脉-双腋动脉架桥3例,升主动脉-单腋动脉、单ICA架桥5例,1例合并腹主动脉闭塞的复合型,一期行升主动脉-双腋动脉、单ICA架桥,二期行单侧腋股搭桥术。结果经胸行人工血管旁路术可明显改善头臂型大动脉炎所导致的严重脑缺血症状。15例手术患者无一例死亡,术后随访3~40个月,患者均无明显脑缺血症状复发,并能正常地工作、生活。结论重症头臂型大动脉炎的患者如果出现严重的脑缺血症状,急性期如果激素治疗无效,或在非活动期,都应积极行人工血管旁路术。该手术不仅疗效确切,能迅速缓解症状,挽救患者的生命,预防失明和偏瘫;而且远期疗效肯定,辅以长期的药物治疗,能够达到治愈的效果。     

267例主髂动脉闭塞的手术治疗经验

目的 探讨肾动脉开口水平以下腹主动脉闭塞及髂动脉闭塞的手术方式选择及治疗经验。方法 回顾性分析267例主、髂动脉闭塞患者的临床资料。结果 267例患者全部行手术治疗。行腹主动脉－髂（股）动脉人工血管转流术145例,髂动脉－股动脉人工血管转流术40例,股动脉－股动脉人工血管转流术45例,腋动脉－股动脉人工血管转流术37例。总有效率为96．5％,围手术期病死率为3．5％。267例中178例得到随访,平均随访时间5年9个月,人工血管通畅率为82．0％。结论 符合正常血液动力学手术的主要术式是腹主动脉－（双）髂、股动脉人工血管转流术,对于年老、体弱者,特别是全身一般状况较差,伴有冠心病、高血压、脑动脉硬化、脑梗塞等慢性疾病的患者,应采用腋动脉－（双）髂股动脉人工血管转流术或股动脉－股动脉人工血管转流术,可明显减低手术病死率。     

颈部动脉血流重建治疗重症多发性大动脉炎导致脑缺血

目的 观察多发性大动脉炎导致的重度脑缺血外科治疗的效果,并评估经颅多普勒超声(TCD)在手术中的作用.方法 2003年3月至2008年2月,共治疗16例多发性大动脉炎患者,男性4例,女性12例;平均年龄32岁,平均病程7.5年.临床表现主要为头晕、头痛、眩晕和眼部视力障碍等.DSA和血管彩色多普勒超声显示多数患者的颈动脉和椎动脉有不同程度的病变.8例患者行升主动脉(主动脉弓)-双腋(肱)/锁骨下动脉人工血管旁路移植术;3例行升主动脉-双腋(肱)/锁骨下动脉人工血管旁路移植-单侧颈内动脉自体大隐静脉旁路移植术;3例行升主动脉-一侧锁骨下动脉和颈动脉人工血管旁路移植术;2例单纯行升主动脉-右颈内动脉自体大隐静脉旁路移植术,其中1例同时行升主动脉-一侧颈内动脉和冠状动脉旁路移植术.有4例在原来接受升主动脉-双腋动脉人工血管旁路移植的基础上,又行一侧人工血管-一侧颈内动脉自体大隐静脉旁路移植术.14例患者术中采用TCD监测双侧大脑中动脉血流,2例尝试分别经一侧锁骨下穿刺和一侧股动脉穿刺与颈动脉穿刺临时转流.结果 手术成功率为100%,无死亡病例.手术后出现伸舌歪斜3例,术后2周缓解.脑部缺血症状与体征均有不同程度的改善,总的有效率为100%.全部患者获得随访,平均随访时间2.2年.所有患者未出现症状复发.2例患者术后4年内出现吻合口处动脉瘤,1例为双侧.结论 颈部动脉血流重建是治疗多发性大动脉炎导致脑缺血的有效方法.术中TCD监测大脑中动脉的血流变化,并据此调整血压,对于预防脑缺血后的过度灌注有重要作用.     

DSA监视下急性下肢缺血的介入联合手术治疗

目的 探讨急性下肢缺血手术与介入联合的治疗方法。方法 分析2001年1月至2006年1月收治的72例（76条肢体）急性下肢缺血患者在DSA监测下行下肢动脉重建的临床资料。72例患者手术方式包括：（1）Fogarty导管取栓术45例；（2）Fogarty导管取栓＋股总动脉分叉处内膜剥脱＋补片成形5例；（3）Fogarty导管取栓＋球囊扩张支架植入2例；（4）Fogarty导管取栓术＋球囊扩张4例；（5）Fogarty导管取栓＋人工血管架桥术6例，其中股-股转流3例、腋-双股转流1例、股-胭转流1例、腹主动脉-双股动脉转流1例。（6）Fogarty导管取栓＋截肢（二期）6例；（7）Fogarty导管取栓＋腹主动脉夹层开窗术。结果 72例中，56例（59条肢体）救肢成功；7例（7条肢体）术前趾端坏死截除后愈合；6例（6条肢体）截肢；3例（4条肢体）围手术期发生多脏器功能衰竭死亡。结论 DSA监测下手术与介入联合治疗急性下肢缺血有助于提高重建下肢动脉供血成功率。手术的效果取决于肢体缺血的时间和程度以及对并发症的有效处理。     

Ⅰ型头臂型大动脉炎致颅内缺血14例临床分析

目的探讨大动脉炎导致颅内缺血的血管旁路术的选择及疗效。方法回顾性分析2005—2015年首都医科大学宣武医院血管外科14例Ⅰ型头臂型大动脉炎致颅内缺血病人的临床资料。14例均采用动脉旁路术,其中单侧颈总动脉闭塞且willis环不完整行升主动脉-单侧颈内动脉搭桥5例;双侧颈总动脉闭塞且willis环完整行升主动脉-单侧颈内动脉搭桥5例;双侧颈总动脉及双侧锁骨下动脉闭塞且willis环完整行升主动脉-双侧腋动脉搭桥1例;单侧颈总动脉及双侧锁骨下动脉闭塞且willis环完整行升主动脉-双侧腋动脉搭桥3例。结果 14例病人手术成功,共搭桥18条人工血管,1例术后出现右下肺感染及胸腔积液,1例术后人工血管急性血栓形成。病人术后症状明显改善10例、好转3例、无变化1例,近期治疗有效率为92.9%(13/14),人工血管通畅率为94.4%(17/18)。随访5~115个月,1例在术后5个月突发脑出血死亡,3条血管分别在术后6、66、79个月发生单侧颈内动脉人工血管闭塞,其余13条人工血管通畅,通畅率为81.3(13/16)。结论大脑willis环完整性对Ⅰ型头臂型大动脉炎导致颅内缺血的血管旁路术的选择有一定参考价值。     

Ⅲ型夹层动脉瘤介入治疗误堵颈动脉的处理

目的 总结Ⅲ型夹层动脉瘤介入治疗误堵左颈总动脉的处理和经验教训.方法 4例Ⅲ型夹层动脉瘤患者行支架型人工血管封堵降主动脉内膜破口时不慎误堵塞左颈总动脉.4例患者均为男性,年龄37～45岁,平均年龄41岁.1例因存在内漏加Cuff时将第一个支架推向近侧导致左颈总动脉和左锁骨下动脉堵塞,经球囊拖向下方后解决;1例放置支架时支架前跳堵塞左颈总动脉和左锁骨下动脉.立即从股动脉进抓捕器抓住从左上肢肱动脉进入升主动脉的刻度猪尾导管将支架拖向远侧后恢复左颈总动脉和左锁骨下动脉血流;1例因定位误差导致支架堵塞2/3左颈总动脉和左锁骨下动脉,立即显露左颈总动脉分叉经颈外动脉置入左颈总动脉支架(chimney技术)后左颈总动脉血运完全恢复;1例是在心外科误将前端无裸支架的支架型人工血管当成有裸支架而将一半的无名动脉、左颈总动脉和左锁骨下动脉封堵,经正中开胸行升主动脉双颈动脉及左腋动脉人工血管搭桥后缓解.结果 4例患者均成功封堵Ⅲ型主动脉夹层的近侧内膜破口,无明显内漏,无脑梗死和左上肢缺血表现.结论 介入治疗Ⅲ型主动脉夹层误堵颈动脉后需立即通过手术或介入手段解决以避免发生脑缺血并发症.     

锁骨下动脉盗血综合征25例报告

我院１９８２～１９９２年共收治的２５例锁骨下动脉盗血综合征。主要病因是动脉硬化（１４例，占５６％）及大动脉炎（９例，占３６％），半数以上患者有长期吸烟史。主要临床表现为患肢脉弱或无脉（８８％），双上肢血压差别明显（９６％），脑缺血症状与手部运动关系密切等。本组手术治疗及扩张２０例，其中锁骨下动脉与颈总动脉架桥１５例，腋－腋动脉架桥２例，经胸升主动脉与颈总动脉架桥２例，经皮经腔血管成形术１例。术后上肢症状明显改善１５例（７５％），神经症状明显改善１０例（５０％）。随访２～１００个月，有效率达８５％。文内就病因、诊断、偷流对脑血流的影响以及手术适应证和各类手术方式的优缺点进行了比较。     

内脏动脉重建联合主动脉腔内修复杂交手术经验总结

目的总结内脏动脉重建联合主动脉腔内修复杂交手术经验。方法12例杂交手术一期或二期完成。内脏动脉重建术中制作多分支人工血管。人工血管主体与腹主动脉或髂动脉吻合,远端各分支与双侧肾动脉、肠系膜上动脉、腹腔干及其分支分别吻合。前期部分肾动脉的处理采用自体肾移植,后期完全采取人工血管旁路方案。出院后CT血管造影（CTA）随访各内脏动脉吻合口是否通畅。结果12例内脏动脉重建术,重建腹腔干及其分支共11支,肠系膜上动脉12支,肾动脉共18支（包括自体肾移植5支）。内脏动脉人工血管吻合方式,前期采用端侧吻合,后期优先采用端端吻合。3例发生腹膜后出血。2例自体肾移植发生肾积水、尿漏。1例内脏动脉重建术后因胸腹主动脉瘤破裂死亡。1例发生急性呼吸窘迫综合征（ARDS）后继发心功能衰竭死亡。内脏动脉重建术相关围手术期死亡率为9．1％（1／11）。无一例发生截瘫。术后CTA随访7例,重建内脏动脉共23支全部通畅。结论杂交手术治疗累及内脏动脉的主动脉扩张性病变有效可行。手术方案的演变表明合理的内脏动脉解剖入路、人工血管旁路设计和吻合方式是手术成功的关键因素。     

血管内覆膜支架系统在主动脉夹层二期手术重建肾动脉中的应用

目的探讨血管内覆膜支架系统在主动脉夹层二期手术重建肾动脉中的应用效果。方法分析2010年5月至2018年5月宜昌市第一人民医院收治的10例累及腹腔内脏动脉的主动脉夹层进行二期手术中接受开放手术的患者临床资料。结果手术均获得成功,无围术期死亡病例。术后腹主动脉CT血管造影示患者人工血管及支架内血流均通畅,缝扎的腹主动脉不显影。二期手术后随访0.5～3.0年,患者人工血管及支架内血流均通畅,未见狭窄,缝扎的胸腹主动脉不显影。6例患者因髂动脉有破口致髂动脉仍有夹层表现,未做处理,随访假腔未见增大。结论血管内覆膜支架系统可代替缝合线连接两根血管,尤其适用于解剖位置较深、不方便暴露和吻合的肾动脉重建,具有缩短肾热缺血时间、节省手术时间、创伤小、操作方便等优点,值得在临床中推广。     

主动脉夹层的外科治疗

目的总结84例主动脉夹层患者的外科治疗经验,探讨手术技巧和围术期处理,以提高手术疗效。方法50例Stanford A型主动脉夹层患者在体外循环下（11例采用深低温停循环技术）行Bentall手术或Cabrol手术24例,升主动脉人工血管置换术8例,Trusler手术5例,Wheat手术5例,升主动脉＋主动脉全弓或半弓人工血管置换术8例;34例Stanford B型主动脉夹层采用带膜支架主动脉腔内修复术治疗。结果住院死亡11例,死亡率13．1％。术中死亡3例,其中1例升主动脉＋次全弓人工血管置换患者因术中主动脉开放后主动脉根部大出血无法止血;1例升主动脉部分切除＋人工血管置换患者心脏无法复跳;1例升主动脉＋半弓血管置换患者因降主动脉夹层破裂死亡。术后早期死亡8例,其中死于低心排血量综合征2例,肺部感染2例,肾功能衰竭2例,呼吸衰竭1例,永久性神经系统损害1例。术后发生并发症16例。随访62例（84．9％,62／73）,随访时间3个月～10年。随访期间死亡2例,其中1例死于心内膜炎,1例猝死（原因不明）。结论快速准确地诊断、个体化的手术方案和精确的手术技术是主动脉夹层手术成功的关键。     

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??Intracranial ischemia caused by type ?? Takayasu's arteritis : A clinical analysis of 14 cases LIU Yi-ren, GU Yong-quan, GUO Lian-rui, et al. Department of Vascular Surgery, Xuanwu Hospital, Capital University of Medical Sciences, Beijing 100053, China
Corresponding author??GU Yong-quan??E-mail??15901598209@163.com
Abstract Objective To explore the choice and effect of vascular bypass treatment for intracranial ischemia caused by Takayasu's arteritis. Methods The clinical data of 14 cases of intracranial ischemia cased by type I Takayasu's arteritis admitted from 2005 to 2015 in Department of Vasculary Surgery, Xuanwu Hospital,Capital University of Medical Sciences were analyzed retrospectively. All patients received vascular bypass. Five cases of unilateral carotid artery occlusion with incomplete willis ring were performed ascending aorta to uiilateral carotid artery bypass. Five cases of bilateral carotid artery occlusion with complete willis ring were performed ascending aorta to unilateral carotid artery bypass. One case of bilateral carotid artery and subclavian artery occlusion with complete willis ring was performed ascending aorta to bilateral axillary artery bypass. Three cases of unilateral carotid artery and bilateral subclavian artery occlusion with complete willis ring were performed ascending aorta to bilateral axillary artery bypass. Results Vascular bypass treatment were completed in 14 cases and 18 artificial blood vessels were used. Postoperative pulmonary infection and pleural effusion occured in 1 case, and thrombosis was found in artificial blood vessels in 1 case after operation. Ischemic symptoms was significantly improved in 10 cases. Three cases get better. Symptoms were not improved in 1 case. The total effective rate of group was 92.9%(13/14), and the total patency of graft was 94.4%(17/18). All the cases were followed up 5 to 115 months. One died of cerebral hemorrhage after 5 months. Artificial vascular occlusion occurred in 3 cases in the 6th, 66th and 79th month respectively after operation. Operation kept other blood vessels pristine and the total patency was 81.3% (13/16). Conclusion The willis's circle will be reference for the operative choice of vascular bypass treatment for intracranial ischemia caused by type I Takayasu's arteritis.     

Surgical procedures in the management of Takayasu's arteritis

Takayasu's arteritis is an inflammatory arteriopathy that often progresses to obliteration of multiple large arteries. Variable results have been reported after medical and surgical management. Twenty female patients with Takayasu's arteritis were treated from 1973 to 1989. Eleven (55%) patients had hypertension. Upper or lower extremity ischemia was present in 12 (60%) patients and cerebrovascular insufficiency in seven (35%). Nine patients initially managed with corticosteroids had no improvement in signs or symptoms of arterial insufficiency. Eleven patients had 16 vascular procedures for the following indications: renovascular hypertension (6), extremity ischemia (5), cerebrovascular insufficiency (2), dilation ascending aorta with aortic insufficiency (1), thoracic aortic aneurysm (1), abdominal aortic aneurysm (1). Procedures included aortorenal bypass (5), carotid-subclavian, axillary, or brachial bypass (4), aorto-carotid bypass (2), aneurysm resection (2), supra-celiac aorto-femoral bypass (1), ascending aorta/aortic valve replacement (1), and nephrectomy (1). Clinical improvement occurred in all patients. There were no operative deaths. All are alive at a mean follow-up of 5.75 years (6 months to 16 years). Revision of the initial reconstruction has been required for recurrent renovascular hypertension in one patient and extremity ischemia in another. The other nine patients remain symptomatically improved. Symptomatic Takayasu's arteritis frequently requires arterial reconstruction. Symptomatic improvement and excellent long-term graft patency can be expected after arterial reconstruction.     

重症头臂型大动脉炎的诊治经验

目的 探讨重症头臂型大动脉炎的诊断和治疗方案。方法 12例重症头壁型大动脉炎中8例行人工血管旁路术,3例行颈总动脉球囊导管扩张术,1例保守治疗,结果 术后随访3-89个月,手术、扩张、保守3种治疗方法均明显地改善了脑缺血症状,并能正常生活,在手术治疗的患者中以行升主动脉-单侧颈动脉人工血管旁路术疗效最好。结论 重症头壁型大动脉炎的患者如果处于活动期应尽量以保守治疗为主,保守治疗可能缓解脑缺血的症状,处于非活动期时可根据情况选择介入或手术治疗,一侧颈总动脉没有完全闭塞可行股动脉穿刺置管对狭窄之颈总动脉进行球囊导管扩张术,如双侧颈总动脉均完全闭塞,我们主张以选择升主动脉-单侧颈内动脉人工血管旁路的手术方式,术中及术后应控制血压,并预防脑水肿的发生。     

Takayasu's arteritis: surgical considerations.

Takayasu's arteritis, the nonspecific occlusive disease originally believed to affect young Oriental women exclusively, was identified in a 19-year-old man who had severe involvement of the aortic arch and its branches. Successful surgical treatment was accomplished with a bypass from the ascending aorta to the supraceliac abdominal aorta using a tube graft. The right vertebral artery, as the single patent vessel reaching the head, was revascularized distal to the stenosis with a tube graft that extended from the aortic graft. Revascularization of ischemic organ systems and body areas may be accomplished in most patients with Takayasu's arteritis using the bypass concept and fabric conduit grafts.     

Femoro-internal carotid artery bypass for cerebral ischemia in takayasu's arteritis

In two patients with Takayasu's arteritis, severe cerebral ischemia was successfully treated by femoral to internal carotid artery bypass using a polytetrafluoroethylene (PTFE) graft through a subcutaneous tunnel. All of the arch branches were critically stenotic or occluded in both patients. The entire thoracic aorta was affected by the active inflammation process in one patient and there was marked calcification in the other patient. In these situations we hesitate to use the thoracic aorta as the donor site of bypass. Considering that Takayasu's arteritis affects the thoracic aorta and the proximal portions of its branches, the femoro-internal carotid artery bypass can be constructed without involving severely diseased vessels and can be expected to result in good cerebral revascularization.     

A surgically treated case of Takayasu's arteritis complicated by aortic dissections localized in the ascending and abdominal aortae

Because complication by aortic dissection is markedly rare in patients with Takayasu's arteritis, a limited number of reports have been published regarding surgically treated cases of Takayasu's arteritis that is complicated by aortic dissection. When graft replacement of the ascending aorta and aortic arch and extra-anatomic bypass grafting were performed in a 72-year-old japanese woman with Takayasu's arteritis, which was complicated by aortic dissections localized in the ascending and abdominal aortae, the postoperative course of this patient was satisfactory. It was considered that the media became friable in this patient because of the presence of Takayasu's arteritis and that hypertension that persisted for a long time caused the independent development of aortic dissections in the ascending and abdominal aortae.     

解剖外途径动脉转流术治疗锁骨下动脉闭塞症

为提高锁骨下动脉闭塞症的治疗效果,作者报告了１９８９年～１９９６年采用非经胸解剖外途径治疗２０例锁骨下动脉闭塞症的经验。本组男９例,女１１例。１７例有上肢缺血表现,１１例有脑部缺血症状。１７例行颈动脉－锁骨下／腋动脉转流,３例行腋动脉－腋动脉转流术。除１例大动脉炎因远端流出道差转流血管阻塞疗效不理想外,其余患者患肢及脑缺血表现均明显改善或消除。无手术死亡。作者认为采用解剖外途径治疗锁骨下动脉闭塞症,无需开胸,创伤小,操作简便安全,并发症少,通畅率高,尤其适合于手术耐受性差的患者,值得进一步推广使用。     

重症头臂型大动脉炎的诊治经验

目的:探讨重症头臂型大动脉炎治疗方案的选择。方法:28例重症头臂型大动脉炎病人中17例行人工血管旁路术,5例行球囊导管扩张术,6例行保守治疗。结果:手术、扩张、保守3种治疗方法均明显地改善了病人的脑缺血症状。术后5至91个月随访,病人均无明显脑缺血症状,并能正常地工作、生活。结论:重症头臂型大动脉炎的病人如果处于活动期应尽量以保守治疗为主,保守治疗可以缓解脑缺血的症状;处于非活动期时可根据情况选择介入或手术治疗。一侧颈总动脉狭窄可行颈总动脉球囊导管扩张术;双侧颈总动脉均完全闭塞,则主张选择升主动脉鄄单侧颈内动脉人工血管旁路的手术方式,不仅疗效肯定,而且能够避免或减轻术中、术后脑水肿的发生。术中及术后应控制血压,并同时应用甘露醇和皮质激素,预防脑水肿的发生。     

大动脉炎的介入及外科治疗

目的 探讨介入技术和外科手术在大动脉炎治疗中的应用.方法 2006年1月至2009年12月共收治大动脉炎26例,男女比例为1:4.2,平均年龄(27±15)岁;Lupi-Herre法分型,Ⅰ型16例,Ⅱ型7例,Ⅲ型3例.16例患者实施介入治疗,9例行开放手术,1例患者保守治疗.结果 16例患者实施介入治疗23次,其中1...