大动脉转换术113例的手术结果分析

目的回顾性分析大动脉转换术的手术疗效。方法2001年1月至2005年12月,采用大动脉转换术纠治完全性大动脉错位113例,其中室间隔完整型大动脉错位（TGA／IVS）60例,伴室间隔缺损大动脉错位（TGA／VSD）53例。患儿体重最轻2,3kg,年龄最小出生后6h。在深低温停循环和低流量下行大动脉转换术。结果手术总死亡率9．7％,其中TGA／IVS死亡5例,手术死亡率8．3％,TGA／VSD死亡6例,手术死亡率11.3％。随着手术方法的不断改进和围手术期以及体外循环转流技术的提高,其手术死亡率不断下降,从早期的手术死亡率16.6％降至目前的5．6％。结论冠状动脉畸形是导致大动脉转换术死亡的关键,TGA／VSD的冠状动脉畸形发生率较TGA／IVS要高。主动脉和肺动脉的位置并不影响手术成功率。左心室与右心室压力比例〈0．6时,不能行大动脉转换术,否则术后将出现严重左心室低心排。     

Utility of 16-multidetector CT angiography in the preoperative evaluation of vascular and ureteral anatomy of donor nephrectomy

ObjectiveTo evaluate the accuracy of 16-section multi-detector row computed tomography (MDCT) angiography in the preoperative evaluation of renal transplant donors in comparison with intra-operative findings.Patients and methodsIn this prospective study 89 consecutive renal donors (69 men and 20 women) underwent 16-MDCT angiography followed by open surgical donor nephrectomy from January 2008 to March 2010. We reported the number and origin of renal arteries and the presence of early branching arteries. Renal venous anatomy was evaluated for the presence of major and minor venous anomalies. The renal calyces and ureters were assessed with delayed excretory phase images. On a 3D workstation, images were evaluated by the radiologist and the urologist. These CT angiography results were compared with surgical findings.ResultsThe mean age of the donors was 31 years. Open donor nephrectomy was performed on the left in 52 and on the right in 37 subjects. At surgery, accessory renal arteries were found in 14 kidneys (double arteries to 13 kidneys and triple arteries to one kidney). CT and surgical findings agreed in 92% of subjects. Seven small accessory renal arteries in seven donors were missed by radiology reviewers. Early branching of the renal arteries was shown in 5 arteries, and CT matched surgical findings in 88 cases (99%). Renal vein anomalies were present in six subjects, three of them were missed with the preoperative CT. The major shortcoming of MDCT angiography was noted in identifying minor venous anatomy. The presence of discrepancies between pre-operative MDCT and the findings at surgery did not affect the clinical outcome of transplantation, except in one case where intra-operative surgical distress was noted due to failure in identifying multiple major renal veins.Conclusions16-MDCT angiography is a good modality in the pre-operative evaluation of live renal donors. However, it provides suboptimal information on renal vascular anatomy, particularly complex venous patterns. Surgeons should not rely fully on pre-operative CT angiography while performing donor nephrectomy.     

Immediate results of reconstructive operations in arteriosclerosis obliterans of the iliac and femoral arteries]

The work generalizes the immediate results of restoration of the main and collateral blood flow in 240 patients with arteriosclerosis obliterans of the iliac and femoral arteries. The outcomes of surgical treatment were judged according to the clinical and ultrasonic evaluation of regional hemodynamics. The results were found to be good in 84 (35.0%), satisfactory in 104 (47.5%), and poor in 42 (17.5%) patients. The results of operations on the iliac and femoral arteries are shown separately, as well as the results of surgery in their combined lesions. Thromboses of the reconstructed arteries and prostheses were encountered in 10 (4.17%), hemorrhages in 8 (3.33%), wound infection in 16 (6.67%), and venous thromboses in 4 (2.5%) patients. For the prevention of thromboses of the deep veins the author claims dosed physical exercises on a constructed training apparatus to be advisable. Amputation of the extremity was carried out in 10 (4.17%) patients because surgical correction of the blood flow proved ineffective and specific complications occurred.     

Diagnosis and surgical treatment of pathologic tortuosity of carotid and vertebral arteries

The article summarizes an experience with 179 surgical interventions on patients with pathological tortuosity of brachiocephalic arteries. The optimal described diagnostic algorithm for this pathology included ultrasonic dopplerography, transcranial dopplerography, angiography or magnetic resonance tomography in the angiography regimen. Clinical and angiographic indications to surgical treatment of this pathology were determined. The operative treatment was carried on in patients with neurological symptoms having kinks of brachiocephalic arteries. The intraoperative strategy depending on the type and localization of the disease are analyzed. Stabile regression of manifestations of vascular cerebral insufficiency after surgical correction of the pathological tortuosity of the brachiocephalic arteries was achieved in 76% of the patients.     

腹腔内脏动脉瘤的外科治疗——附46例分析

目的探讨腹腔内脏动脉瘤(VAAs)的合理治疗策略。方法回顾性分析我院2000～2012年间随访资料完整的46例VAAs病例的临床资料及其治疗效果。结果 46例患者中男性21例,女性25例,其中肾动脉瘤10例,肠系膜上动脉瘤8例,肝动脉瘤7例,脾动脉瘤16例,胃十二指肠上动脉瘤2例,多发性VAA3例。37例接受介入治疗,9例接受开放手术,一次手术技术成功率为95.9%,二次手术技术成功率为100%。术后1例并发肠瘘、腹腔感染和肾功能损害,经治疗后康复出院。随访5～120(平均47.5)个月,除1例大动脉炎患者因再发肾动脉瘤破裂死亡外其余患者均存活。结论介入治疗及开放手术相结合是治疗VAA的合理手段,应根据患者的具体情况选择相应的治疗方式。     

合并异常冠状动脉法洛四联症和右心室双出口一期根治术

目的 总结合并异常冠状动脉的法洛四联症和右心室双出口一期根治术的经验，探讨有关外科技术的改进。方法1995年6月至2002年6月完成该类一期根治术12例，其中2例采取了肺动脉移位、3例在游离的左前降支下加宽右室流出道、5例改变右室切口并在冠状动脉下缝合、2例经肺动脉和右房疏通流出道。结果无手术死亡。随访3个月～6年，无晚期死亡和并发症发生。结论合并异常冠状动脉的法洛四联症和右心室双出口的一期根治手术是可行的，且效果良好，但必须采用适当的外科技术以保护异常的冠状动脉。     

Surgical treatment of the brain ischemic disease

There were examined 825 patients, in whom affection of extracranial arteries was revealed, including 340 (41.2%) men and 485 (58.8%) women, 27 to 73 years old. Atherosclerotic stenosis and occlusion of extracranial arteries was diagnosed in 305 (40.0%), pathologic kinking of vessels on atherosclerosis and hypertonic disease background--in 196 (23.8%), pathological kinking, caused by aortoarteriitis and fibrose--muscular displasia--in 197 (23.9%), hypoplasia of arteries--in 54 (6.5%), aortoarteriitis--in 73 (8.8%) patients. Stages I-IV ischemia together with proven affection of extracranial arteries served as indication for surgical treatment of chronic cerebro-vascular insufficiency. Depending on character of the arteries affection 11 kinds of operative interventions were conducted, using complex intraoperative program of the brain defense. Total number of reconstructive operations performed was 967. In 752 (91.2%) patients immediate good and satisfactory results were noted. In the late period 450 patients were examined: good results were achieved in 64.9%, satisfactory--in 22%, in 30 (6.7%) improvement did not occur and 28 (6.2%) died. Introduction of the proposed complex examination and surgical treatment program have permitted to improve the results of treatment of the patients, suffering chronic brain ischemia.     

Surgical manipulation of primate cerebral arteries in established vasospasm

It is generally believed that surgery in the face of angiographic vasospasm is dangerous due to an increased incidence of postoperative cerebral ischemia. One theory is that arterial narrowing is exacerbated by surgical manipulation of vasospastic vessels during aneurysm dissection and clipping. This theory was tested in a primate model of cerebral vasospasm and the results reported. Six monkeys underwent baseline cerebral angiography, followed by induction of subarachnoid hemorrhage (SAH) on both sides of the circle of Willis. An equal amount of fresh autologous blood clot was placed around each internal carotid, anterior cerebral, and middle cerebral artery. Six days later, angiography was repeated and the right craniectomy was reopened for clot evacuation and surgical manipulation of the right cerebral arteries, including placement of a temporary aneurysm clip on the right middle cerebral artery. The left cerebral arteries were not exposed or manipulated, and served as controls. Twenty-four hours later angiography was repeated, then the animals were killed. Equal and significant vasospasm (greater than 40% reduction in vessel caliber compared to baseline, p less than 0.05) was seen in the middle cerebral arteries on both sides of the circle of Willis in all animals 6 and 7 days after SAH. There was no significant change in the severity of vasospasm on Day 7 compared with Day 6 in the right cerebral arteries. Increased risk of postoperative cerebral ischemia for surgery in the peak vasospasm period may be due to mechanisms other than increased arterial narrowing precipitated by surgical manipulation.     

法洛四联症伴冠状动脉畸形的外科治疗

目的：总结法洛四联症伴冠状动脉畸形手术治疗经验,探讨冠状动脉畸形在法洛四联症纠治手术中的意义。方法：自1994年1月至1999年12月,手术治疗法洛四联症伴冠状动脉畸形15例,年龄43d-8岁,其中右冠状动脉起源于左冠状动脉或左前降支6例,单支左冠状动脉和左前降支起源于右冠状动脉各3例。双前降支,单支右冠状动脉和右冠状动脉肺动脉瘘各1例。一期根治手术13例,姑息手术2例。结果：姑息手术无死亡,根治手术早期死亡1例;无冠状动脉手术意外损伤;随访结果满意。结论：根据肺血管条件和畸形冠状动脉走行特点,选择适当的手术方式和右室流出道重建方法可提高手术效果;冠状动脉畸形不再是法洛四联症纠治手术中的风险因素。     

Hyperbaric oxygenation for treatment of extremities major arteries

The results of hyperbaric oxygenation therapy in surgical treatment of 44 patients with traumatic injuries of major arteries of the extremities were analysed. Associated injuries of the veins were observed in 27 (61.4%) patients, damages to the nerves--in 32 (72.7%), to the bones and joints--in 5 (11.4%), and to the soft tissues--in all of the patients. The indications for the hyperbaric therapy were: severe acute ischemia, major soft tissue damages and bone fractures, wound infection (purulent, anaerobic) complications and emergency ligation procedures on arteries. The use of hyperbaric oxygenation procedure together with extracorporeal methods for detoxication and reconstructive operations on vessels gives us possibility to broaden the indications for reconstructive operations and to prevent and control ischemic and infectious complications, endotoxicosis, increase the effectiveness of surgical treatment in victims with the injuries of major arteries of the extremities.     

The "ultraperipheral" revascularization in arteriosclerotic obstruction of tibial vessels. Experimental study

In arteriosclerotic obstruction of the main tibial arteries, the tibial collateral vessels are usually patent, and about 70% of these arteries are potentially suitable for surgical revascularization. The present study aimed at investigating the practical feasibility of a selective revascularization procedure on these tibial muscular arteries (ultraperipheral revascularization). Six lower limbs amputated at thigh level for arteriosclerotic gangrene with complete obstruction of the main tibial arteries, were studied: the tibial collateral muscular vessels showed patency in 65% of cases. The authors propose a surgical technique for the revascularization of these peripheral vessels with the use of a vascular prosthesis. The "post-operative" angiographic studies showed that revascularization of these peripheral muscular arteries was possible.     

Simultaneous reconstructive operations in combined lesions of the coronary arteries, abdominal aorta and arteries of the lower extremities]

The work deals with the results of one-stage reconstructive surgical interventions in 15 patients with affection of the coronary arteries, abdominal aorta, and lower limb arteries. All patients underwent operation for the creation of an aortocoronary shunt in combination with various types of vascular reconstructive operations, including the formation of an ascending aorta -bifemoral shunt in 3 patients. The total hospital mortality was 26.7%. The authors discuss the indications and the surgical tactics of one-stage reconstructive interventions in combined affection of the coronary and peripheral arteries.     

Pedal Bypass for Limb Salvage: Impact of Diabetes on Long-Term Outcome

Use of pedal bypass can salvage limbs of patients with critical ischemia. The aim of this study was to evaluate the results of surgical revascularization of pedal arteries in diabetic patients and to assess the impact of diabetes on long-term outcome. We performed a retrospective analysis of all consecutive pedal bypasses done between January 1, 1987 and December 31, 1997. Demographic data, surgical indications, operative variables, and postoperative results including graft patency and limb salvage were compared between diabetic and nondiabetic patients. The results of this comparison showed that pedal bypass can safely and effectively relieve critical ischemia in diabetic patients. Diabetics have less early graft thrombosis and superior long-term graft patency. Despite higher incidence of renal insufficiency or failure and more tissue loss, diabetics can achieve similar excellent limb salvage rates. This outcome justifies aggressive revascularization of pedal arteries in diabetic as well as nondiabetic patients with critical limb ischemia.     

Regional hemodynamics and its surgical correction in combined arteriosclerotic lesions of the iliac and femoral arteries

The authors analyse the regional hemodynamics and the results of surgical treatment of 81 patients with coexistent atherosclerotic affections of the iliac and femoral arteries. Radiocontrast angiography and ultrasonic dopplerometry were conducted by elaborated methods for morphofunctional characteristics of arterial circulation. Inclusion of the internal iliac and deep femoral arteries in the main blood flow was the principal method of surgical correction. A differentiated choice of the reconstructive operation allowed a positive result of treatment to be produced in 80.25% of patients in the immediate and in 76.31% of patients in the late-term postoperative periods.     

Surgical techniques in combined operations on the coronary and brachiocephalic arteries]

The author possesses some experience in surgical treatment of 34 patients with coexistent lesions of the coronary and brachiocephalic arteries. He discusses the results of one-stage operations in 11 patients with a severe clinical picture of ischemia of the heart and brain. The surgical techniques of one-stage operations is described in detail and clinical cases are reviewed. The flow of blood in the ++brachiocephalic arteries was restored before beginning extracorporeal circulation in all cases. One patient died on the 3rd postoperative day.     

Distal percutaneous transluminal angioplasty through infrainguinal bypass grafts.

AIM: to evaluate the results of transluminal angioplasty (PTA) performed through infrainguinal bypass grafts for stenotic or occlusive lesions at the distal anastomosis and/or in the runoff arteries. Design: retrospective clinical study. MATERIAL AND METHODS: forty-one patients underwent 57 procedures at the distal anastomosis (n=13), in the runoff arteries (n=32) or at both locations (n=12) at a median of 9.6 months (range, 2-76 months) after infrainguinal bypass grafting. Nineteen procedures were on the popliteal artery, the rest on the crural arteries. Eleven procedures related to occlusions less than 5 cm in length. RESULTS: technical success was achieved in 91%. Primary and primary assisted graft patency rates at 3 years were 32% and 53%, respectively. There were no significant differences in patency rates with regard to the graft material, the type of lesion, the level of PTA, the status of runoff and the use of thrombolysis before PTA. No patients underwent amputation as a direct consequence of failed PTA or graft occlusion. One patient underwent acute surgical intervention due to graft occlusion at the time of attempted PTA. CONCLUSION: the results of PTA at the distal anastomosis and/or in the runoff arteries in limbs with infrainguinal bypass seemed to be inferior to the results of surgical revisions reported in literature. However, as failed PTA did not jeopardise vein-patch angioplasty or jump grafting, it is a reasonable alternative to surgical intervention in selected cases.     

Lumbar sympathectomy in atherosclerosis obliterance of lower limb arteries and age of the patients

In the elderly and old patients with atherosclerosis of lower limb arteries, ultrasonic dopplerography assisted study of hemodynamics in foot with use of Valsalva and corinfar tests was carried out. It is revealed that these patients retain high reaction to sympathetic influences. The obtained data were the base for use of lumbar sympathectomy in 419 patients over 65 years as an independent method of surgical treatment and in combination with reconstructive operations on major arteries. Good results were obtained in 70.1% operated patients, satisfactory results--in 22.7%. There were no significant differences in the results of lumbar sympathectomy between this age group and younger patients.     

Early angiographic assessment of coronary revascularizations using the internal mammary artery. Apropos of a consecutive and prospective series of 180 bypass grafts]

This report describes a consecutive and prospective series of 136 patients, who underwent coronary bypass using the internal mammary arteries. Coronary angiography was routinely performed on all patients 8 days after surgery. A total of 137 operations (1 reoperation) were performed on 180 coronary arteries using 132 left internal mammary arteries and 25 right internal mammary arteries. Direct bypass was performed 133 times (73.8%), sequential bypass 23 times (25.5%) and free graft once. Bypass involved 1 coronary artery 89 times (65.4%), 2 coronary arteries 46 times (33.8%) and 3 coronary arteries in 1 case. The overall early success rate of internal mammary bypass in this series was 94.8% including 2 bypasses which were patent but non-functional. Of the 23 sequential bypasses, only 1 anastomosis out of 46 was not patent for a success rate of 97.3%. These good results are attributed to the large diameter of the mammary artery. Early postsurgical imaging is valuable for several reasons. It allows detection of surgical errors and improvement of the procedure. It enables distinction between residual primary surgical stenosis and secondary stenosis or genuine restenosis. It allows analysis of perioperative complications allows. No correlations between myocardial infarction and bypass obstruction were found. Finally, it permits endoluminal therapies such as thrombolysis (1 case in this series) and dilatation (2 cases). In conclusion, although we do not perform angiography routinely, our policy is to perform imaging in all cases of postoperative complications and after certain procedures such as sequential bypass.     

Staged repair of tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries

OBJECTIVE: To assess the results of a staged surgical approach for tetralogy of Fallot with pulmonary atresia, hypoplastic or absent pulmonary arteries, and major aortopulmonary collateral arteries. METHODS: We retrospectively reviewed a consecutive series of these patients from a single institution. RESULTS: From July 1993 to April 2001, 46 consecutive patients with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collateral arteries were treated with staged surgical repair. The operative sequence usually began with a central aortopulmonary shunt followed by unifocalization of aortopulmonary collateral arteries depending on the source and distribution of pulmonary blood flow. Twenty-eight patients (61%) subsequently underwent complete repair with ventricular septal defect closure and right ventricle to pulmonary artery connection. Those patients who underwent complete repair had a median of 3 total operations (range 1-6). The ratio of the mean pulmonary artery pressure to the mean systemic blood pressure at the time of complete repair was 0.36 (range 0.19-0.58). Two of the 28 repaired patients (7.1%) required subsequent fenestration of the ventricular septal defect closure due to later development of supersystemic right ventricular pressure and right ventricular failure. Eighteen patients (39%) have undergone 1 or more staging operations and are considered good candidates for eventual complete repair. There were no hospital deaths. There was 1 late death (2.2%; 95% CI 0.4-11.3%) in a patient born prematurely who developed severe bronchopulmonary dysplasia precluding complete repair. CONCLUSIONS: For tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries, a staged surgical approach yields low overall mortality and acceptable hemodynamics after complete repair.     

Recurrence of ischemia of the lower limbs in patients with functioning vascular prosthesis

On the basis of experience in surgical treatment of 242 patients with recurrent ischemia of the lower limbs in late periods after operations on the aorta and peripheral arteries, the authors singled out a group of patients (44) with unobstructed but hemodynamically incompetent vascular prostheses. Their hemodynamic changes were caused by stenosis of the vascular anastomoses and shunts or by the development of occlusions of arteries beyond the reconstructed segments. The authors relate all these complications to the prethrombotic stage of late reocclusions and insist in their recognition before the development of thrombosis of the vascular prosthesis. The important role of dynamic Doppler flowmetry in early diagnosis is shown. Reoperations for correction of the blood flow were conducted on 40 patients. The results were good in 92.5% of them. The authors recommend wider use of preventive operations which contribute to the improvement of surgical treatment of patients with late reocclusions of arteries and vascular prostheses.