腔内修复术与开放手术治疗急性Stanford B型主动脉夹层疗效评价

目的系统评价腔内修复术（覆膜支架置入术）与开放手术治疗急性Stanford B型主动脉夹层的有效性与安全性。方法计算机检索1991年1月至2013年1月期间收录在CNKI、万方、维普、Cochrane图书馆临床对照试验中心注册库、OVID、Pubmed Medline、EBSCO、EMBASE、Springer Link、Science Direct等数据库中关于主动脉腔内修复术和开放手术治疗急性StanfordB型主动脉夹层的临床对照试验文献,用RevMan5.1软件对符合标准的临床试验数据进行分析。结果8个临床试验共纳入5618例急性B型主动脉夹层患者,腔内修复术组与开放手术组治疗后30d死亡率差异有统计学意义,腔内修复组明显优于开放手术组[OR=0.55,95％CI（0.46～0.65）,P〈0.00001]。另外,中风（OR=0.57,95％C1（0.39～0184）,P=0.005]、呼吸衰竭[OR=0.64,95％CI（0.53～0.78）,P〈0.00001]和心脏并发症[OR=O.49,95％CI（0.38～0.64）,P〈0.00001]的发生率差异均有统计学意义,腔内修复组优于开放手术组;截瘫[OR=I.30,95％C1（0.82～2.05）,P=0.26]和急性肾功能衰竭[OR=0.86,95％CI（0.41～1.80）,P=0.69]的发生率差异无统计学意义。结论腔内修复术可以作为治疗急性StanfordB型主动脉夹层的首选治疗方法。     

急性Stanford B型主动脉壁间血肿的治疗

目的 探讨急性Stanford B型主动脉壁间血肿的治疗方法和预后.方法 总结2001年1月至2008年3月收治的Stanford B型主动脉壁间血肿29例的临床资料.依据以下标准将患者分为三组:(1)有主动脉硬化性穿透性溃疡;(2)血压不易控制;(3)持续胸背部不适.符合上述任何一项的患者入选为腔内治疗组(13例),其余患者归入药物治疗组(16例).腔内治疗组采用降主动脉覆膜支架置入术;药物治疗组只接受降压、止痛等内科保守治疗.结果 本组29例患者均获随访,随访时间6～89个月,平均(19±16)个月,药物治疗组16例患者3例病情进展为夹层予支架治疗,2例突发主动脉破裂而死亡,疾病恶化率为31.25%,死亡率为12.5%;腔内支架治疗组13例患者随访期间未见夹层复发、支架移位及其他并发症.总共置入覆膜支架16个.结论 急性Stanford B型主动脉壁间血肿疾病恶化率高,腔内覆膜支架置入术是积极有效的治疗方法.     

血管腔内覆膜支架治疗主动脉B型夹层78例

主动脉夹层发病突然，病死率高。尽管手术风险大，传统上仍以外科治疗作为挽救病人生命的主要方法。随着介入产品和介入技术的不断进步，血管腔内覆膜支架治疗主动脉夹层的应用范围不断扩展，治疗效果不断提高。现报道我们3年来采用血管腔内覆膜支架治疗主动脉B型夹层的情况如下。[第一段]     

支架象鼻加左锁骨下动脉开窗术治疗Stanford B型主动脉夹层的临床研究

主动脉夹层是心血管外科的重症,其自然经过险恶,病死率较高.随着覆膜支架的应用,介入治疗已成为StanfordB型主动脉夹层治疗方式之一.但是对于降主动脉存在多个破口且真腔小假腔大的Stanford B型主动脉夹层,支架象鼻手术仍然是最佳选择.     

覆膜支架血管腔内修复术治疗Stanford B型主动脉夹层动脉瘤的效果

目的探讨覆膜支架血管腔内修复术治疗Stanford B型主动脉夹层动脉瘤的效果。方法回顾性分析2018-01—2020-01南阳市第二人民医院心外科收治的80例Stanford B型主动脉夹层动脉瘤患者的临床资料。根据治疗方法分为对照组与观察组,各40例。对照组行药物治疗,观察组进行覆膜支架血管腔内修复术治疗。检测治疗前后患者的白细胞介素(IL-1β)、γ-干扰素(IEF-γ)、血管内皮细胞生长因子(VEGF)水平,统计并发症发生率、病死率、再次介入手术率以及生活质量QLQC-30评分。结果治疗前2组患者的IL-1β、IEF-γ以及VEGF水平差异无统计学意义(P>0.05)。治疗后,观察组患者的IL-1β、IEF-γ、VEGF水平、并发症发生率、病死率,以及再次介入手术率明显低于对照组,QLQC-30评分明显高于对照组,差异均有统计学意义(P<0.05)。结论覆膜支架血管腔内修复术治疗Stanford B型主动脉夹层动脉瘤,能有效改善患者的免疫功能,降低并发症发生率、病死率,以及再次介入手术率,有利于提高患者的生活质量。     

无症状主动脉夹层的诊治

目的探讨无症状主动脉夹层的诊治方法及疗效。方法回顾性分析2002年1月至2006年6月我院收治的10例无症状主动脉夹层患者的病例资料,并随访观察其疗效。结果2例行开放手术治疗的A型夹层及6例接受覆膜支架腔内隔绝术的B型夹层效果良好,住院期间无严重并发症发生,随访至今生存良好。2例接受保守治疗的B型夹层患者1例尚健在,1例随访期间发生猝死,考虑死于主动脉破裂。结论无症状主动脉夹层发病隐匿,极易发生漏诊及误诊,临床上应保持高度警惕。无症状主动脉夹层同样易发生再夹层及瘤样扩张,同样有破裂危险,应积极采用手术治疗或介入治疗。覆膜支架腔内修补是治疗B型无症状主动脉夹层的有效方法。     

主动脉夹层的治疗进展

主动脉夹层发病急骤、病死率高、预后差。近年来随着腔内技术治疗主动脉疾病的发展,极大地改善了主动脉夹层的治疗效果,连同治疗理念亦发生了重大的变革。分类上,出现了一些新的分型系统来指导夹层的诊疗;治疗上,Stanford A型夹层仍以开放手术为主;复杂性Stanford B型夹层,腔内修复术已成为首选手术方式,同时越来越多的证据表明,对于非复杂性Stanford B型夹层,早期行腔内修复术远期效果更佳。     

老年StanfordB型主动脉夹层的手术治疗

目的 探讨老年Stanford B型主动脉夹层患者的手术治疗方法.方法 老年Stanford B型主动脉夹层患者47例分为两组,开放组采用深低温停循环下带支架人工血管置入术31例,介入组经股动脉行腔内覆膜支架人工血管植入术16例.结果 开放组,2例死于多器官功能衰竭,1例死于急性心梗;2例术后出现脑梗塞,其中1例死亡;一过性精神障碍11例,声音嘶哑3例.介入组,术后出现左上肢缺血3例,脑梗塞2例,其中1例术后出现大面积脑梗塞,8d后死亡.结论 对老年胸降主动脉夹层者须根据患者的不同情况,采用适合的治疗方法,以提高治疗效果.     

B型主动脉夹层的腔内治疗及其中期疗效观察

目的探讨B型主动脉夹层腔内修复术(EVAR)的适应证、围手术期并发症及中期治疗效果。方法 1998年11月至2009年2月对115例Stanford B型主动脉夹层患者行覆膜支架腔内修复术治疗。随访75例,随访时间1～83个月,分析其临床特点及随访疗效。结果 113例(共122枚)支架置入成功,破口封堵满意。杂交手术:术前2例,术中1例。围手术期并发症:锁骨下动脉窃血征4例;肺部感染3例;下肢动脉栓塞、急性脑梗死、肾功能衰竭各2例;移植物感染、急性肠缺血、消化道出血、A型主动脉夹层各1例。围手术期死亡5例(4.42%)。随访75例中支架近、远端内漏9例,5例患者行二次腔内修复术;继发A型主动脉夹层2例。随访中死亡6例(8%),4例分别死于心肌梗死、脑溢血、A型夹层破裂,2例死因不明。结论覆膜支架EVAR是治疗急、慢性B型主动脉夹层的有效方法,但应控制适应证,术中仔细操作和术后监护对于减少并发症具有重要意义。加强随访依从性尤为重要。     

B型主动脉夹层的腔内治疗及疗效观察

目的 探讨B型主动脉夹层腔内修复术的中期疗效.方法 回顾性分析1998年11月至2009年2月行覆膜支架腔内修复治疗115例B型主动脉夹层的临床资料.男7l例,女44例;年龄32～87岁,平均(56±11)岁.伴发病:高血压105例,糖尿病24例,冠心病14例,下肢动脉硬化11例,慢性肾功能不全7例,另5例有近期外伤史.结果 115例中,113例支架置入成功,释放支架人工血管122枚,破口封堵满意.3例同时行相关杂交手术.围手术期内并发症:下肢动脉栓塞2例,急性脑梗塞致偏瘫2例,移植物感染1例,锁骨下动脉窃血征4例,急性肠缺血1例,肺部感染3例,消化道出血l例,肾功能衰竭2例,A型夹层1例.围手术期死亡5例(4.42%).随访75例,随访率66.4%,随访时间7-83个月,平均随访44.5个月.其中支架近远端内漏9例,5例患者行二次腔内修复术;继发A型主动脉夹层2例,再次行血管置换手术.随访中死亡6例(8%),4例分别死于心肌梗死、脑出血、A型夹层破裂等,2例死因不明.结论 覆膜支架腔内修复术是治疗急慢性B型主动脉夹层的有效方法.     

Meta-analysis of Prolene Hernia System mesh versus Lichtenstein mesh in open inguinal hernia repair

BackgroundThis study was designed to systematically analyse all published randomized clinical trials comparing the Prolene Hernia System (PHS) mesh and Lichtenstein mesh for open inguinal hernia repair.MethodA literature search was performed using the Cochrane Colorectal Cancer Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE, Embase and Science Citation Index Expanded. Randomized trials comparing the Lichtenstein Mesh repair (LMR) with the Prolene Hernia System were included. Statistical analysis was performed using Review Manager Version 5.1 software. The primary outcome measures were hernia recurrence and chronic pain after operation. Secondary outcome measures included surgical time, peri-operative complications, time to return to work, early and long-term postoperative complications.ResultsSix randomized clinical trials were identified as suitable, containing 1313 patients. There was no statistical difference between the two types of repair in operation time, time to return to work, incidence of chronic groin pain, hernia recurrence or long-term complications. The PHS group had a higher rate of peri-operative complications, compared to Lichtenstein mesh repair (risk ratio (RR) 0.71, 95% confidence interval 0.55–0.93, P = 0.01).ConclusionThe use of PHS mesh was associated with an increased risk of peri-operative complications compared to LMR. Both mesh repair techniques have comparable short- and long-term outcomes.     

Complications following total ankle arthroplasty: A systematic literature review and meta-analysis

BackgroundTotal ankle arthroplasty (TAA) is increasingly used as a treatment for end-stage ankle arthropathy. However, TAA may be more sensitive to complications, failure and subsequent re-operations compared to ankle arthrodesis. The aim of this systematic review and meta-analysis is to generate an overview of complications of TAA surgery.MethodsPubMed, EMBASE and the Cochrane library were searched between 2000 and 2020 to identify all papers reporting on complications in TAA surgery. Meta-analysis was conducted based on type of complication in TAA surgery. Pooled estimates of complications were calculated using a random effects model. Risk of bias and quality was assessed using the Cochrane risk of bias and ROBINS-I tools. The confidence in estimates was rated and described according to the recommendations of the GRADE working group.ResultsOne hundred twenty-seven studies were included in this systematic review. All combined, they reported on 16.964 TAAs with an average follow-up of 47.99 ± 29.18 months. Complications with highest reported pooled incidence were intra-operative fracture 0.06 (95 %CI 0.04–0.08) (GRADE Very low) and impingement 0.06 (95 %CI 0.04–0.08) (GRADE low) respectively.ConclusionReported complication incidence of TAA surgery is still high and remains a significant clinical problem that can be severely hampering long-term clinical survival of the prosthesis. The results of this systematic review and meta-analysis can help guide surgeons in informing their patient about complication risks. Implementation of more stringent patient selection criteria might contribute to diminishing TAA complication rates.     

Previous thoracic aortic repair is not associated with adverse outcomes after thoracic endovascular aortic repair

BackgroundAs many as 20% of patients who have undergone previous thoracic aortic repair will require reintervention, which could entail thoracic endovascular aortic repair (TEVAR). A paucity of data is available on mortality and the incidence of spinal cord ischemia (SCI) and other postoperative complications associated with TEVAR after previous aortic repairs exclusive to the thoracic aorta. The aim of the present study was to assess the effect of previous thoracic aortic repair on the 30-day mortality and SCI outcomes for patients after TEVAR.MethodsThe Society for Vascular Surgery Vascular Quality Initiative database was queried for all cases of TEVAR from 2012 to 2018. Patients were excluded if they had undergone previous abdominal aortic repair, the TEVAR had extended beyond aortic zone 5, or SCI data were missing. The 3 cohorts compared were TEVAR with previous ascending aortic or aortic arch repair (group 1), TEVAR with previous descending thoracic aortic repair (group 2), and TEVAR without previous repair (group 3). The primary outcomes of interest were 30-day mortality and SCI. The secondary outcomes included stroke, myocardial infarction, cardiac complications, respiratory complications, postoperative length of stay, and reintervention. The patient variables were compared using χ² tests, analysis of variance, or Kruskal-Wallis tests, as appropriate. Logistic regression analysis was performed to identify the predictors of 30-day mortality and SCI.ResultsA total of 4010 patients met the inclusion criteria, with 470 in group 1, 132 in group 2, and 3408 in group 3. The 30-day mortality was 4% (19 of 470) in group 1, 6% (8 of 132) in group 2, and 6% (213 of 3408) in group 3 (P = .17). The incidence of SCI was 3% (14 of 470) in group 1, 3% (4 of 132) in group 2, and 3.8% (128 of 3408) in group 3 (P = .65). Stroke, reintervention, myocardial infarction, and cardiac complications were not significantly different among the 3 groups. The incidence of respiratory complications was greatest for group 3 (11%; 360 of 3408) compared with groups 1 (9%; 44 of 470) and 2 (4%; 5 of 132; P = .034). Similarly, the postoperative length of stay was longest for group 3 (9.6 ± 19.4 days vs 8.2 ± 18.3 days for group 1 and 5.9 ± 8.6 days for group 2; P = .038). The independent predictors of 30-day mortality for all TEVAR patients included units of packed red blood cells transfused intraoperatively, urgent or emergent repairs, older age, increasing serum creatinine level, inability to perform self-care, total procedure time, occlusion of the left subclavian artery intraoperatively, distal endograft landing zone 5, and diabetes. The predictors of SCI included the total procedure time, urgent and emergent repairs, and increasing serum creatinine level.ConclusionsTEVAR after previous thoracic aortic repair was not associated with an increased risk of SCI or 30-day mortality compared with TEVAR without previous aortic repair.     

Blunt thoracic aortic injury: a single institution comparison of open and endovascular management

OBJECTIVE: To review the treatment of blunt thoracic aortic injuries (BAI) at a single institution over the past 12 years and compare pre-, peri-, and postoperative variables and outcomes of both open (OR) and thoracic endovascular (TEVAR) repair of these injuries. METHODS: All cases of confirmed BAI from 1994 to present were included in this retrospective review. Data collected included demographic data, injury severity score, Glasgow coma score, arrival hemodynamic variables, and associated injuries. Operative data included: type of procedure (OR or TEVAR), duration of procedure, need for and amount of blood transfused, use of anticoagulation, type of anesthesia, and service performing the procedure. Outcomes evaluated were: death, paraplegia, length of stay, days ventilated, and procedure related complications. Specific to EVAR; access, stent graft type and number, presence of endoleak and long-term clinical and radiologic follow-up were evaluated. RESULTS: Thirty cases of blunt thoracic aortic injury were identified. Two patients received no treatment and died, 28 patients were treated (OR 16, TEVAR 12) and included for comparison. There were no significant differences between groups with respect to preoperative variables with the exception of significantly more associated intra-abdominal injuries in the TEVAR group (P = .03). Five patients in the OR group (31.2%) died in the perioperative period. There were no deaths in the TEVAR group (P =.05). One OR patient (6.25%) suffered postoperative paraplegia. No paraplegia occurred in the TEVAR group. Intraoperative variables were similar between groups with the exception of mean units of blood transfused (OR 8.5 units, vs TEVAR 0.2 units, P = .002). Ten patients in the OR group either died or had a procedure related complication compared with none in the TEVAR group (P = .001). There was no difference in length of stay or length of mechanical ventilation between the groups. There were no procedure or device related complications in the TEVAR group during follow-up (mean 15.3 months, range 1 to 53.5 months). CONCLUSIONS: Endovascular repair of BAI results in significantly less combined mortality and morbidity when compared to OR. Significantly less blood is needed intraoperatively in the TEVAR group. No complications from stent graft insertion have been observed during follow-up. Endovascular repair is replacing open repair as the treatment of choice for BAI at our institution.     

Systematic review of laparoscopic versus open surgery for colorectal cancer

BACKGROUND: This study compares the efficacy and safety of laparoscopic surgery (LS) and open surgery (OS) for colorectal cancer. METHODS: An electronic search of the literature was undertaken to identify primary studies and systematic reviews. Information on the efficacy and safety of LS versus OS was analysed. A meta-analysis was conducted to examine long-term outcomes. RESULTS: A systematic review published in 2000 and 12 more recent randomized clinical trials were identified. Compared with OS, LS reduced blood loss and pain, and resulted in a faster return of bowel function and earlier resumption of normal diet. Hospital stay was up to 2 days shorter after LS. No significant differences between the techniques were noted in the incidence of complications or postoperative mortality. The time required to complete LS was significantly longer (0.5-1.0 h more). No significant differences were found between the two procedures in terms of overall mortality, cancer-related mortality or disease recurrence. CONCLUSION: LS takes longer than OS but offers several short-term benefits. However, complication rates are similar for both procedures and no differences were found in long-term outcomes.     

Outcomes and risk management in type B aortic dissection patients with acute kidney injury: a concise review

PurposeType B aortic dissection is a rare but life-threatening disease. Thoracic endovascular aortic repair (TEVAR) was widely used for Type B aortic dissection patients in the last decade due to the lower mortality and morbidity compared with open chest surgical repair (OCSR). AKI in type B aortic dissection is a well-recognized complication and indicates poor short-term and long-term outcome. The objective of this concise review was to identify the risk factors and the impact of AKI on type B aortic dissection patients.Methods and resultsA literature search was performed using PubMed, Embase, MEDLINE, and Cochrane Library with the search terms ‘type B aortic dissection’ and ‘acute kidney injury’ (AKI), and all English-language literatures published in print or available online from inception through August 2020 were thoroughly reviewed. Studies that reported relative AKI risks and outcomes in type B aortic dissection patient were included. Major mechanisms of AKI in type B aortic dissection included renal hypoperfusion, inflammation response, and the use of contrast medium. Type B aortic dissection patients with AKI significantly had increased hospital stay duration, need of renal replacement therapy, and 30-d and 1-year mortality.ConclusionsAKI in type B aortic dissection is a well-recognized complication and associated with poor short-term and long-term outcome. Early identification of high-risk patients, early diagnosis of AKI, stabilization of the hemodynamic parameters, avoidance of nephrotoxic drugs, and optimization of the use of contrast agents are the major strategies for the reduction of AKI in type B aortic dissection patients.     

Endovascular repair for ruptured thoracic aortic aneurysm and traumatic aortic injury

In contrast to high mortality of open surgery for thoracic aortic catastrophes including ruptured thoracic aortic aneurysm (RTAA) and traumatic aortic injury (TAI), excellent short-term outcomes of thoracic endovascular aortic repair (TEVAR) have recently been reported. We report our single-center experiences with TEVAR for aortic catastrophes. Thirteen patients with thoracic aortic catastrophes (RTAA in 7 patients, TAI in 6 patients) have received TEVAR from February 2004 to June 2010. In cases of RTAA, 5 descending aortic aneurysm ruptures and 2 aortic arch aneurysm ruptures were included. In patients with arch aneurysm ruptures, fenestrated stent grafting (SG) and SG combined with arch debranching were performed. In all cases of TAI, aortic injuries occurred near the isthmus and 5 patients received fenestrated SG. The initial success rate was 100% and there was no perioperative death. Mean duration of observation was 24 months, which revealed 4 late deaths. The causes of late death were liver failure, cerebral contusion, senility and unknown. A patient with RTAA experienced a type III endoleak as an aorta-related event 24 months after operation. There was no enlargement of aneurysm in any patient. TEVAR for aortic catastrophes seems to be performed safely with acceptable outcomes. Although morphological incompatibility, unstable preoperative haemodynamics and longer time for preparation may become impediments to perform TEVAR, we believe that TEVAR should be the 1st choice for life-threatening aortic catastrophes. However, a careful follow-up is necessary because TEVAR has several unique late complications.     

Early outcomes of thoracic endovascular stent-graft repair for acute complicated type B dissection using the Gore TAG endoprosthesis

We assessed the technical success and early outcome of thoracic endovascular aortic repair (TEVAR) for complicated acute type B thoracic aortic dissection treated at a single institution using a commercially available device. All patients with symptomatic complicated acute type B thoracic aortic dissection treated with TEVAR since Food and Drug Administration approval of the Gore (Flagstaff, AZ) TAG endoprosthesis were identified from a prospectively maintained vascular registry. Clinical indications, operative technique, perioperative complications, follow-up imaging, and mortality were analyzed. Between March 2005 and November 2007, 127 TEVARs using the TAG endoprosthesis were performed, of which 15 (11.8%) were for complicated acute type B thoracic aortic dissection. Indications for repair were malperfusion (53%), persistent pain (27%), and primary aortic failure (33%). Technical feasibility and success with deployment proximal to the entry tear was 93.3%, requiring at least partial coverage of the left subclavian artery in seven (46.7%). Adjunctive procedures required at the time of TEVAR included renal stent (n = 2), iliac stent (n = 3), and access-artery open repair (n = 2). Twelve patients (80%) had immediate resolution of the malperfusion deficit. Major perioperative complications included paraplegia (13.3%), renal failure requiring hemodialysis (13.3%), and stroke (6.7%). Perioperative mortality was 13.3%, occurring in one patient presenting with rupture and one with profound heart failure on admission. For complicated acute type B thoracic aortic dissection, TEVAR using commercially available stent grafts showed high technical success, excellent results at resolving malperfusion, and acceptably low complications and perioperative mortality.     

Extracorporeal shockwave therapy compared with standard care for diabetic foot ulcer healing: An updated systematic review

Emerging evidence suggests that extracorporeal shockwave therapy (ESWT) may improve time to DFU healing. The aim of this review was to appraise the evidence on role of ESWT in DFU healing and impact of different ESWT doses. Databases were searched for trials comparing ESWT plus standard care to standard care alone in participants with DFUs. Search results were reviewed by two independent reviewers. The Cochrane Risk of Bias 2 tool and GRADE approach was used to assess bias and certainty. The primary outcome was time to healing. The search identified 345 papers after duplicates removed. Six trials consisting of 471 participants were included. There was unclear or high risk of bias across all domains. Time to ulcer healing was probably shorter in patients treated with ESWT compared with standard ulcer care alone (GRADE: low certainty). Patients treated with ESWT were more likely to heal at 20 weeks post-ESWT compared with those treated with standard ulcer care alone (GRADE: low certainty). There was significant heterogeneity. ESWT remains a promising new treatment but the translation into routine clinical practice is still limited by the low certainty of evidence surrounding its effectiveness, case selection and optimum dose.     

Nutritional outcomes in patients undergoing transoral robotic surgery for head and neck cancers compared to conventional open surgery. Systematic review

This systematic review examined nutritional outcomes in patients undergoing transoral robotic surgery (TORS), compared to open surgery (OS) for head and neck cancer. PUBMED, CINAHL, and Web of Science were systematically reviewed. Target nutritional outcomes included: weight, nutritional status, use of enteral feeding, swallowing function/ability, and time to oral diet. Risk of bias was assessed using the risk of bias in non-randomized studies tool, and certainty of evidence was assessed using grading of recommendations, assessment, development, and evaluation (GRADE). Eight studies were included (total n = 608). Compared to OS, TORS probably reduces short- and long-term enteral feeding use or duration (GRADE “moderate” certainty), may reduce time to full swallow ability (GRADE “low” certainty), but it remains uncertain whether TORS reduces long-term patient reported swallowing function or time to oral feeding (GRADE “very-low” certainty). No studies examined nutritional status or weight. There is limited body of evidence examining nutrition outcomes following TORS. Further studies are warranted, which may improve the certainty of evidence and assist in determining the optimal nutrition care for these patients.