颈动脉瘤的外科治疗

目的探讨颈动脉瘤的外科治疗。方法回顾性分析2005年8月—2010年5月收治的16例颈动脉瘤患者的临床资料。发病至入院时间平均(31.0±0.7)个月。1例为双侧发病,15例患者为单侧发病;发病部位颈总动脉5例,颈内动脉9例,颈外动脉2例。7例患者无明显临床症状,5例伴有不同程度神经压迫症状,4例患者颈部外伤后出现颈部包块就诊。所有患者均行外科手术或血管腔内治疗。结果 16例患者均一期手术成功,无手术死亡。其中9例行外科手术,7例行血管腔内治疗。术后随访11例,随访时间平均(23.3±0.7)个月。超声检查:5例移植大隐静脉血管通畅;4例行覆膜支架患者例颈动脉通畅,瘤腔完全闭塞;2例支架内血栓形成,颈动脉闭塞,但无临床症状,未再外科干预。结论颈动脉瘤发生率虽低,但潜在风险高,一旦确诊,应积极治疗。开放手术疗效确切,血管腔内治疗微创,两者均为有效的外科治疗手段。     

下肢动脉硬化性闭塞症血管重建197例分析

目的 探讨传统外科手术、血管腔内治疗和杂交手术在下肢动脉硬化性闭塞症血管重建中的应用.方法 回顾性分析1998年1月至2008年12月接受血管重建手术的197例下肢动脉硬化性闭塞症患者临床资料,其中外科手术77例,血管腔内治疗82例,杂交手术38例.探讨3种血管重建方法的适应证、治疗效果、并发症及围手术期死亡率.结果 外科手术成功率97.4%(75/77),腔内治疗90.24%(74/82),杂交手术81.58%(31/38).随访2～112个月,平均随访46个月,随诊率71%(164/197).远期通畅率在主髂和股腘动脉中外科手术(57%和51%)高丁腔内治疗(48%和42%),但差异无统计学意义;远期通畅率在多节段病变和动脉狭窄并血栓形成中杂交手术(54%、26%、28%)明显高于其他方法(48%、23%).并发症在主髂和股腘动脉中外科手术(31%、12%)明显高于血管腔内治疗(31%、11%),在多节段病变(36%)明显高于腔内治疗和杂交手术(12%、15%).外科手术对于主髂和多节段动脉病变的围手术期死亡率分别为1.5%、2.0%,其他部位病变为0%;血管腔内治疗和杂交手术均为0%.结论 对于主髂和股腘动脉,外科于术是长段闭塞性病变、血管腔内治疗是短段非闭塞性病变的首选.杂交手术对多节段病变和动脉狭窄并血栓形成更具优势.对于膝下病变,血管腔内治疗能取得较好疗效,但远期通畅率不佳.     

下肢动脉硬化性闭塞症血管重建197例分析

目的 探讨传统外科手术、血管腔内治疗和杂交手术在下肢动脉硬化性闭塞症血管重建中的应用.方法 回顾性分析1998年1月至2008年12月接受血管重建手术的197例下肢动脉硬化性闭塞症患者临床资料,其中外科手术77例,血管腔内治疗82例,杂交手术38例.探讨3种血管重建方法的适应证、治疗效果、并发症及围手术期死亡率.结果 外科手术成功率97.4%(75/77),腔内治疗90.24%(74/82),杂交手术81.58%(31/38).随访2～112个月,平均随访46个月,随诊率71%(164/197).远期通畅率在主髂和股腘动脉中外科手术(57%和51%)高丁腔内治疗(48%和42%),但差异无统计学意义;远期通畅率在多节段病变和动脉狭窄并血栓形成中杂交手术(54%、26%、28%)明显高于其他方法(48%、23%).并发症在主髂和股腘动脉中外科手术(31%、12%)明显高于血管腔内治疗(31%、11%),在多节段病变(36%)明显高于腔内治疗和杂交手术(12%、15%).外科手术对于主髂和多节段动脉病变的围手术期死亡率分别为1.5%、2.0%,其他部位病变为0%;血管腔内治疗和杂交手术均为0%.结论 对于主髂和股腘动脉,外科于术是长段闭塞性病变、血管腔内治疗是短段非闭塞性病变的首选.杂交手术对多节段病变和动脉狭窄并血栓形成更具优势.对于膝下病变,血管腔内治疗能取得较好疗效,但远期通畅率不佳.     

下肢动脉硬化性闭塞症血管重建197例分析

目的 探讨传统外科手术、血管腔内治疗和杂交手术在下肢动脉硬化性闭塞症血管重建中的应用.方法 回顾性分析1998年1月至2008年12月接受血管重建手术的197例下肢动脉硬化性闭塞症患者临床资料,其中外科手术77例,血管腔内治疗82例,杂交手术38例.探讨3种血管重建方法的适应证、治疗效果、并发症及围手术期死亡率.结果 外科手术成功率97.4%(75/77),腔内治疗90.24%(74/82),杂交手术81.58%(31/38).随访2～112个月,平均随访46个月,随诊率71%(164/197).远期通畅率在主髂和股腘动脉中外科手术(57%和51%)高丁腔内治疗(48%和42%),但差异无统计学意义;远期通畅率在多节段病变和动脉狭窄并血栓形成中杂交手术(54%、26%、28%)明显高于其他方法(48%、23%).并发症在主髂和股腘动脉中外科手术(31%、12%)明显高于血管腔内治疗(31%、11%),在多节段病变(36%)明显高于腔内治疗和杂交手术(12%、15%).外科手术对于主髂和多节段动脉病变的围手术期死亡率分别为1.5%、2.0%,其他部位病变为0%;血管腔内治疗和杂交手术均为0%.结论 对于主髂和股腘动脉,外科于术是长段闭塞性病变、血管腔内治疗是短段非闭塞性病变的首选.杂交手术对多节段病变和动脉狭窄并血栓形成更具优势.对于膝下病变,血管腔内治疗能取得较好疗效,但远期通畅率不佳.     

下肢动脉硬化性闭塞症血管重建197例分析

目的 探讨传统外科手术、血管腔内治疗和杂交手术在下肢动脉硬化性闭塞症血管重建中的应用.方法 回顾性分析1998年1月至2008年12月接受血管重建手术的197例下肢动脉硬化性闭塞症患者临床资料,其中外科手术77例,血管腔内治疗82例,杂交手术38例.探讨3种血管重建方法的适应证、治疗效果、并发症及围手术期死亡率.结果 外科手术成功率97.4%(75/77),腔内治疗90.24%(74/82),杂交手术81.58%(31/38).随访2～112个月,平均随访46个月,随诊率71%(164/197).远期通畅率在主髂和股腘动脉中外科手术(57%和51%)高丁腔内治疗(48%和42%),但差异无统计学意义;远期通畅率在多节段病变和动脉狭窄并血栓形成中杂交手术(54%、26%、28%)明显高于其他方法(48%、23%).并发症在主髂和股腘动脉中外科手术(31%、12%)明显高于血管腔内治疗(31%、11%),在多节段病变(36%)明显高于腔内治疗和杂交手术(12%、15%).外科手术对于主髂和多节段动脉病变的围手术期死亡率分别为1.5%、2.0%,其他部位病变为0%;血管腔内治疗和杂交手术均为0%.结论 对于主髂和股腘动脉,外科于术是长段闭塞性病变、血管腔内治疗是短段非闭塞性病变的首选.杂交手术对多节段病变和动脉狭窄并血栓形成更具优势.对于膝下病变,血管腔内治疗能取得较好疗效,但远期通畅率不佳.     

下肢动脉硬化性闭塞症血管重建197例分析

目的 探讨传统外科手术、血管腔内治疗和杂交手术在下肢动脉硬化性闭塞症血管重建中的应用.方法 回顾性分析1998年1月至2008年12月接受血管重建手术的197例下肢动脉硬化性闭塞症患者临床资料,其中外科手术77例,血管腔内治疗82例,杂交手术38例.探讨3种血管重建方法的适应证、治疗效果、并发症及围手术期死亡率.结果 外科手术成功率97.4%(75/77),腔内治疗90.24%(74/82),杂交手术81.58%(31/38).随访2～112个月,平均随访46个月,随诊率71%(164/197).远期通畅率在主髂和股腘动脉中外科手术(57%和51%)高丁腔内治疗(48%和42%),但差异无统计学意义;远期通畅率在多节段病变和动脉狭窄并血栓形成中杂交手术(54%、26%、28%)明显高于其他方法(48%、23%).并发症在主髂和股腘动脉中外科手术(31%、12%)明显高于血管腔内治疗(31%、11%),在多节段病变(36%)明显高于腔内治疗和杂交手术(12%、15%).外科手术对于主髂和多节段动脉病变的围手术期死亡率分别为1.5%、2.0%,其他部位病变为0%;血管腔内治疗和杂交手术均为0%.结论 对于主髂和股腘动脉,外科于术是长段闭塞性病变、血管腔内治疗是短段非闭塞性病变的首选.杂交手术对多节段病变和动脉狭窄并血栓形成更具优势.对于膝下病变,血管腔内治疗能取得较好疗效,但远期通畅率不佳.     

下肢动脉硬化性闭塞症血管重建197例分析

目的 探讨传统外科手术、血管腔内治疗和杂交手术在下肢动脉硬化性闭塞症血管重建中的应用.方法 回顾性分析1998年1月至2008年12月接受血管重建手术的197例下肢动脉硬化性闭塞症患者临床资料,其中外科手术77例,血管腔内治疗82例,杂交手术38例.探讨3种血管重建方法的适应证、治疗效果、并发症及围手术期死亡率.结果 外科手术成功率97.4%(75/77),腔内治疗90.24%(74/82),杂交手术81.58%(31/38).随访2～112个月,平均随访46个月,随诊率71%(164/197).远期通畅率在主髂和股腘动脉中外科手术(57%和51%)高丁腔内治疗(48%和42%),但差异无统计学意义;远期通畅率在多节段病变和动脉狭窄并血栓形成中杂交手术(54%、26%、28%)明显高于其他方法(48%、23%).并发症在主髂和股腘动脉中外科手术(31%、12%)明显高于血管腔内治疗(31%、11%),在多节段病变(36%)明显高于腔内治疗和杂交手术(12%、15%).外科手术对于主髂和多节段动脉病变的围手术期死亡率分别为1.5%、2.0%,其他部位病变为0%;血管腔内治疗和杂交手术均为0%.结论 对于主髂和股腘动脉,外科于术是长段闭塞性病变、血管腔内治疗是短段非闭塞性病变的首选.杂交手术对多节段病变和动脉狭窄并血栓形成更具优势.对于膝下病变,血管腔内治疗能取得较好疗效,但远期通畅率不佳.     

下肢动脉硬化性闭塞症血管重建197例分析

目的 探讨传统外科手术、血管腔内治疗和杂交手术在下肢动脉硬化性闭塞症血管重建中的应用.方法 回顾性分析1998年1月至2008年12月接受血管重建手术的197例下肢动脉硬化性闭塞症患者临床资料,其中外科手术77例,血管腔内治疗82例,杂交手术38例.探讨3种血管重建方法的适应证、治疗效果、并发症及围手术期死亡率.结果 外科手术成功率97.4%(75/77),腔内治疗90.24%(74/82),杂交手术81.58%(31/38).随访2～112个月,平均随访46个月,随诊率71%(164/197).远期通畅率在主髂和股腘动脉中外科手术(57%和51%)高丁腔内治疗(48%和42%),但差异无统计学意义;远期通畅率在多节段病变和动脉狭窄并血栓形成中杂交手术(54%、26%、28%)明显高于其他方法(48%、23%).并发症在主髂和股腘动脉中外科手术(31%、12%)明显高于血管腔内治疗(31%、11%),在多节段病变(36%)明显高于腔内治疗和杂交手术(12%、15%).外科手术对于主髂和多节段动脉病变的围手术期死亡率分别为1.5%、2.0%,其他部位病变为0%;血管腔内治疗和杂交手术均为0%.结论 对于主髂和股腘动脉,外科于术是长段闭塞性病变、血管腔内治疗是短段非闭塞性病变的首选.杂交手术对多节段病变和动脉狭窄并血栓形成更具优势.对于膝下病变,血管腔内治疗能取得较好疗效,但远期通畅率不佳.     

下肢动脉硬化性闭塞症血管重建197例分析

目的 探讨传统外科手术、血管腔内治疗和杂交手术在下肢动脉硬化性闭塞症血管重建中的应用.方法 回顾性分析1998年1月至2008年12月接受血管重建手术的197例下肢动脉硬化性闭塞症患者临床资料,其中外科手术77例,血管腔内治疗82例,杂交手术38例.探讨3种血管重建方法的适应证、治疗效果、并发症及围手术期死亡率.结果 外科手术成功率97.4%(75/77),腔内治疗90.24%(74/82),杂交手术81.58%(31/38).随访2～112个月,平均随访46个月,随诊率71%(164/197).远期通畅率在主髂和股腘动脉中外科手术(57%和51%)高丁腔内治疗(48%和42%),但差异无统计学意义;远期通畅率在多节段病变和动脉狭窄并血栓形成中杂交手术(54%、26%、28%)明显高于其他方法(48%、23%).并发症在主髂和股腘动脉中外科手术(31%、12%)明显高于血管腔内治疗(31%、11%),在多节段病变(36%)明显高于腔内治疗和杂交手术(12%、15%).外科手术对于主髂和多节段动脉病变的围手术期死亡率分别为1.5%、2.0%,其他部位病变为0%;血管腔内治疗和杂交手术均为0%.结论 对于主髂和股腘动脉,外科于术是长段闭塞性病变、血管腔内治疗是短段非闭塞性病变的首选.杂交手术对多节段病变和动脉狭窄并血栓形成更具优势.对于膝下病变,血管腔内治疗能取得较好疗效,但远期通畅率不佳.     

下肢动脉硬化性闭塞症血管重建197例分析

目的 探讨传统外科手术、血管腔内治疗和杂交手术在下肢动脉硬化性闭塞症血管重建中的应用.方法 回顾性分析1998年1月至2008年12月接受血管重建手术的197例下肢动脉硬化性闭塞症患者临床资料,其中外科手术77例,血管腔内治疗82例,杂交手术38例.探讨3种血管重建方法的适应证、治疗效果、并发症及围手术期死亡率.结果 外科手术成功率97.4%(75/77),腔内治疗90.24%(74/82),杂交手术81.58%(31/38).随访2～112个月,平均随访46个月,随诊率71%(164/197).远期通畅率在主髂和股腘动脉中外科手术(57%和51%)高丁腔内治疗(48%和42%),但差异无统计学意义;远期通畅率在多节段病变和动脉狭窄并血栓形成中杂交手术(54%、26%、28%)明显高于其他方法(48%、23%).并发症在主髂和股腘动脉中外科手术(31%、12%)明显高于血管腔内治疗(31%、11%),在多节段病变(36%)明显高于腔内治疗和杂交手术(12%、15%).外科手术对于主髂和多节段动脉病变的围手术期死亡率分别为1.5%、2.0%,其他部位病变为0%;血管腔内治疗和杂交手术均为0%.结论 对于主髂和股腘动脉,外科于术是长段闭塞性病变、血管腔内治疗是短段非闭塞性病变的首选.杂交手术对多节段病变和动脉狭窄并血栓形成更具优势.对于膝下病变,血管腔内治疗能取得较好疗效,但远期通畅率不佳.     

Mycotic aneurysm after kidney transplantation

PURPOSE: The study aim was to report six cases of mycotic aneurysms in renal transplant patients and to review the literature on this subject. PATIENTS AND METHODS: Six patients, aged from 13 to 59 years, who had undergone renal transplantation 4 months to 16 years earlier, developed a mycotic aneurysm after bacteremia. The diagnosis was based on morphological investigations (echotomography, arteriography, spiral computed tomography) and bacteriological studies (blood culture, culture of the aneurysmal wall and content). The aneurysm was located in five cases at the anastomosis of the renal artery with the iliac axis, and in one case on the popliteal artery and tibioperoneal trunk. All patients were treated surgically: five reconstructions were performed using two arterial iliac prostheses, three hypogastric artery autografts and one saphenous vein graft (combined with an iliac prosthesis); one repair was impossible because of profuse local suppuration, and endoaneurysmorraphy with multiple ligatures of the popliteal vessels was performed. Postoperative radiological control was performed in all cases of arterial repair. All patients received antibiotic therapy during three to six months after the operation. RESULTS: No postoperative mortality occurred. All kidney transplants were salvaged. Anatomical results of arterial reconstructions were satisfactory in all cases and remained so during the follow-up. CONCLUSIONS: Mycotic aneurysms after renal transplantation are rare since only six observations with a kidney transplant in place have been published in the literature with a single long-lasting kidney salvage. Surgical treatment is mandatory to prevent rupture. Survival of patients occurred exclusively in operated cases.     

Techniques for preserving vertebral artery perfusion during thoracic aortic stent grafting requiring aortic arch landing.

Thoracic endografting offers many advantages over open repair. However, delivery of the device can be difficult and may necessitate adjunctive procedures. We describe our techniques for preserving perfusion to the left subclavian artery despite endograft coverage to obtain a proximal seal zone. We reviewed our experience with the Talent thoracic stent graft (Medtronic, Santa Rosa, CA). From 1999 to 2003, 49 patients received this device (29 men, 20 women). Seventeen patients required adjunctive procedures to facilitate proximal graft placement. We performed left subclavian-to-left common carotid artery transposition (6), left common carotid-to-left subclavian artery bypass with ligation proximal to the vertebral artery (7), and left common carotid-to-left subclavian artery bypass with proximal coil embolization (4). Patients who had anatomy unfavorable to transposition or bypass with proximal ligation (large aneurysms or proximal vertebral artery origin) were treated with coil embolization of the proximal left subclavian artery in order to prevent subsequent type II endoleaks. Technical success rate of the carotid subclavian bypass was 100%. Patient follow-up ranged from 3 to 48 months with a mean of 12 months. Six patients had follow-up <6 months owing to recent graft placement. Primary patency was 100%. No neurologic events occurred during the procedure or upon follow-up. One patient had a transient chyle leak that spontaneously resolved in 24 hours. Another patient had a phrenic nerve paresis that resolved after 3 weeks. We believe that it is important to maintain patency of the vertebral artery specifically when a patent right vertebral system and an intact basilar artery is not demonstrated. Furthermore, we describe a novel technique of coil embolization of the proximal left subclavian artery in conjunction with left common carotid-to-left subclavian artery bypass. This circumvents the need for potentially hazardous mediastinal dissection and ligation of the proximal left subclavian artery in cases of large proximal aneurysms or unfavorable vertebral artery anatomy.     

Ancillary techniques to facilitate endovascular repair of aortic aneurysms.

PURPOSE: The ability to treat abdominal aortoiliac aneurysms and thoracic aortic aneurysms may be limited by coexisting arterial disease. Device deployment may be impaired by occlusive disease and tortuosity of the arteries used to access the aneurysm or by suitability of the implantation sites. In this study we describe the auxiliary procedures performed to circumvent these obstacles and thereby enable endovascular aneurysm repair. PATIENTS AND METHODS: Between January 1, 1993, and December 31, 1999, 390 patients treated for aneurysm of the aorta with endovascular devices were entered prospectively in a vascular registry. Fifty (12%) of the 390 patients required adjunctive surgical techniques to (1) create or extend the length of the proximal or distal device implantation site or (2) permit device navigation through diseased iliac arteries. Auxiliary techniques used to extend or enhance implantation sites were elephant trunk graft (n = 2), the construction of renovisceral bypass grafts (n = 1), and subclavian artery transposition (n = 2). Plication of the common iliac artery at its bifurcation was performed in conjunction with femorofemoral bypass graft in nine patients to allow preservation of pelvic circulation by avoiding internal iliac artery sacrifice. Construction of a bypass graft to transpose the internal iliac artery orifice was performed in one patient. The auxiliary techniques used to facilitate device navigation were iliac artery angioplasty or stenting (n = 8), external iliac artery endovascular endarterectomy or straightening (n = 14), endoluminal iliofemoral bypass conduit (n = 5), and the construction of an open iliofemoral bypass conduit (n = 8). RESULTS: Successful deployment of the endovascular devices was achieved in 49 (98%) of 50 patients. Auxiliary techniques were successful in providing access for endovascular device deployment in all 35 patients (100%). Mean follow-up for techniques to facilitate device navigation is 26 months for endovascular procedures and 42 months for the open bypass graft construction patients; no occlusions were observed at this moment. There were five patients with incisional hematomas that did not necessitate intervention. Fourteen (94%) of 15 patients underwent successful device implantation after the auxiliary maneuvers to enhance implantation site. Mean follow-up for implantation site manipulation is 28 months. One of the subclavian transpositions had a new onset of Horner's syndrome, two of nine patients who had common iliac artery ligated had retroperitoneal hematomas that did not necessitate interventions, and no colon ischemia was seen. The patient who underwent nonanatomic bypass grafting of viscero-renal arteries had a retroperitoneal hematoma that necessitated reexploration. CONCLUSIONS: Significant coexisting arterial disease may be encountered in patients with aortic or iliac aneurysms. Identification of coexisting arterial diseases is essential to help tailor the appropriate supplemental surgical procedure to allow the performance of endovascular aneurysm repair in patients who would otherwise require open surgical repair.     

Initial experience with transluminally placed endovascular grafts for the treatment of complex vascular lesions.

OBJECTIVES: Complex arterial occlusive, traumatic, and aneurysmal lesions may be difficult or impossible to treat successfully by standard surgical techniques when severe medical or surgical comorbidities exist. The authors describe a single center's experience over a 2 1/2-year period with 96 endovascular graft procedures performed to treat 100 arterial lesions in 92 patients. PATIENTS AND METHODS: Thirty-three patients had 36 large aortic and/or peripheral artery aneurysms, 48 had 53 multilevel limb-threatening aortoiliac and/or femoropopliteal occlusive lesions, and 11 had traumatic arterial injuries (false aneurysms and arteriovenous fistulas). Endovascular grafts were placed through remote arteriotomies under local (16[17%]), epidural (42[43%]), or general (38[40%]) anesthesia. RESULTS: Technical and clinical successes were achieved in 91% of the patients with aneurysms, 91% with occlusive lesions, and 100% with traumatic arterial lesions. These patients and grafts have been followed from 1 to 30 months (mean, 13 months). The primary and secondary patency rates at 18 months for aortoiliac occlusions were 77% and 95%, respectively. The 18-month limb salvage rate was 98%. Immediately after aortic aneurysm exclusion, a total of 6 (33%) perigraft channels were detected; 3 of these closed within 8 weeks. Endovascular stented graft procedures were associated with a 10% major and a 14% minor complication rate. The overall 30-day mortality rate for this entire series was 6%. CONCLUSIONS: This initial experience with endovascular graft repair of complex arterial lesions justifies further use and careful evaluation of this technique for major arterial reconstruction.     

Idiopathic true brachial artery aneurysm in a nine-month infant

Upper extremity peripheral artery aneurysms are a rarely encountered arterial disorder. Brachial artery aneurysms seen in the pediatric age group are generally trauma resultant. A nine-month-old male infant patient presented with complaints of an asymptomatic mass in the arm. Following Doppler ultrasonography and magnetic resonance imaging (MRI) examinations, saccular aneurysm, originating from the left brachial artery was diagnosed in the patient without history of trauma. The aneurysm was resected by surgical intervention, and primary repair of the brachial artery was performed by end-to-end anastomosis. No complication was observed during the follow-up. Surgical intervention for upper extremity aneurysms should be initiated without delay in order to prevent extremity ischemia and amputation.     

覆膜支架在周围动脉血管损伤救治中的应用

目的 探讨应用覆膜支架腔内隔绝技术治疗周围动脉血管损伤的方法和经验.方法 共收集20例患者资料,开放性损伤13例,闭合性损伤7例.其中,尖锐物穿通伤8例,顿挫伤导致动脉闭塞5例,创伤后假性动脉瘤形成3例,医源性动脉损伤4例.动脉管壁损伤较轻者直接使用覆膜支架进行腔内隔绝治疗;针对管壁破损严重、断裂或血管内膜严重挫伤闭塞者则多采用顺、逆行途径相结合的方法开通血管后成功实施腔内重建.结果 手术成功率100％,无肢体丧失和围手术期死亡.所有患者随访3～24个月,平均12.8个月.上肢动脉损伤者术后彩色多普勒检查显示患肢血循环良好,患侧与健侧上肢血压差小于10％,下肢血管损伤患者患侧ABI由术前平均0.37±0.16提高至术后0.96±0.08.仅2例患者术后随访CT血管造影发现支架两端存在轻度狭窄.结论 覆膜支架腔内隔绝技术治疗周围动脉损伤,安全、微创、并发症少、效果满意,是一种可靠的治疗方法.     

颅内外动脉狭窄合并颅内动脉瘤同期血管内治疗的效果分析

目的探讨同期治疗颅内外动脉狭窄合并颅内动脉瘤的策略及临床效果。方法回顾性分析2013年4月至2018年9月于北京大学第一医院神经外科行同期血管内治疗的15例颅内外动脉狭窄合并颅内动脉瘤患者的临床资料。男性6例,女性9例,年龄(63.9±9.1)岁(范围:43~79岁);动脉狭窄部位共15处,狭窄程度为75%~95%,其中前循环8处,后循环7处;动脉瘤共17个,最大径(5.3±1.2)mm(范围:3~7 mm),其中前循环动脉瘤11个、后循环动脉瘤6个。患者均行同期动脉狭窄支架成形及动脉瘤栓塞术治疗。记录患者围手术期及术后临床症状、影像学资料及并发症情况。结果15处动脉狭窄均成功置入支架(残余狭窄<30%);17个动脉瘤中,10个行单纯弹簧圈栓塞,7个行支架辅助弹簧圈栓塞,均完全栓塞。围手术期1例患者出现轻微脑梗死症状,其余未发生手术相关并发症。术后随访(43.8±8.2)个月(范围:24~85个月),患者术后6~12个月均复查数字减影血管造影,其中2例出现无症状性支架内再狭窄,所有动脉瘤未见复发。截至末次随访时,患者均未出现颅内出血、缺血性卒中等相关症状。结论颅内外动脉狭窄合并颅内动脉瘤应根据血管狭窄的部位、程度及动脉瘤的大小、形态、位置、数量及两者的位置关系等因素综合分析,制定个体化的治疗策略,给予同期血管内治疗可能是一种安全、有效的治疗方法。     

Endovascular exclusion of popliteal artery aneurysms with expanded polytetrafluoroethylene stent-grafts: early results

There is increasing interest in using endovascular methods instead of surgical reconstruction to treat popliteal artery aneurysms. Exclusive use of the Viabahn stent-graft, a nitinol stent covered with expanded polytetrafluoroethylene, was assessed in the treatment of patients who presented with popliteal artery aneurysms in the absence of acute limb ischemia. Technical success, endoleaks, graft patency, freedom from amputation, and aneurysm sac flow and size changes were assessed by duplex ultrasound. From June 2004 to March 2006, 16 men (mean age, 76 years; range, 65-83) underwent endovascular exclusion of 23 popliteal artery aneurysms (mean diameter, 2.5 cm; range, 1.3-6.7 cm). Nine lesions had partial thrombus on preprocedural duplex imaging. Nineteen of the 23 limbs treated had at least 2-vessel tibial artery runoff. Procedures were performed under local anesthesia using ipsilateral percutaneous antegrade arterial access. All patients received 75 mg/day of clopidogrel afterward. Follow-up assessments included direct clinical examinations and duplex ultrasonography performed 1, 3, 6, and 12 months after the procedure. Primary patency and amputation-free survival were calculated using Kaplan-Meier analysis. Complete aneurysm exclusion (technical success) was achieved in all cases. During the mean follow-up of 7 months (range, 1-21 months), 22 of 23 treated limbs remained asymptomatic. One stent-graft thrombosis occurred 6 months after the procedure and was successfully treated with percutaneous mechanical thrombectomy, balloon angioplasty of a stent-graft stenosis, and insertion of an uncovered nitinol stent. No popliteal artery aneurysm sac size enlargements or endoleaks were detected. At 12 months, the treated limb mean ankle-brachial index was 1.0 (range, 0.82-1.31) and the primary and secondary patency rates were 93% and 100%, respectively. Early results with Viabahn endovascular stent-graft exclusion of asymptomatic popliteal artery aneurysms are promising. Patient selection for endovascular repair depends on suitable popliteal artery anatomy, extent of aneurysmal degeneration, and quality of tibial arterial runoff.     

Endoluminal repair of aneurysms associated with coarctation

BACKGROUND: Late aneurysm formation is a well-recognized complication of surgery for aortic coarctation. Open surgery to repair these aneurysms is associated with significant morbidity and mortality. Endoluminal repair is an attractive alternative to open surgery. METHODS: Data were collected prospectively on consecutive patients who presented with aneurysms associated with coarctation RESULTS: Between June 1999 and October 2001, 5 patients underwent elective endoluminal repair for coarctation aneurysms. All procedures were technically successful and no patients died. Four patients previously had open surgery to repair aortic coarctation, and 1 presented with an aneurysm associated with a previously unrecognized coarctation. The median follow-up was 7 months (range, 3 to 29 months), and to date, all aneurysms remain excluded. CONCLUSIONS: Endoluminal repair is a promising alternative to redo open surgery for thoracic aneurysms associated with previous surgery for aortic coarctation. Long-term follow-up is required to assess the durability of the stent grafts.     

Endografting of the thoracic aorta:

BACKGROUND: Thoracic aortic dissections, ruptures, fistulae, and aneurysms pose a unique surgical challenge. Traditional repair of thoracic aortic aneurysms involves thoracotomy with graft interposition. Despite advances in perioperative care and both total and partial cardiopulmonary bypass, conventional surgery carries a significant morbidity and mortality. Principal complications include bleeding, paraplegia, stroke, cardiac events, pulmonary insufficiency, and renal failure. Recent enthusiasm for innovative endovascular therapies to treat aortic disease has spurred many centers to investigate endoluminal grafting of the thoracic aorta. Early reports on endovascular repair using custom made "first generation devices" demonstrated the technique to be feasible with a mortality and morbidity comparable to open repair. METHODS AND RESULTS: From February 2000 to February 2001, endovascular stent graft repair of the thoracic aorta was performed in 46 patients (mean age 70; 29 male and 17 female) using the Gore Excluder. Twenty-three patients (50%) had atherosclerotic aneurysms, fourteen patients (30%) had dissections, three patients (7%) had aortobronochial fistulas, three patients (7%) had pseudoaneurysms, two patients (4%) had traumatic ruptures, and one patient (2%) had a ruptured aortic ulcer. Patient characteristics, procedural variables, outcomes, and complications were recorded. All patients were followed with chest CT scans at 1, 3, 6, and 12 months. Mean follow up was 9 months ranging from 1 to 15 months. All procedures were technically successful. There were no conversions. Average duration of the procedure was 120 minutes. Average length of stay was 6 days, but most patients left the hospital within 4 days (64%) after endoluminal grafting. Overall morbidity was 23%. Two patients (4%) had endoleaks that required a second procedure for successful repair. Two patients (4%) died in the immediate postoperative period. There were no cases of paraplegia. At follow-up, one patient had an endoleak found the day after the procedure and another patient had an endoleak 6 moths post procedure. Both were treated successfully with additional stent grafts. There were no cases of migration. One patient died of a myocardial infarction 6 months after graft placement. The Gore Excluder device was voluntarily recalled on February 26, 2001. Therefore, from June 2000 to January 2001, 37 patients underwent endovascular stent graft repair of the thoracic aorta for various disease entities using our customized thoracic graft (Endomed). Twenty-seven patients (73%) had aneurysms, six (16%) had dissections, two (5%) had pseudoaneurysms, one (2%) had a traumatic transection, and one patient (2%) had an embolizing ulcer. Patients were followed with CT scans at 1, 3, 6, and 12 months. All procedures were technically successful. There were no conversions. The average age was 68 years.(17-87). And the male and female ratio was 24/13. One patient died in the operating room from iliac rupture and one died from embolization/stroke in the immediate postoperative period. Two patients died within 30 days from comorbid factors. The total 30-day mortality was 10%. Two patients had endoleaks. One returned to the operating room and needed an additional cuff. The other had a small leak in a proximal dissection that is being followed. There were no cases of paraplegia. CONCLUSION: Thoracic endoluminal grafting is a safe and feasible alternative to open graft repair and can be performed successfully with good results. Early data suggest that an endoluminal approach to these disease entities maybe favorable to open resection and graft replacement. Technical details of Endoluminal stent grafting of the thoracic aorta for different disease entities have been discussed at length.