髂内动脉在肾移植术后髂外动脉出血中的应用

目的:探讨肾移植术后感染性外动脉移植肾动脉吻合口出血的处理。方法:采用自体髂内动脉片或段修补、串接治疗髂外动脉吻合口大出血。结果:修复后的髂外动脉血流通畅,患侧下肢血供良好。结论:感染性移植肾动脉髂外动脉吻合口出血为肾移植术后严重并发症,单纯缝扎止血常难以奏效,与其他方法比较,自体髂内动脉片或段修补、串接修补缺损的髂外动脉操作简单,效果非常满意。     

大隐静脉逆转代替髂外动脉治疗肾移植术后血管并发症(附2例报告)

目的探讨肾移植术后血管并发症的处理及在紧急状态下替代血管治疗的应用。方法中南大学湘雅三医院移植中心于2009年12月至2012年3月收治了两例肾移植术后反复髂外动脉出血的患者。两例手术探查出血为原髂外动脉吻合口处有破溃,给予切除移植动脉吻合口处的髂外动脉,取同侧自体下肢的大隐静脉逆转替代切除的髂外动脉。结果两例患者术后均恢复良好,下肢血运正常,行走自如,其中1例患者存活至今达4年,术后未再次出血;另1例患者手术后已愈1年余,下肢血运正常。结论肾移植术后反复髂外动脉破裂出血是导致患者死亡的严重并发症之一,紧急处理非常重要,采用自体血管重建不失为一种较有效和便捷的处理方法。     

选择髂内或髂外动脉吻合对移植肾的影响

目的 探讨肾移植动脉重建选择髂外或髂内动脉时移植肾血流参数、肾脏功能和血管并发症的差异。方法 135例初次肾移植患者随机分为2组，2组患者平均年龄、HLA错配数目、淋巴细胞毒试验、冷／热缺血时间差异均无统计学意义（P〉0．05），术后免疫抑制剂应用方案相同。应用髂外动脉端侧吻合66例，髂内动脉端端吻合69例。随访3个月，比较2组患者肾脏功能、彩色多普勒肾脏血流参数和血管并发症发生率。结果 髂内动脉、髂外动脉组2组患者术后3个月时肾功能监测指标（Cr：118．41 vs123．68μmol／L），移植肾主肾动脉、段动脉、大叶间动脉血流及阻力指数差异无统计学意义（P〉0．05）。结论 肾移植动脉重建选择髂内外动脉对移植肾功能及血液流变学无明显影响，动脉选择应根据患者具体情况决定。     

糖尿病性肾病合并髂动脉严重硬化患者的肾移植手术处理

目的 探讨糖尿病肾病合并髂动脉严重硬化患的肾移植手术技巧。方法 15例糖尿病肾病合并髂动脉严重硬化的肾移植患，8例次清除髂内动脉内膜硬化斑块后，由钛轮钉端端吻合动脉；10例次剥离髂总或髂外动脉硬化内膜，与肾动脉端侧吻合。结果 术后心跳骤停死亡1例；1例病人连续3次发生移植肾血流灌注不足导致的移植肾原发性无功能，第4次肾移植肾功能良好；其余13例病人首次移植术后肾功能良好。结论 严重动脉硬化患的动脉吻合困难，为保证移植肾有足够的血流灌注，应根据病人的不同情况选择吻合血管，并行硬化内膜切除术。     

糖尿病髂动脉硬化患者肾移植术51例报告

目的探讨糖尿病髂动脉硬化患者的肾移植手术特点。方法51例糖尿病合并髂动脉硬化的肾移植受者共行肾移植术54例次。其中肾动脉与髂外动脉直接端侧吻合13例次；切除硬化内膜，肾动脉与髂总／髂外动脉端侧吻合19例次；切除硬化内膜，肾动脉与髂内动脉钛环钉法端端吻合22例次。结果发生移植肾血流灌注不足致移植肾原发性无功能3例次，发生移植肾功能延迟恢复9例次（17．6％），其余42例次移植肾功能恢复良好。围手术期死亡2例（均为心跳骤停）。随访11—70个月，1年人／肾存活率为89．8％／87．8％，3年存活率为84．4％／81．3％。结论糖尿病髂动脉硬化患者移植肾动脉吻合困难，为保证移植肾有充足的血流灌注，应根据患者的不同情况选择吻合血管，并行硬化动脉内膜切除术。合并冠心病的患者肾移植术前应先行心肌再血管化手术。     

肾移植术中采用供肾动脉与髂外动脉吻合的体会

对２７例髂内动脉有严重动脉粥样硬化的肾移植受者实施供肾动脉与受者髂外动脉端侧吻合术，术后除有３例患者因环孢素用量过大使移植肾功能恢复略延迟外，其它２４例患者均于术后４天内肾功能恢复正常，且无一例外科并发症。认为该术式可作为髂内动脉情况异常的一种弥补方法，但不宜作为常规术式。     

探讨肾动脉多支畸形的供肾在体外血管重建中的方式及在肾移植中的应用

目的探讨。肾动脉多支畸形的供。肾在体外血管重建中的方式及其在肾移植中的应用。方法对5例肾动脉多支畸形供肾的修整采取截取受者同侧髂内动脉的方法，依据供肾动脉的分支数而保留髂内动脉的分支数；在体外将供肾动脉各分支与髂内动脉大分支的开口进行端端吻合，然后将髂内动脉主干与受者髂外动脉行端侧吻合。将肾动脉重建后的供肾应用于双侧肾动脉瘤患者的自体肾移植术1例、亲属活体供肾肾移植术3例和尸体肾移植术1例。结果术后5例受者均未发生外科并发症。1例术后发生短暂的急性。肾小管坏死，但48h后进人多尿期，肾功能恢复顺利。术后随访10-36个月，受者移植。肾功能全部正常，肾动脉及分支未发生血栓或闭塞。结论采用受者的髂内动脉体外重建供。肾动脉的方法，可有效修复肾动脉3支以上以及。肾动脉过短的供肾，是一种安全可行的血管重建的方法，血管并发症较低，可有效应用于肾移植。     

腹膜后肉瘤联合大段髂外动脉切除后与髂内动脉吻合重建可行性分析

目的 探讨腹膜后肉瘤联合大段髂外动脉切除后与同侧或对侧髂内动脉进行吻合的可行性与安全性。方法 回顾性分析2017年1月至2019年9月北京大学肿瘤医院软组织与腹膜后肿瘤中心收治的5例腹膜后肉瘤联合大段（5~8 cm）髂外动脉切除病例的临床资料,均未使用人工血管,而采用与同侧或对侧髂内动脉进行吻合重建。 结果 5例病人均完整切除肿瘤,手术时间为380～540 min,术中出血600～4000 mL。术后病理学检查示,平滑肌肉瘤2例,去分化脂肪肉瘤1例,多形性脂肪肉瘤1例,多形性未分化肉瘤1例。肿瘤最大径为15～23 cm,均为R0切除。无腹腔感染、腹腔出血、消化道或泌尿道瘘等术后并发症。术后1周增强CT检查示动脉吻合通畅,术后住院时间为10～20 d,无围手术期死亡。随访33（12~45）个月,重建动脉均保持通畅,无复发和死亡病例。结论 腹膜后肉瘤联合大段髂外动脉切除后可选择与同侧或对侧髂内动脉进行吻合重建,安全可行。     

腹腔镜下左髂总动脉-股动脉人工血管旁路移植治疗髂外动脉闭塞症一例

目的总结腹腔镜下人工血管旁路移植治疗髂外动脉闭塞症的手术技巧和临床效果。方法 2011年12月,收治1例57岁髂外动脉硬化闭塞症男性患者。患者双下肢间歇性跛行;下肢动脉造影示左髂外动脉闭塞,右髂总动脉狭窄;心电图示窦性心律,完全性右束支传导阻滞,ST段改变;踝肱指数(ankle brachial index,ABI):左侧0.59,右侧0.54。于全麻下行腹腔镜下左髂总动脉-股动脉人工血管旁路移植术。结果术后人工血管通畅,吻合口无漏血,患者跛行症状明显改善。术后1周左侧ABI增加至1.09;术后1个月血管造影显示血管通畅。结论腹腔镜下主-髂动脉重建既保留开腹动脉旁路移植效果好的特点,又具有腔内支架成形创伤小、术后恢复快的优点。     

移植肾动脉瘤五例报告

目的 探讨移植肾动脉瘤(RAA)的病因、诊断及治疗. 方法 1998年8月至2004年12月共行同种异体肾移植手术1251例,发生RAA 5例(0.4%).5例均为男性,平均年龄43岁,移植肾血管吻合方式均为移植肾动脉一髂内动脉端端吻合.患者主要临床表现为进行性肾功能减退,突发少尿或无尿,顽固性高血压及肾区疼痛,均经彩色多普勒超声、数字减影血管造影检查确诊为动脉瘤,动脉瘤大小1.8 cm×2.0 cm×2.0 cm～4.0 cm×4.0 cm×5.0 cm. 结果 移植肾动脉吻合口动脉瘤2例,1例发现动脉瘤后1个月内移植肾功能丧失,行移植肾切除术,术后规律透析治疗,随访1年后行二次肾移植;1例移植肾失功后1周内行对侧髂窝二次肾移植手术,保留原移植肾,术后随访2年肾功能正常.RAA合并近端移植肾动脉狭窄2例,1例行吻合口球囊扩张并放置支架后,以弹簧螺圈栓塞动脉瘤,术后随访1年肾功能稳定;1例行移植肾切除、二次.肾移植术,术后随访3年肾功能正常.吻合口髂内动脉侧粥样硬化斑块导致髂内动脉狭窄、移植肾动脉侧动脉瘤1例,行移植肾切除术,术后2 d因脑干栓塞死亡. 结论 移植肾动脉-髂内动脉端端吻合易诱发血管并发症,RAA治疗应谨慎采用开放手术切除,可选择近期行二次肾移植和血管内介入治疗.     

Hypogastric artery autograft treating hemorrhage with infection of external iliac artery secondary to renal transplantation

Massive hemorrhage from infected anastomosed site between the graft artery and the external iliac artery is one of the most serious complications of renal transplantation. Clinically, it is a rare but fatal occasion. We reported here one case of hemorrhage with infection in the iliac artery anastomosed site treated successfully with hypogastric artery autograft interposition in March 2003.     

Use of an autogenous hypogastric artery patch graft for living related donor kidneys with multiple renal arteries.

A kidney with triple renal arteries was removed from an HLA identical donor and transplanted to her brother using the donor hypogastric artery as an autogenous graft. The kidney was preserved by hypothermic, hyperkalemic, hyperosmolar washout solution while the three separate renal artery-hypogastric artery autograft anastomoses were being performed in an ex vivo position. Subsequently, the end to side autogenous hypogastric artery patch graft to external iliac artery anastomosis was completed. Prompt renal function occurred and after 18 months the serum creatinine level remained unchanged.     

Renal artery aneurysm secondary to Candida albicans in four kidney allograft recipients

INTRODUCTION: Infection is a frequent cause of morbidity and mortality in solid organ transplant recipients. It may occur at different periods after transplantation. We report four cases of mycotic aneurysms due to Candida albicans (CA) in renal transplant recipients occurring early after kidney transplantation. CASE REPORTS: Four patients (three men, one woman) aged from 24 to 55 years who underwent cadaveric renal transplantation from three different donors developed a mycotic aneurysm at 9 to 90 days after transplantation. In all cases aneurysms were located at the anastomosis between the renal graft artery and the iliac axis. The clinical presentations were fever in three cases, including endocarditis in one patient or deterioration of graft function in two cases and hemorrhagic shock secondary to a ruptured renal artery in the fourth case, which led to death. The arterial aneurysm was discovered at autopsy. The diagnosis of a mycotic aneurysm was based on morphological investigations: echotomography, spiral computed tomography, and arteriography. In all cases bacteriological studies (blood culture, culture of the aneurysmal wall and content) isolated CA. In three patients CA was isolated from the preservation solution; it was of the same phenotype as the one isolated from the aneurysm in one recipient. Antifungal therapy was started in patients who lived, but all kidney transplants had to be removed. Anatomical results of arterial reconstructions were satisfactory in all cases and remained so during the follow-up. CONCLUSION: The insidious presentation and clinical course of mycotic aneurysms due to CA require a high degree of suspicion to make the correct diagnosis.     

Two Laparotomy Surgeries to Achieve Hemostasis After Kidney Transplantation in a Patient With Frailty: A Case Report

BackgroundThe assessment of frailty before and after kidney transplantation is becoming more important in the aging population. It is recommended to recognize the post-transplant risks and establish a treatment strategy. We report the case of a patient who underwent 2 laparotomy hemostasis procedures due to frailty after kidney transplantation.Case ReportA 72-year-old woman presented with end-stage renal failure due to an unknown primary disease. She was also found to be frail when assessed using the physical frailty phenotype. She underwent ABO-incompatible kidney transplantation from her husband at the end of March 2020. On the first postoperative day, re-operation for hematoma evacuation was performed. The bleeding point could not be identified at that time. Progression of anemia was observed on the sixth postoperative day, and computed tomography showed no obvious bleeding. Subsequently, the renal allograft started functioning immediately, without rejection. However, emergency laparotomy for hematoma removal was performed on the 22nd postoperative day. Bleeding had occurred from the anastomotic region of the renal allograft artery and the external iliac artery. Her serum creatinine levels and renal function remained stable one month after surgery.ConclusionsWe encountered a case of living-donor kidney transplantation in a frail older woman who underwent 2 laparotomies due to hemorrhage. Perioperative risk management is necessary for patients with a high risk of postoperative bleeding. To ensure a good outcome, preoperative and postoperative rehabilitation is important for patients with frailty.     

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.     

Mycotic Pseudoaneurysm After Kidney Transplantation: Two Case Reports

Background

Vascular complications after kidney transplantation may cause allograft loss. Here, we describe 2 patients with extrarenal mycotic pseudoaneurysm after kidney transplantation.

Trapping and revascularization for a dissecting aneurysm of the proximal posteroinferior cerebellar artery: technical case report and review of the literature

OBJECTIVE AND IMPORTANCE: Subarachnoid hemorrhage caused by an isolated dissection of the proximal portion of the posteroinferior cerebellar artery (PICA) is a rare problem. The optimal treatment to use for patients presenting with this clinical scenario varies and therefore is controversial in the literature. We report a patient in whom this problem was treated effectively with trapping of the diseased segment and revascularization of the PICA. We report this case to review this rare topic and to present our perspective on the indications for and the effectiveness of trapping and revascularization for proximal PICA dissections that cause hemorrhage. CLINICAL PRESENTATION: A 55-year-old man was transferred to our institution and admitted for Hunt and Hess Grade IV subarachnoid hemorrhage, which improved to Hunt and Hess Grade III after ventricular drainage. Imaging revealed the source of the hemorrhage to be a pseudoaneurysm related to the dissection of the proximal portion of the PICA. INTERVENTION: Three days after the initial bleeding episode, we operated on the patient. After the occipital artery was prepared for bypass, the diseased segment was trapped. The occipital artery-to-PICA anastomosis was then immediately performed distal to the trapped segment. CONCLUSION: On the basis of our experience, the literature regarding this topic, and the anatomy of the perforators of the PICA, we think that the best treatment for a pseudoaneurysm located within the first three segments of the PICA is trapping of the diseased segment followed by revascularization distal to the trapped segment. This approach should prevent rehemorrhage and should avoid iatrogenic ischemic complications of the brainstem.     

腹腔镜下双侧髂内动脉结扎骶前分离后路切除骶骨肿瘤的初步探讨

目的探讨腹腔镜下双侧髂内动脉结扎、瘤体前方组织分离、裸化后进行骶骨肿瘤切除的价值和意义。方法回顾性分析21例骶骨肿瘤患者行腹腔镜下双侧髂内动脉结扎、骶骨肿瘤前方组织分离后瘤体切除的临床资料。结果骶骨肿瘤均被顺利切除,术中出血500—1900ml,平均800ml。所有患者均获得3—25个月的随访,平均随访时间11个月。其中1例患者术后2个月复发（为尤文肉瘤,术后拒绝行放、化疗）,1例转移性骶骨肿瘤于术后9个月死于脑转移,其余未出现复发。结论腹腔镜下双侧髂内动脉结扎、瘤体前方组织分离后行骶骨肿瘤切除,不仅可明显减少手术出血及瘤体切除的难度,而且手术创伤小,是一种有效的手术方法。