Vascular surgery is a challenging discipline and complex aneurysms can present an entire range of technical difficulties. To overcome these problems good technical skills are mandatory. However, it is also worth remembering a few basic rules:? The simplest solution is often the best.? All cases need careful planning, including that of the approach? A successful anastomosis requires good aortic tissue? Minimal dissection reduces morbidity. 相似文献
Aortic valve sparing operations were developed to preserve the aortic valve in patients with ascending aortic aneurysm and aortic insufficiency or patients with aortic root aneurysm. There are 2 types of aortic valve sparing operations, remodeling of the aortic root and reimplantation of the aortic valve. The author believes that remodeling of the aortic root is more appropriate for older patients with ascending aortic aneurysm, dilated aortic sinuses, and normal aortic annulus, whereas reimplantation of the aortic valve is more appropriate for young patients with aortic root aneurysm in whom dilation of the aortic annulus is commonly associated. Although remodeling of the aortic root has been extensively used in patients with aortic root aneurysm, the long-term results are somewhat inferior to reimplantation in most series. The late results of aortic valve sparing operations have been excellent, and these operations have become an important addition to the surgical armamentarium to treat patients with proximal aortic aneurysms. 相似文献
Objectives. Type 2 diabetes mellitus has been linked to a decreased risk for abdominal aortic aneurysm (aortic diameter ≥30?mm, AAA) development in men. The aim of this study was to evaluate if such an effect is detectable already around the time of diabetes diagnosis. Design. We cross-sectionally compared aortic diameter at ultrasound screening for AAA in 691 men aged 65 years with incipient or newly diagnosed type 2 diabetes (group A) with 18,262 65-year old control men without diabetes (group B). Results. Aortic diameter did not differ between groups (18.8[17.4–20.8] vs. 19.0[17.5–28.7] mm; p?=?0.43). AAA prevalence was 2.5% in group A and 1.5% in group B (p?=?.010). In logistic regression taking group differences in body mass index (BMI), smoking, presence of atherosclerotic disease and hypertension into account, the difference in AAA prevalence was no longer significant (p?=?.15). Among men in group A, C-peptide (r?=?.093; p?=?.034), but not HbA1c (r?=?.060; p?=?.24) correlated with aortic diameter. Conclusion. Among 65 year old men aortic diameter and AAA prevalence do not differ between those with newly diagnosed type 2 diabetes and those without diabetes. Putative protective effects of type 2 diabetes mellitus against aortic dilatation and AAA development therefore probably occur later after diagnosis of diabetes. 相似文献
Background. The decision whether or not to recommend resection of moderately large descending thoracic and thoracoabdominal aneurysms requires weighing the relatively high mortality and significant risk of paraplegia associated with operation against the likelihood that the aneurysm will rupture spontaneously, with an almost invariably fatal outcome. To better define the risk of aneurysm rupture, we undertook a prospective study of patients who had not had operation on their moderately large descending thoracic and thoracoabdominal aneurysms.
Methods. Patients were enrolled at the time of their second computed tomographic scans: three-dimensional computer-generated reconstructions allowed determination of several dimensional parameters for each study, including diameters and cross-sectional areas at the site of maximal dilatation in the descending aorta and in the abdomen as well as total thoracoabdominal surface area. Comparisons of serial studies permitted calculation of yearly rates of change in these dimensions.
Results. Of 114 patients, 8 died of causes unrelated to the aneurysm, 26 died of rupture, 20 met previously determined criteria for operation, and 60 survived without operation or rupture. Multivariate regression analysis identified maximal diameter in the descending and in the abdominal aorta as independent risk factors for rupture, as well as older age, the presence of even uncharacteristic pain, and a history of chronic obstructive pulmonary disease. A piecewise exponential model enabled construction of an equation allowing calculation of rate of rupture in patients in whom the values of the risk factors are known, and also of the probability of rupture in a given individual over a specified time interval.
Conclusions. Because using this equation--based on easily determined risk factors (age, pain, chronic obstructive pulmonary disease, maximal thoracic and maximal abdominal aortic diameter)--allows the risk of aneurysm rupture within a given interval to be estimated fairly accurately for each individual patient, it is our current practice to recommend operation when the calculated risk of rupture within 1 year exceeds the anticipated mortality of elective operation, rather than relying on general operative guidelines based almost exclusively on aneurysm size. 相似文献
Background: Conventional surgical repair of the aortic arch using cardiopulmonary bypass and deep hypothermic circulatory arrest still carries a substantial rate of mortality and morbidity especially myocardial injury, and predicts a high incidence of permanent neurological injury.Endovascular stent-graft placement has been developed as an effective treatment modality in various diseases of the descending aorta. Technological improvements nowadays allow deployment in the distal arch in most instances. However, in case of total involvement of the aortic arch endovascular Sg repair, the challenge is to maintain blood flow to the brain and upper extremities, that may require covering one or more aortic branches in order to establish a secure proximal landing zone, and to ensure complete exclusion of the lesion.The aim of this study is to report our ongoing experience with endovascular treatment of aortic arch aneurysms. Methods: During two years, 16 patients were treated with thoracic stent-grafts, after aortic arch debranching for repair of aortic arch aneurysm. All patients were at high risk for open repair and not candidates for standard endovascular repair due to inadequate proximal landing zones.Device design and implant strategy were on the basis of evaluation of aortic morphology with spiral CT. Stent grafts were inserted to repair the arch after supra-aortic vessel transposition was performed. Follow-up was 100% complete (mean 18 ±2.5 months, range 12–24 months). Follow-up included clinical examination, chest X-ray and computed tomography at discharge, 6 months after stent-graft placement and yearly thereafter.Results: Primary technical success rate was 100%. Patency of all endografts and conventional bypasses was 100%. No endoleak or graft migration was observed. There were no neurological complications. Surgical conversion was never required.Conclusion: Hybrid aortic arch repair is technically challenging but feasible. This novel approach may be an alternative to standard open procedures in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger series. 相似文献
ObjectivePhysician-modified fenestrated stent grafts (PMSGs) are a useful option for urgent or semiurgent treatment of complex abdominal aortic aneurysms (CAAAs). The aim of this study was to describe in-hospital outcomes of custom-made fenestrated stent grafts (CMSGs) and PMSGs for the treatment of CAAAs and thoracoabdominal aortic aneurysms (TAAAs).MethodsIn this single-center, retrospective study, all consecutives patients with CAAAs or TAAAs undergoing endovascular repair using Zenith CMSGs (Cook Medical, Bloomington, Ind) or PMSGs between January 2012 and November 2017 were included. End points were intraoperative adverse events, in-hospital mortality, postoperative complications, reinterventions, target vessel patency, and endoleaks.ResultsNinety-seven patients were included (CMSGs, n = 69; PMSGs, n = 28). The PMSG group included more patients assigned to American Society of Anesthesiologists class 4 (n = 14 [50%] vs n = 16 [23%]; P = .006) and more TAAAs (n = 17 [61%] vs n = 10 [15%]; P < .0001). Intraoperative adverse events were recorded in eight (11%) patients in the CMSG group vs six (21%) patients in the PMSG group. No intraoperative death or open conversion occurred. In-hospital mortality rates were of 4% (n = 3) in the CMSG group and 14% in the PMSG group (n = 4). Chronic renal failure was an independent preoperative risk factor of postoperative death or complications (odds ratio, 4.88; 95% confidence interval, 1.65-14.43; P = .004). Rates of postoperative complications were 22% (n = 15) and 25% (n = 7) in the CMSG and PMSG groups. Spinal cord ischemia rates were 4% (n = 3) and 7% (n = 2) in the CMSG and PMSG groups. Reintervention rates were 16% (n = 11) in the CMSG group and 32% (n = 9) in the PMSG group. At discharge, target vessel patency rate in CMSGs was 98% (n = 207/210). All target vessels (n = 98) were patent in the PMSG group. Endoleaks at discharge were observed in 24% of the CMSG group (n = 16) vs 8% of the PMSG group (n = 2).ConclusionsOur study showed clinically relevant differences of several important in-hospital outcomes in the CMSG and PMSG groups. Larger cohorts and longer follow-up are needed to allow direct comparison. PMSGs may offer acceptable in-hospital results in patients requiring urgent interventions when CMSGs are not available or possible. 相似文献
Spontaneous rupture of the left subclavian artery is a rare condition that requires immediate surgical intervention. A 21‐year‐old man with a history of membranoproliferative glomerulonephritis, failed kidney transplant, and history of a type A aortic dissection that was surgically repaired was admitted with altered mental status and hypotension. He was found to have a left subclavian artery rupture. This was successfully managed with emergent thoracic endovascular aortic repair and carotid‐subclavian bypass. 相似文献
This paper describes our technique and results with total laparoscopic aortic aneurysm repair. Material and Methods: A transperitoneal left retrorenal access was used in all cases. Special laparoscopic clamps often in combination with balloon catheters were used to occlude the aorta and the renal arteries. Exactly the same techniques like in open surgery were used. Either a tube graft or a bifurcated graft, anastomosed with the iliac arteries or the femoral arteries, was implanted to exclude the aneurysm.Laparoscopic surgery is becoming a third way to perform aortic aneurysm repair. In contrast to EVAR it can offer to aneurysm patients the same definitive outcome which we obtain in open surgery. 相似文献
We present a case of a ruptured aortic aneurysm in an 11-year-old boy presenting with loss of consciousness. The presentation, management, pathology, and gravity of this condition are discussed 相似文献
Purpose: To analyze our contemporary experience in open abdominal aortic aneurysm (AAA) repair. We focused on the effects of suprarenal (SR) aortic cross-clamping and adjunctive renal reconstruction (RR) on postoperative outcomes.Methods: We retrospectively reviewed our institutional data of 141 consecutive patients who received elective open AAA repair between January 2014 and December 2020.Results: Seventy-five procedures were performed with SR aortic cross-clamping, 20 of which required an adjunctive RR. Patients in the SR group had a higher incidence of postoperative acute kidney injury (AKI) (18.7% vs. 7.6%, P = 0.045). There were no significant between-group differences in other major complications. The 30-day mortality rate in the infrarenal (IR) and SR groups was 0% and 1.3%, respectively. After a median follow-up of 33 months, the rates of chronic renal decline in the IR (18.2%) and SR (21.3%) groups were similar. All reconstructed renal arteries were patent without reintervention. The 5-year overall survival rate in the IR and SR groups was 88.8% and 83.2%, respectively.Conclusions: SR aortic cross-clamping was associated with postoperative AKI but neither SR aortic cross-clamping nor RR affected the long-term renal function or mortality. Open repair remains an essential option for patients with AAA, especially those with complex anatomy. 相似文献
Objectives: to determine the value of pharmacological treatment of type B aortic dissection (B AD) in face of new forms of treatment.Design: this is a retrospective study of the period from 1990 to 2000. Files of 81 patients have been reviewed and completed by questionnaires.Results: Two B AD died after admission without any treatment, 10 were operated on with 7 discharged alive (group I); 69 received hypotensive agents and ß-blockers, 65 were discharged alive (group II). Late mortality of the group I is 3/7, not related with B AD. Late mortality after mean follow-up of 56.8 months is 27/65 with 4/27 related to B AD (4 ruptures, 2 operated on). Non fatal secondary surgery amounts 5 in 4 patients. Total B AD aortic events comprise 8/65 patients. Type A AD were operated on successfully (8: 4 before B AD, and 4 after B AD). Degenerative abdominal aortic aneurysms were present, operated (9) or not (3), in the history of patients and 3 more appear subsequently. At 10 years, actuarial survival is 40% ±18.Conclusion: in non-complicated cases of B AD, medical treatment is a reasonable choice, provided that a strict follow-up of the thoracic abdominal aorta is performed. 相似文献
Endoleak and endotension may prevent the successful exclusion of an aneurysm after endovascular aortic aneurysm repair (EVAR). The pressurization in the excluded aneurysm sac caused by endotension may lead to rupture of the aneurysm; however, the cause of endotension and its underlying mechanisms remain unclear. We report a case of infrarenal abdominal aortic aneurysm (AAA) complicated by persistent endotension after EVAR. Although no endoleaks were found on conventional double-phase computed tomographic scans, a thrombosed endoleak existed in the side branch and attachment site of the endograft. After treating the undetectable thrombosed endoleaks, physical examination revealed that the pressure of the excluded aneurysm had diminished, with shrinkage of the aneurysm. This case report suggests that a high-pressure undetectable type I or type II endoleak could be a major cause of endotension. Thus, postoperative evaluation of the attachment site of an endograft is important after EVAR. 相似文献