腹主动脉瘤的血管腔内治疗

目的 探讨腹主动脉瘤(AAA)血管腔内治疗后的短期临床效果.方法 回顾性分析2009年4月～2010年7月我科收治的8例AAA患者的临床资料.结果 患者均接受血管腔内治疗,手术成功率7/8,死亡1人.5例植入分叉型支架,2例植入直型支架,1例支架释放不成功.1例术后第2天右髂动脉支架折叠成角,远端血栓形成,给予局部溶栓成功后第3天血栓再次形成,急诊行左股－右股动脉旁路转流术.1例术后第2天出现急性肾功能不全,2个月后出现结肠缺血表现,给予对症治疗后好转.1例术中主体支架释放不成功,急诊行开腹手术,取出支架,行AAA修补术,术后第2天因呼吸循环衰竭死亡.随访1～16个月,中位随访时间5个月,至最后一次随访(死亡)时止,无内漏发生,无支架明显移位及动脉瘤腔内血栓形成.结论 AAA血管腔内治疗后的短期临床疗效满意,远期疗效有待进一步随访.     

Endurant支架血管植入治疗腹主动脉瘤的经验

目的 评估新一代Endurant支架血管植入治疗腹主动脉瘤的近期临床结果.方法 回顾性分析2010年7月至2011年6月收治的用Endurant支架血管治疗腹主动脉瘤68例患者的临床资料.其中男57例,女11例.术前ASA(American Society of Anesthesiologists)评分Ⅱ级15例,Ⅲ级32例,Ⅳ级21例.按照经典解剖形态学分析,本组有26例患者近端瘤颈不理想.结果 13例破裂性腹主动脉瘤行急诊手术,其余55例为择期手术.手术技术成功率100％,平均手术时间(96±29) min,平均出血量(99 ±68) ml,对比剂平均用量(122±65) ml.术后即时造影显示有Ⅱ型内漏18例(26％),无中转手术、及Ⅰ或Ⅲ型内漏、及支架内血栓形成等并发症.术后反应综合征发生率为72％ (49/68).术后平均随访时间(8±5)个月,随访率为82.4％ (56/68).结论 无论对于一般的还是有复杂解剖特点的腹主动脉瘤患者均可安全植入Endurant支架血管,近期疗效是满意的.     

腹主动脉瘤血管腔内治疗与开放手术治疗的疗效比较

目的 比较腹主动脉瘤血管腔内治疗与开放手术治疗的近期疗效。方法 对34例肾下型腹主动脉瘤患者的临床资料进行分析，比较腔内治疗组（15例）与传统开放手术治疗组（19例）的术前状况、手术相关情况、术后并发症、死亡率及手术前后的实验室检查数据。结果 腔内组术中出血量和输血量明显少于手术组（P=0．005、P=0．015），腔内组术后平均禁食时间和平均住院时间较手术组明显缩短（P〈0．0l、P：0．001）。手术组术后并发症发生率明显高于腔内组（P〈0．01）。术后第3天白细胞计数腔内组明显低于手术组（P=0．020）；术后第5天红细胞计数及血肌酐水平在腔内组均明显高于手术组（P=0．011、P=0．034）。结论 腹主动脉瘤血管腔内治疗具有安全、微创、对人体内环境干扰小的优点，近期疗效较传统开放手术好。     

腹主动脉瘤的腔内治疗最新进展和现状

腹主动脉瘤腔内治疗技术使腹主动脉瘤的外科治疗有了突破性进展。与传统开腹手术方法相比,腹动脉瘤的腔内治疗特点是创伤小,出血少,可避免传统开腹手术所带来的巨大创伤和降低病人心肺等重要脏器的严重并发症和死亡率,尤其为高危病例提供了治疗的机遇。本文就腹主动脉效瘤腔内治疗中的一些相关问题,如支架血管系统的设计特点,腹主动脉瘤腔内治疗的适应证和禁忌证,治疗条件和技术要领以及治疗结果和并发症等进行综述。     

腹主动脉瘤腔内治疗现状

1991年,Parodi等发明人工血管内支架（stent graft,SG）并用于临床成功治愈腹主动脉瘤（abdominal aortic aneurvsm,AAA）,此后腹主动脉瘤腔内治疗（endovascular abdominal aortic aneurysm repair,EVAR）取得迅速发展。由于EVAR避免了传统开腹手术创伤大和出血多的缺点,使高龄或伴有心、肺、肝、肾功能不全的患者获得积极治疗的机会。一般来讲,腔内治疗主要是指肾下型腹主动脉瘤。     

腹主动脉瘤腔内隔绝术后内漏

腹主动脉瘤腔内隔绝术后内漏 (ｅｎｄｏｌｅａｋ)是腹主动脉瘤腔内治疗过程中所产生的并发症[1] 。腔内治疗的方法是在腹主动脉瘤腔内放置带膜的血管支架 ,用移植物将循环血流和动脉瘤囊相隔开 ,使动脉瘤不再承受到循环血流的冲击 ,不再承受动脉压的压力 ,腹主动脉瘤不再增大和破裂。如果经过腔内隔绝术后 ,移植物外层的动脉瘤囊内仍有循环血流进入或进出 ,说明动脉瘤未与循环系统完全隔开 ,动脉瘤继续扩大甚至发生破裂 ,导致腹主动脉瘤隔绝手术的失败[2 ,3] 。所有类型移植物的内漏率是 2 4% (12 4/ 5 2 3) ,即发性内漏率约为 17% (89/ 5 2…     

腹主动脉瘤腔内修复术后髂支支架内闭塞的危险因素分析

目的:探讨腹主动脉瘤腔内修复术(EVAR)后髂支支架内闭塞的危险因素。方法:收集2011年1月—2015年12月行EVAR的腹主动脉瘤患者的临床资料,采用1:3配比病例对照方法,每个发生髂支支架内闭塞的病例随机选择3例同性别、年龄±3岁、使用同厂家的同种类型支架未发生髂支支架内闭塞的患者为对照,对EVAR后髂支支架内闭塞危险因素行单因素和多因素Logistic回归分析。结果:共495例腹主动脉瘤患者行EVAR,11例(2.2%)发生髂支支架内闭塞。术后发生髂支支架内闭塞的平均时间为2~20周。单因素分析显示,术前髂动脉扭曲成角≥60°(P=0.001),术前髂动脉狭窄≥50%(P=0.002),髂支支架远端口径放大率15%(P=0.004)等因素与EVAR后髂支支架内闭塞有关;Logistics回归分析显示,以上述因素均为EVAR后髂支支架内闭塞的独立危险因素(均P0.05)。结论:术前根据髂动脉解剖特性严格制定计划,选择合适的支架口径是减少术后髂支内闭塞的关键。应识别高危人群,针对可控因素采取预防措施,以避免及减少术后支架内闭塞的发生。     

腹主动脉瘤的腔内治疗最新进展和现状(文献综述)

腹主动脉瘤腔内治疗技术使腹主动脉瘤的外科治疗有了突破性进展。与传统开腹手术方法相比，腹主动脉瘤的腔内治疗特点是创伤小，出血少，可避免传统开腹手术所带来的巨大创伤和降低病人心肺等重要脏器的严重并发症和死亡率，尤其为高危病例提供了治疗的机遇。本文就腹主动脉瘤腔内治疗中的一些相关问题，如支架血管系统的设计特点、腹主动脉瘤腔内治疗的适应证和禁忌证、治疗条件和技术要领以及治疗结果和并发症等进行综述。     

吻合性假性腹主动脉瘤六例报告

本文通过对6例吻合性假性腹主动脉瘤的外科治疗，进一步探讨其预防、诊断和手术方式。认为B超是早期诊断和有效的检查手术。避免吻合性假性腹主动脉瘤的产生除了纠正高血压、高脂血症、吸烟等危险因素以外，强调正规的外科解剖和无损伤的操作，尽可能采用端-端吻合，降低吻合口张力．防止手术野的感染和血肿形成。     

应用国产整体式分叉型支架腔内治疗肾下型腹主动脉瘤

目的探讨应用国产整体式分叉型支架腔内治疗肾下型腹主动脉瘤的效果。方法回顾性分析2009年9月—2011年6月采用国产整体式分叉型支架腔内隔绝术治疗27例肾下型腹主动脉瘤患者的临床资料。结果 27例腹主动脉瘤腔内修复均获成功,术后随访2～20个月复查CTA,DSA证实:瘤体被完全隔绝,支架无移位、扭曲及内漏现象。结论应用国产整体式分叉型支架腔内治疗肾下型腹主动脉瘤安全有效,与分体式支架相比,其简便、经济、并发症少。     

腹主动脉瘤伴高血压患者介入治疗围手术期血压的护理干预

目的总结腹主动脉瘤伴高血压患者介入治疗围手术期血压护理干预的具体措施、经验。方法对8例实施腔内隔绝术治疗的腹主动脉瘤伴高血压的患者,实施积极的血压治疗及护理干预。结果本组患者在围手术期血压保持平稳,能顺利接受治疗。结论围手术期积极的护理干预措施,能有效预防并发症的发生,保证治疗的顺利进行。     

个体化血管内介入治疗椎动脉夹层动脉瘤

目的观察个体化血管内介入治疗椎动脉夹层动脉瘤(VADA)的临床效果。方法回顾性分析38例VADA患者(43枚动脉瘤)。其中10例(10枚)动脉瘤破裂出血,对6枚采用动脉瘤填塞及载瘤动脉闭塞术,4枚以单支架辅助弹簧圈栓塞。对未破裂33枚动脉瘤均行载瘤动脉重建术,以单支架辅助弹簧圈栓塞3枚,双支架辅助弹簧圈栓塞25枚,三支架辅助弹簧圈栓塞5枚。结果血管内介入治疗所有43枚VADA均获成功,对28枚实现完全及次全栓塞、15枚实现部分栓塞。术后随访12个月,34例(38枚动脉瘤)接受全程复查,其中21枚治愈、11枚改善、6枚稳定,未见复发,无新发脑出血或脑缺血症状;改良Rankin量表(mRS)评分0～1分30例,2分2例,3分1例,4分1例。结论根据具体情况采用个体化血管内介入治疗VADA安全、有效,且预后较好。     

腔内隔绝术治疗腹主动脉瘤(附5例报告)

目的探讨腹主动脉瘤腔内隔绝术的适应症及其并发症的防治。方法对5例患者采用经股动脉植入支架-人造血管复合移植物,对腹主动脉瘤进行腔内隔绝术。结果5例手术均获成功,无任何并发症发生。结论腔内隔绝术治疗腹主动脉瘤具有简捷、微创、并发症少、术后恢复快等优点,为治疗本病的首选方法。     

带膜支架在神经介入治疗中的应用

随着介入技术的飞速发展，带膜支架在神经介入治疗中的应用越来越受到重视。本文介绍了带膜支架的材料和其在神经介入治疗中的临床应用，带膜支架在颅内缺血性和出血性疾病的应用中正日益显示出其显著的疗效，但也有其不足之处。随着相关理论研究的深入及新材料工艺的进步，带膜支架在脑血管疾病治疗中的应用将会更加广泛。     

Evolution of open aneurysmorrhaphy for management of sac expansion after endovascular repair of abdominal aortic aneurysms

ObjectiveWe evaluated the perioperative and mid-term clinical outcomes of open aneurysmorrhaphy (OA) for the treatment of sac expansion after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms.MethodsOA involves sac exposure without dissection of the proximal or distal neck, sacotomy and ligation of back-bleeding vessels, preservation of the prior stent graft, and tight closure of the sac around the stent graft. We performed a retrospective review of all patients who had undergone OA for nonruptured sac expansion after standard EVAR at our institution between January 2015 and June 2021. The primary end points were 30-day mortality and aneurysm-related death. The secondary end points were postoperative complications, overall survival, freedom from reintervention, and sac regrowth rate.ResultsA total of 28 patients had undergone OA. Their mean age was 76.9 ± 6.7 years. The median sac diameter at OA was 79 mm (interquartile range [IQR], 76-92 mm). The median duration from the index EVAR to OA was 82 months (IQR, 72-104 months). Preoperative computed tomography angiography confirmed a type II endoleak (EL) in 20 patients, 1 of whom had had a coexisting type Ia EL; a type IIIb EL was identified in 1 patient. Concomitant endovascular procedures had been performed in six patients to treat a type I or III EL or reinforce the proximal and distal seals. The OA technique has been modified since 2017, with the addition of more aggressive dissection of the sac and complete removal of the mural thrombus to further decrease the sac diameter. Postoperative complications occurred in two patients and included abdominal lymphorrhea and failed hemostasis of the common femoral artery requiring surgical repair in one patient each. The 30-day mortality was 0%. During the median follow-up of 36 months (IQR, 14-51 months), the overall survival was 92.7% and 86.9% at 12 and 36 months, respectively, without any aneurysm-related death. In the late (2017-2021) treatment group, the median sac diameter immediately after OA was smaller than that in the early (2015-2016) treatment group (early group: median, 50 mm; IQR, 39-57 mm; vs later group: median, 41 mm; IQR, 32-47 mm; P = .083). Furthermore, in the late group, the sac regrowth rate was lower (early group: median, 0.36 mm/mo; IQR, 0.23-0.83 mm/mo; vs late group: median, 0 mm/mo; IQR, 0-0.11 mm/mo; P = .0075) and the freedom from reintervention rate was higher (late group: 94.7% at both 12 and 36 months, respectively; early group: 71.4% and 53.6% at 12 and 36 months, respectively; log-rank P = .070).ConclusionsOur results have shown that OA for the management of post-EVAR sac expansion is feasible with acceptable mid-term outcomes. Aggressive dissection and tight plication of the sac might be imperative for better mid-term outcomes after OA.     

自制国产化支架-移植物腔内治疗腹主动脉瘤的实验研究

目的 探讨自制国产化支架、移植物在治疗犬腹主动脉瘤中的作用。方法 以国产镍钛合金丝纺织成网状管型支架,外套以国产真丝涤纶交织人造血管,装入导鞘制成支架-移植物系统;用胰蛋白酶灌注犬肾下腹主动脉段形成动脉瘤模型;用血管腔内技术将支架-移植物置入腹主动脉内,隔绝血流分别于第1周、1个月、3个月和6个月末观察通畅度及新生内膜生长。结果 20条模型犬接受手术,成功19条,支架置入后能充分展开并恢复形状,1个月末,支架内表面90%被新生内膜覆盖,3个月末几达100%,6个月末,79%的支架保持通畅,无移位、内漏等并发症。结论 自制国产化支架、移植物有良好的生物相容性和较高的通畅率,可用于腹主动脉瘤的治疗。     

Simple renal cyst and its association with sac shrinkage after endovascular aneurysm repair for abdominal aortic aneurysms

ObjectivePatients with abdominal aortic aneurysm (AAA) frequently have simple renal cyst (SRC), a common manifestation of connective tissue degeneration. This study aimed to determine whether SRC is a risk factor for failure of sac shrinkage after endovascular aneurysm repair (EVAR).MethodsBetween October 2013 and May 2017, there were 155 consecutive patients with an infrarenal AAA or a common iliac artery aneurysm who underwent EVAR with the GORE C3 Excluder (W. L. Gore & Associates, Flagstaff, Ariz) at Tokyo Medical University Hospital. All these patients were registered in a prospectively maintained database. Any kidney lesion >5 mm in diameter, with no evidence of contrast enhancement or septation and with low attenuation, was defined as SRC. A change in sac size of >5 mm from baseline was considered significant. The patients were divided into those with SRC and those without SRC, and sac shrinkage at 1 year and 2 years was compared. The presence of SRC was assessed with respect to being a risk factor for failure of sac shrinkage at 1 year using univariate and multivariable logistic regression analysis.ResultsThe patients were divided into two groups: those with SRC (92 patients [59.0%]) and those without SRC (63 patients [41.0%]). At 1 year and 2 years, significant differences were observed in the proportion of sac shrinkage between patients with SRC and those without SRC (19.2% vs 42.4% [P = .003] and 19.6% vs 53.3% [P = .001], respectively). Patients with SRC showed significantly less sac shrinkage than those without SRC at 1 year and 2 years (−2.0 ± 5.5 mm vs −4.4 ± 6.2 mm [P = .002] and −1.8 ± 6.3 mm vs −6.4 ± 8.6 mm [P = .005], respectively). Multivariable analysis demonstrated that SRC (odds ratio, 0.28; 95% confidence interval, 0.12-0.63; P = .002) and initial sac size (odds ratio, 1.05; 95% confidence interval, 1.01-1.09; P = .027) were positive and negative risk factors for sac shrinkage, respectively.ConclusionsThe presence of SRC is a risk factor for failure of sac shrinkage after EVAR. This suggests that AAA in patients with SRC has a more degenerated wall than in those without SRC. The property of the aneurysm wall may be associated with sac shrinkage after EVAR.     

Non-activated autologous platelet-rich plasma for the prevention of inguinal wound-related complications after endovascular repair of abdominal aortic aneurysms

The endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs) usually involves the surgical exposure and catheterization of the femoral arteries. Several inguinal surgical wound-related complications have been reported postoperatively. The aim of this report was to evaluate the safety and efficacy of intraoperative application of autologous platelet-rich plasma (PRP) for the prevention of wound-related complications in AAA EVAR. The authors conducted a patient- and assessor-blinded controlled trial involving 100 subjects undergoing EVAR of an AAA. PRP was produced using an autologous platelet separator and was applied, without prior thrombin activation, in 50 patients eligible for inclusion. The results were compared with a control group of 50 patients who underwent AAA EVAR within the same time period. The primary outcome was the difference in postoperative hospital stay. Secondary outcomes included subjective assessment of wound healing and wound-related complications. Age, sex, and other comorbidities related to wound healing were not significantly different between cases and controls. One patient treated with PRP developed a unilateral wound infection with lymphorrhea, and two patients developed a bi-lateral superficial infection. Twelve patients within the control group developed a wound-related complication. The postoperative hospitalization was significantly lower in the PRP group. The overall surgical wound-related complications rate was also significantly lower in the PRP group. Application of non-thrombin-activated PRP seems to prevent major postoperative wound-related complications (p = .026) and shorten postoperative hospital stay duration after femoral artery exposure and catheterization for AAA EVAR (mean, 4.48 +/- 0.48 vs. 6.14 +/- 0.39 days).     

Limb graft occlusion after endovascular aneurysm repair with the Cook Zenith Alpha abdominal graft

ObjectivePrior reports of the low profile Zenith Alpha abdominal graft (Cook Medical Inc, Bloomington, IN) have shown impaired limb graft patency to be the primary causes of reintervention. Special notices from the manufacturer have indicated certain instructions for use (IFU) violations as the main reasons for these complications. In the present study, we assessed the incidence of limb graft occlusion (LGO) and analyzed the effects of the detailed anatomic risk factors for LGO highlighted in the IFU and previously reported studies.MethodsA retrospective study was performed of 241 patients treated with the low profile Zenith Alpha at a single institution from October 1, 2015 to September 30, 2018. All computed tomography angiograms were analyzed using three-dimensional software. Data were extracted from the electronic medical records until the end of the study period (December 31, 2020). The cumulative incidence of LGO and LGO-related reinterventions were assessed. A regression analysis was performed to evaluate the possible risk factors associated with the development of LGO at specified time points. These included aortic and iliac diameters, graft component oversizing, iliac tortuosity and calcification, overlap of graft components, proximal alignment of ipsilateral and contralateral legs, and sealing zone in the external iliac artery. Reader agreement of iliac calcification and tortuosity was assessed in patients with LGO.ResultsA total of 33 limbs (7%) in 27 patients (11%) had become occluded. The cumulative incidence of LGO was 7% (95% confidence interval [CI], 5%-9%) per limb up to 3 years postoperatively. The previously described risk factors for LGO were studied using regression analysis; however, no positive association with LGO was identified. Heavily calcified common iliac arteries (CIAs) and external iliac arteries were protective against LGO compared with noncalcified vessels up to 3 years postoperatively (decreased risk, 17% [95% CI, ?27% to ?7%]; P = .001; and 15% [95% CI, ?26 to ?5]; P = .005, respectively). The reader agreement of iliac calcification and tortuosity showed substantial agreement (CIA intrareader kappa = 0.75; CIA interreader kappa = 0.62) and almost perfect agreement (intrareader kappa = 0.85; interreader kappa = 0.84), respectively.ConclusionsThe cumulative incidence of LGO after endovascular aneurysm repair with the Zenith Alpha graft was 7% per limb up to 3 years postoperatively. None of the analyzed risk factors suggested by the IFUs or current literature were positively associated with LGO.