腹主动脉瘤术中不同髂内动脉处理的疗效观察

目的：探讨腹主动脉瘤（AAA）术中结扎或是封闭髂内动脉（IIA）对患者疗效的影响。 方法：回顾性分析2010年6月—2014年6月中南大学湘雅医院手术治疗的108例AAA患者临床资料,其中腔内修复61例,开放手术44例,杂交手术3例。44例开放手术中结扎双侧IIA 7例,结扎单侧IIA 8例;61例腔内修复术中封闭双侧IIA 3例,封闭单侧IIA 5例。 结果：无术中死亡,围手术期30 d内有6例死亡均与处理IIA无关。开放手术结扎或腔内修复封闭双侧IIA的10例患者中,1例（1/10）出现直肠缺血症状,经过抗凝和扩血管治疗1个月后症状缓解;2例（2/10）出现术后一过性的臀肌疼痛,保守治疗后症状消失;均未出现间歇性跛行。开放手术结扎或是腔内修复封闭单侧IIA的13例患者中均未出现直肠缺血,臀肌疼痛或是间歇性跛行。 结论：AAA患者术中结扎或是封闭单侧IIA对患者术后状况无明显影响;结扎或是封闭双侧IIA可能出现直肠缺血或是臀肌疼痛等盆腔缺血的表现,但可经保守治疗缓解。     

Delayed rupture of an internal iliac artery aneurysm following proximal ligation for abdominal aortic aneurysm repair

This is a report of a patient presenting with a contained rupture of an internal iliac aneurysm following proximal ligation after abdominal aortic aneurysm repair three years earlier. The patient presented with a large pelvic mass with symptoms of urgency, frequency, dysuria, tenesmus and fevers associated with anemia. Following evacuation of the aneurysm and direct suture ligation of the distal branches of the internal iliac artery, the patient's aortic graft was covered with omentum which also filled the pelvic cavity. The importance of proximal and distal control of aneurysms and/or the importance of complete luminal control of internal iliac artery aneurysms is emphasized by this case.     

腹主动脉瘤腔内修复术封闭髂内动脉后的初步观察

目的观察腹主动脉瘤腔内修复术(EVAR)封闭髂内动脉后臀肌和下肢缺血情况。方法回顾性分析2006年1月～2011年1月在我院行EVAR术的174例患者的临床资料。腹主动脉瘤最大直径[(55.2±12.9)mm],累及髂总动脉52例(29.9%)。EVAR治疗方法包括置入分叉型覆膜支架169例(97.1%),单臂型5例(2.9%)。术中封闭单侧髂内动脉29例,封闭双侧髂内动脉10例。观察围手术期和随访期患者臀肌和下肢发生缺血情况。结果行EVAR术的174例患者中,173例手术顺利,无中转开腹,1例术中死亡,1例术后死亡。术中封闭单侧髂内动脉29例中有2例出现同侧臀肌轻度疼痛,行走疼痛加重,跛行距离100m,5例出现同侧下肢乏力,间歇性跛行100～200m;封闭双侧髂内动脉10例中有4例术后出现臀肌轻度疼痛,跛行距离200m,均采用扩血管、祛聚保守治疗后2～4周疼痛症状好转,间歇性跛行距离均大于500m,无臀肌坏死发生,无再行介入或外科干预治疗,随访期间跛行距离逐渐增加500～1000m,余未诉特殊不适。结论 EVAR术封闭髂内动脉后臀肌和下肢不同程度缺血,经保守扩血管和祛聚治疗可以缓解,但一定程度会影响患者生活质量,封闭双侧髂内动脉或一侧均应宜慎重。     

腹主动脉瘤腔内修复术中髂动脉瘤的处理策略

目的:探讨腹主动脉瘤合并髂动脉瘤的腔内修复术(EVAR)方法。方法:回顾性分析2007年8月—2014年3月35例腹主动脉瘤合并髂动脉瘤行EVAR术患者资料,其中9例合并单侧髂内动脉瘤,1例合并双侧髂内动脉瘤,14例合并单侧髂总动脉瘤(直径18 mm),11例合并双侧髂总动脉瘤,所用腔内技术包括栓塞髂内动脉瘤后覆盖,髂内动脉瘤单纯覆盖,"喇叭口"支架,以及"三明治"技术重建一侧髂内动脉等。结果:所有腔内技术均获得成功,手术时间(125±40)min,出血量(173±65)m L。术中发现内漏8例(22.9%),其中I型内漏4例(近端2例,远端2例)均经球囊扩张后内漏消失,III型内漏1例,经扩张及部分加弹簧圈栓塞后内漏消失,II型内漏2例及IV型内漏1例,均未予处理。35例术后随访6~60个月,无动脉瘤破裂,2例术后6个月发现腹主动脉瘤体增大,造影确诊远端I型内漏,经弹簧圈栓塞后内漏消失,其余33例瘤体直径无增大。结论:对于合并髂动脉瘤的腹主动脉瘤患者,有效处理髂内动脉,然后根据髂总动脉直径选择合适的治疗方法可以达到理想的近期效果。     

Leg ischemia following surgery for abdominal aortic aneurysm.

Resection of an abdominal aortic aneurysm was associated with intraoperative or postoperative leg ischemia in seven of 100 consecutive survivors of this procedure. Distal embolization of thrombus and debris is the apparent cause in the majority of cases (six). One case of stenosis at a graft-to-vessel anastomosis was identified. Early (intraoperative) thromboembolectomy averted tissue loss in four cases. The role of concurrent lumbar sympathectomy in ameliorating ischemic tissue loss is evaluated. Postaneurysmectomy leg ischemia may accompany other serious complications, particularly hypotension and renal failure.     

结扎双侧髂内动脉的腹主动脉瘤切除术：附5例报告

目的:探讨腹主动脉瘤手术中结扎双侧髂内动脉的安全性及可行性。方法:回顾性分析68例开腹腹主动脉瘤切除术中因故不能行髂内动脉重建而结扎双侧髂内动脉的5例患者的临床资料。结果:5例结扎双侧髂内动脉的患者中，术后1例出现膀胱出血，1例出现阴囊疼痛，1例出现臀部间歇性跛行，1例出现短时腹泻，1例无任何症状。4例出现临床症状的患者经相应治疗后均获明显缓解。结论:腹主动脉瘤手术中无法重建的双侧髂内动脉可以结扎，但应慎重施行。     

Technique for iliac artery reconstruction in abdominal aortic aneurysm repair.

The aim of this retrospective study was to evaluate the technique for iliac artery reconstruction in abdominal aortic aneurysm repair, when external and internal iliac arteries were required to reconstruct individually. Among 203 elective infrarenal abdominal aortic aneurysm repairs, 22 patients (10.8%) required individual reconstruction of bilateral or unilateral iliac arteries, including 56 external or internal iliac arteries. Mainly, three types of procedures were performed: (1) the external iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end manner, and the internal iliac artery was attached to the side of the external iliac artery, (2) the external iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end manner and the internal iliac artery was bypassed with the use of a straight prosthetic graft extending from the limb of the bifurcated graft, and (3) the internal iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end fashion, and the external iliac artery was sewn to the side of the graft limb. In these three types of procedures, the third technique was the easiest and simplest anatomically.     

Exclusion of internal iliac arterial aneurysm concomitant with abdominal aortic aneurysm repair.

BACKGROUND: To study the long-term outcomes after exclusion of internal iliac arterial aneurysm performed concomitantly with abdominal aortic aneurysm repair in patients with ruptured aortic aneurysm or other high-risk conditions. METHODS: The 31 patients who participated in this study underwent emergency (N = 9) or elective surgery (N = 22). The abdominal aortic aneurysm and the common iliac artery were excluded together with the internal iliac aneurysm in 7 patients. Forty-three (12 bilateral and 19 unilateral) internal iliac aneurysms were excluded: 35 by proximal ligation only, 5 by proximal and distal ligation, and 3 by partial resection of the proximal part of the aneurysm. The platelet count and fibrinogen level were evaluated pre- and postoperatively. Pelvic organ ischemia, classed as ischemic colitis, buttock claudication and sexual dysfunction, was examined. RESULTS: The inferior mesenteric artery was reimplanted in 21 patients. The platelet count dropped significantly postoperatively, but the fibrinogen level increased and no bleeding tendency was noted. Ischemic colitis occurred in 7 patients, resulting in colonic infarction in 2 patients. The operative mortality was 16%, and the postoperative observation periods ranged from 4 days to 217 months (mean, 60 months). The incidence of buttock claudication and sexual dysfunction was 12% and 39%, respectively. The excluded aneurysms were all thrombosed at discharge, and no late rupture was noted. The 5- and 10-year survival rate after surgery was 56% and 51%, respectively. CONCLUSIONS: Exclusion of the internal iliac aneurysm concomitant with abdominal aortic aneurysm repair shows acceptable outcome when performed in patients with high-risk conditions.     

Results from coronary artery bypass surgery combined abdominal aortic aneurysm repair.

OBJECTIVE: Complication from coronary artery disease is a major cause of mortality and morbidity in patients undergoing abdominal aortic aneurysm repair. We report our results from coronary artery bypass surgery performed in combination with abdominal aortic aneurysm repair in patients with coronary artery disease and abdominal aortic aneurysm, each being an indication for an emergency operation. METHODS: Seventeen patients underwent combined coronary artery bypass surgery and abdominal aortic aneurysm repair. The mean age of the patients was 67.6 +/- 5.2 years. Four had left main disease, 8 patients had triple-vessel disease, and 12 had a prior myocardial infarction. The average left ventricular ejection fraction was 0.49 +/- 0.13. The average abdominal aortic aneurysm diameter was 6.2 +/- 1.0 cm (range 4.5-8.0 cm). Thirteen patients underwent coronary artery bypass surgery followed by abdominal aortic aneurysm repair after discontinuation of cardiopulmonary bypass. In the remaining four patients, including one patient with severe left ventricular dysfunction, cardiopulmonary bypass was continued as a circulatory assist until the abdominal aortic aneurysm repair was completed. The left internal thoracic artery was used in 14 patients, and the right internal thoracic artery in one patient. RESULTS: Postoperative surgical complications occurred in three patients (bleeding in one patient requiring reoperation, abdominal subcutaneous wound infection in another and transient neural disorder in the others). There were no surgical or in-hospital death. There was no late cardiac complication and no late cardiac death after a mean of 29 months follow-up. CONCLUSIONS: We concluded that combined surgery was reasonable for selected patients with combined coronary artery disease and abdominal aortic aneurysm, each of which is an indication for an urgent operation. The aortic aneurysm repair during cardiopulmonary bypass for patients with severe left ventricular dysfunction was safe and effective.     

Gluteal compartment syndrome following elective unilateral internal iliac artery embolization before endovascular abdominal aortic aneurysm repair

During endovascular abdominal aortic aneurysm repair, aneurysmal involvement of the common or internal iliac arteries occasionally necessitates elective occlusion of one or both internal iliac arteries. Although elective internal iliac artery occlusion is often well tolerated, it can result in complications such as buttock claudication or rest pain, impotence, and colon ischemia. We report a case of gluteal compartment syndrome following elective unilateral internal iliac artery embolization prior to endovascular abdominal aortic aneurysm repair. On the first postoperative day, the patient developed sciatic nerve palsy, rhabdomyolysis, and renal failure, which promptly resolved after emergent operative exploration of his left buttock and debridement of all grossly necrotic muscle. This case emphasizes the point that, although elective internal iliac artery interruption is usually benign, it can have serious and unexpected complications that necessitate expeditious treatment for complete recovery.     

Concomitant unilateral internal iliac artery embolization and endovascular infrarenal aortic aneurysm repair

INTRODUCTION: Endograft limb extension to the external iliac artery with embolization of an internal iliac artery (IIA) may be necessary in patients with abdominal aortic aneurysms (AAAs) extending to the common iliac artery to prevent endoleak during endovascular aortic aneurysm repair (EVAR). Coil embolization of the IIA can be performed at the same operative setting as EVAR or, alternatively, as a staged procedure. Most interventionalists favor the latter approach to avoid excessive contrast material and prolonged operative time. We investigated the clinical outcome of concomitant vs staged unilateral IIA embolization in the setting of EVAR. METHODS: Vascular surgeons at our institution treated 24 patients with infrarenal EVAR and unilateral coil embolization of the IIA from October 1, 2000 to June 30, 2005. All patients had normal renal function. The details of the operative procedure and perioperative complications were compared in patients undergoing concomitant vs staged procedures. Follow up was 1 to 40 months (average, 11 months). RESULTS: Among the 24, 16 underwent concomitant unilateral IIA embolization in the setting of EVAR and eight patients underwent the staged procedure. Average duration of operative time (298 vs 284 minutes), amount of intravenous contrast (215 mL vs 164 mL), and preoperative (1.12 vs 1.26 mg/dL), and postoperative (1.15 v. 1.31 mg/dl) creatinine levels were similar in the concomitant vs staged group, respectively (P > .05 for all factors). More sensitive markers of renal insufficiency such as creatinine clearance were not measured. In the concomitant group, 25% (4/16) of patients reported significant symptoms of buttock claudication ipsilateral to the embolized IIA, which resolved after a mean of 8.8 months (range, 1 to 15 months) vs no cases (0/8) in the staged group (P = .02048). One patient in the staged group developed ischemic colitis, which was treated conservatively. Coil embolizations that were performed as staged procedures were all done on an outpatient basis. All 24 patients were admitted the day of the EVAR and were discharged the next day, except one patient in the concomitant group was discharged the second day after the procedure, and one patient in the staged group was discharged 7 days after the procedure. CONCLUSION: Despite concern of prolonged operative time and the amount of contrast needed to perform concomitant IIA embolization and EVAR, our results showed that in patients with normal renal function, concomitant unilateral IIA embolization in the setting of EVAR was safe and effective and associated with shorter hospitalization compared with staged procedures. The disadvantage of a concomitant procedure is an increased likelihood of transient buttock claudication, but the small number of patients in this series prohibits definite conclusions about this complication. The concomitant procedure may be preferable for infirm patients with normal renal function who would be greatly inconvenienced by two procedures.     

腹主动脉瘤的可视化仿真手术

目的研究可视化仿真手术在腹主动脉瘤(AAA)手术中的应用价值。方法 1例AAA患者64排螺旋CT动脉期、静脉期DICOM数据,用MxLite View DICOM Viewer、DICOM查看器及ACDSeePhoto Manager等软件进行图像重建前处理,然后导入自主开发的医学图像处理系统(MIPS)对CTA图像中的腹部实质脏器及血管进行分割及三维重建,将重建后的各脏器及血管模型导入到FreeForm Model-ing System进行修饰和平滑,使用该系统的力反馈设备PHANToM进行AAA修复术的仿真手术。结果重建的各个腹腔脏器及血管模型形态逼真,立体感强,相互关系明晰;在FreeForm Modeling System仿真环境中,仿真手术符合临床手术过程。结论可视化仿真手术演练可熟悉手术过程,缩短手术时间。     

Minimally invasive vascular surgery for repair of infrarenal abdominal aortic aneurysm with iliac involvement

PURPOSE: A minimally invasive vascular surgery (MIVS) technique for repair of infrarenal abdominal aortic aneurysm (AAA) with iliac involvement was evaluated, and its outcome was compared with conventional open repair. METHODS: Twenty patients with AAA with iliac involvement underwent treatment with bifurcated graft replacement with the MIVS technique. The procedure was performed via minilaparotomy, with the incision length determined according to the extent of the AAA obtained with ultrasound scanning and with the small intestine confined completely within the abdominal cavity. The proximal and distal operating fields were obtained with changing the patient position and arranging for the abdominal incision to be retracted cephalad and caudad. Perioperative courses in these 20 patients (the MIVS group) were analyzed in comparison with 14 patients who underwent conventional open repair, which was performed through the full midline laparotomy with the intestine simply covered with moistened towels (the conventional group). RESULTS: The MIVS technique for AAA repair was performed with a mean abdominal incision length of 8.4 cm and a range from 6.5 to 11.2 cm. The patients in the MIVS group showed earlier resumption of oral intake and ambulation in comparison with those patients in the conventional group (liquid diet: 1.1 +/- 0.3 days versus 2.9 +/- 1.4 days; P <.01; solid diet: 2.0 +/- 0.2 days versus 3.9 +/- 1.4 days; P <.01; ambulation: 2.1 +/- 0.8 days versus 4.3 +/- 2.3 days; P <.01), with comparable mortality and morbidity rates. Accordingly, the patients in the MIVS group were discharged earlier (20.7 +/- 6.3 days versus 33.9 +/- 12.6 days; P <.01), and total hospitalization charges were significantly decreased (2,232,791 +/- 200,747 Japanese yen versus 2,640,441 +/- 243,889 Japanese yen; P <.01). CONCLUSION: The MIVS technique allowed earlier postoperative recovery with comparable morbidity and mortality rates with the conventional technique and, therefore, saved hospital stay length and total hospitalization charges. Thus, the MIVS technique is considered as a new and effective minimally invasive technique for open AAA repair.     

Effect of preoperative renal dysfunction on mortality and postoperative renal failure following endovascular abdominal aortic aneurysm repair

This study was aimed to assess the effect of preoperative renal dysfunction on mortality and postoperative renal failure in patients undergoing elective endovascular repair of abdominal aortic aneurysm. A total of 155 patients with a mean age of 74.9 years (+/-6.4) were included. In all, 31 patients (20%) had a preoperative creatinine level of >1.5 mg/dL, whereas 66 patients (42.6%) had an estimated glomerular filtration rate of <60 mL/min. Perioperative mortality was 2.6% with no significant difference between those with and without abnormal renal indices. Long-term survival at 4 years was 30% in patients with creatinine >1.5 mg/dL compared to over 60% in those with normal creatinine (P < .02). The difference in long-term survival was not as significant in patients with normal or reduced glomerular filtration rate (P = .13). However, neither creatinine nor glomerular filtration rate were found to accurately predict survival even though both demonstrated strong predictivity for postoperative renal failure in patients undergoing elective endovascular repair of abdominal aortic aneurysm.     

Progress in the surgery of abdominal aortic aneurysm]

Between 1960 and 1989, 609 patients were operated on for abdominal aortic aneurysms. They were 38 females and 571 males from 45 to 87 years old (mean 69). The series has been divided into three consecutive periods: From 1960 to 1973, 135 patients (30 ruptures); from 1974 to 1981, 176 patients (55 ruptures) and from 1982 to 1989, 298 patients (49 ruptures). Perioperative mortality for elective surgery was 8.5% during the first period and 3.2% during the last one. For ruptured aneurysms mortality decreased from 66% to 34%. In the same way, the incidence of rupture decreased from 31.2% to 16.4%. Progresses making possible improvements of the results are related to an early detection with ultrasounds and CT scan, a more precise evaluation of associated pathologies, simplification of surgical techniques, evolution of anesthesia and supportive measures (monitoring, autologous transfusion). On the other hand, rupture is still lethal due to delay in diagnosis and surgery, site of the rupture and multiorgans consequences of hemorrhagic shock. It is only by an echographic screening of people at risk (age, cardiovascular diseases) that frequency can be reduced.     

腹主动脉瘤腔内修复术中封闭髂内动脉后的并发症及其与侧支血管形成的关系

背景与目的：腹主动脉瘤腔内修复术（EVAR）由于其安全性和有效性,已逐步成为腹主动脉瘤的一线治疗方法,虽然目前已有各种微创腔内器具和介入技术运用于髂内动脉（IIA）的保留,但临床上需封闭IIA的情况仍不少见,而一旦封闭IIA,尤其进行双侧IIA栓塞的患者,可能出现臀肌缺血、肠道缺血、性功能障碍等并发症。同时,部分IIA侧支建立良好患者行双侧IIA封闭后无明显封闭相关并发症的发生。因此,本研究探讨分析EVAR中封闭单侧或双侧IIA后,臀肌、肠道、生殖器缺血等并发症情况及其与侧支代偿之间的关系。方法：回顾性收集并分析2011年7月—2021年7月在中国人民解放军海军军医大学附属长海医院行EVAR的1 902例患者的基线资料及术前、术中、术后影像学资料,筛选出426例行IIA封闭的患者（62例行双侧IIA封闭,264例行单侧IIA封闭）,并进行并发症相关症状电话随访。统计患者围手术期和随访期患者臀肌缺血、肠道缺血、性功能障碍等相关并发症情况,根据术中及术后影像观察侧支代偿情况,并分析侧支建立与并发症的关系。结果：426例患者中,73例（17.1%）出现臀肌缺血症状,7例（1.6%）出现肠道缺...