36例主动脉瘤治疗体会

目的:探讨主动脉瘤的外科治疗。方法:1995年11月至2006年11月,共收治各类主动脉及夹层动脉瘤患者36例,其中升主动脉瘤5例,腹主动脉瘤15例,胸腹主动脉瘤2例,主动脉夹层动脉瘤14例,36例中采取外科手术治疗18例,腔内支架介入治疗14例。结果:未来得及治疗术前破裂致死亡4例。手术治疗的18例中2例死亡,腔内介入治疗14例全部治愈。结论:对于各类主动脉瘤患者,及时发现,及时确诊,及时救治,根据不同的病例采用不同的治疗方案,取得良好效果。     

彩色多普勒超声诊断主动脉瘤的观察与分析

目的 探讨超声诊断主动脉瘤的可靠性和准确性,评价其临床价值。方法 应用HP2500及TOSHIBA SSA-380A超声诊断仪,检查36例主动脉瘤患者,并将其部分超声检查结果与CT、核磁(MRI)、数字减影血管造影(DSA)及手术结果进行比较。结果 夹层动脉瘤与CT、MRI、DSA检查结果的符合率分别为86%、80%、89%;腹主动脉瘤与MRI、DSA及手术结果的符合率为100%。结论 彩色多普勒超声检查可发现有无主动脉瘤、动脉瘤的大小、范围、搏动和血流状态,对于夹层动脉瘤破裂口的观察、指导临床手术方案的选择有重要意义。     

腹主动脉瘤

腹主动脉瘤患者的死亡率是正常人的４倍，该病对男性的影响是女性的１０倍。其发病机理：因血管平滑肌弹性蛋白的随龄下降及胶原蛋白安全网作用的失效，导致动脉瘤扩张、破裂；几种遗传性连接组织紊乱与其早年的形成有关。各种检查方法中以超声波检查最适合。治疗：对小的动脉瘤应用β受体阻断剂，可减慢其扩大；腹主动脉瘤直径达到５或５．５ｃｍ或年生长率超过１ｃｍ时，考虑手术修补。     

腹主动脉瘤修复术后吻合口动脉瘤的若干问题：附18例报告

我院自１９６０￣１９９１年间对１１４例腹主动脉瘤行修复术后发生１８例吻合口动脉瘤，就其病因、诊断、治疗及预防进行分析探讨。我们认为吻合口动脉瘤的病因是综合性的。行Ｂ超和ＣＴ检查对确诊最有价值，吻合口动脉瘤一经确诊，应立即手术治疗。腹主动脉瘤修复术后长期随防是绝对必要的。     

腹主动脉瘤

应用手术切除腹主动脉瘤并行血管移植术已有30多年的历史。早在1953年就有报道7例腹主动脉瘤切除术和同种血管移植的病人,6例生存。嗣后,切除手术不断改进并广泛用于腹主动脉瘤的治疗,人造血管的应用可能是最主要的进展。很多作者将注意力集中于切除手术的指证方面,提出动脉瘤究竟长至多大才放弃观察代之以手术治疗,新近认为直径超过6厘米的腹主动脉瘤随时可能破裂致死,应予手术,而对直径小于6厘米     

开窗-分支支架系统治疗复杂腹主动脉瘤的进展

正复杂主动脉瘤(complex aortic aneurysms,CAAS):意指肾脏或内脏器官的分支,包括近肾和肾动脉瘤,IV型胸腹主动脉瘤(thoracoabdominal aortic aneurysms,TAAAS)~([1])。CAAS不同于肾下动脉瘤的手术方式,是因为他们的阻断部位位于肾动脉水平以上的主动脉,肠系膜上动脉,或腹腔干,或是IV胸腹主动脉瘤在胸主动脉降部的水平,普遍存在近端锚定区不良,瘤颈短,成角钝等问题,对于应用腔内治疗未达成广泛     

升主动脉瘤合并主动脉瓣关闭不全的外科治疗

目的：回顾性总结自１９９１年１２月至１９９９年５月期间,３３例升主动脉瘤伴主动脉瓣关闭不全外科治疗的经验。方法：３３例升主动脉瘤中,１例为真性动脉瘤。３２例为夹层动脉瘤。夹层动脉瘤按ＤｅＢａｋｅｙ分型法,Ｉ型８例,ＩＩ型２４例,均伴主动脉关闭不全,均行Ｂｅｎｔａｌｌ手术,１０例合并二、三尖瓣关闭不全,做二、三尖瓣整形手术。１例合并冠心病,做内乳动脉与前降支搭桥术,结果：手术死亡率为６．０％（２／３３）,２例分别死于感染性心内膜为和吻合不可控制性渗血,２例有严重脑部并发症,随访时间１～５５个月,远期死亡２例,均系错迷窒息死亡,其余２９例心功能明显改善,眩动脉瘤无复发。结论：（１）升主动脉瘤合并主动脉瓣关闭不全行Ｂｅｎｔａｌｌ手术,采用良好的心肌保护方法,注意吻合技术防止出血,可以取得良好的手术效果。（２）对Ｄ     

6例年轻马方综合征合并胸腹主动脉瘤的外科治疗

目的:马方综合征(MFS)合并胸腹主动脉夹层动脉瘤患者常需再次及多次手术治疗,本研究在于探讨年轻MFS合并胸腹主动脉瘤外科治疗(TAAAR)的特点及经验总结。方法:随访2008年至今,共6例MFS合并胸腹主动脉瘤行外科手术患者,分析弓部及分支血管处理、脊髓动脉及内脏动脉重建方式对再次手术和脊髓保护的影响。结果:随访时间(7.4±3.4)年,6例男性患者,平均年龄25.5岁,共进行13次手术,围手术期无患者死亡,术后截瘫1例,双下肢肌力减退1例;5例为MFS合并Stanford A型主动脉夹层,其中1例一期行Bentall及右半弓替换,二期行CrawfordⅡ型TAAAR,1例一期行孙氏手术,二期行CrawfordⅡ型TAAAR,另外有3例患者一期行Bentall及全弓替换(术中支架左锁骨下动脉"开窗"术),二期行CrawfordⅡ型TAAAR,主动脉根部瘤合并CrawfordⅡ型胸腹主动脉瘤1例,一期行TAAAR,再次手术间隔时间为(5.0±1.8)年。结论:MFS合并主动脉病变,外科同期弓部重建,为二期手术准备,术中支架慎重"开窗",为二期手术"减压";脊髓动脉重建对预防术后截瘫具有重要意义;内脏动脉功能重建,具有多样性,依据术中情况而定,不宜残留病变血管;手术方案个体化即解决"当务之急"同时兼顾后期外科治疗。     

覆膜支架腔内隔绝术治疗高龄胸腹主动脉瘤的疗效

目的：探讨主动脉腔内隔绝术治疗高龄患者胸腹动脉瘤的临床效果。方法：回顾性分析我院2004年2月至2011年7月25例实行覆膜支架腔内隔绝术的高龄胸腹主动脉瘤患者（年龄均≥65岁）的临床资料,总结手术效果,术后并发症和死亡率。结果：24例（96％）康复出院,术后并发症发生率24％（6／25）,病死率4％（1／25）,平均住院时间为（14．36±2．46）d,术后住院时间为（9．50±1．58）d。结论：覆膜支架腔内隔绝术可作为治疗高龄主动脉瘤首选方式,但须严格把握手术指征。     

主动脉瘤的外科治疗

目的总结主动脉瘤的外科治疗、腔内隔绝治疗的经验。方法回顾性分析1992年9月至2005年2月我院收治各类主动脉瘤患者46例的临床资料,男性38例,女性8例;平均年龄51.7岁;升主动脉瘤17例,胸主动脉瘤8例,腹主动脉瘤21例。手术治疗40例,其中Bentall手术10例,同期Bentall联合全弓替换1例,全弓替换2例,单纯升主动脉人工血管替换4例,胸主动脉瘤体切除人工血管置换3例,其中1例同时行双肾动脉搭桥术,胸主动脉瘤人工血管修补2例,1例行包裹术,腹主动脉瘤21例中行腋-股动脉人工血管搭桥2例,“Y”型人工血管置换7例,直型人工血管替换8例。腔内隔绝治疗6例;其中StanfordB型夹层动脉瘤2例,腹主动脉瘤4例。结果手术死亡1例,死亡率为2.5%,腔内隔绝治疗均成功。随访1个月至10年,有10例患者失访,随访期间1例死亡,总死亡率为4.3%。结论外科手术仍然是治疗主动脉瘤的一种十分有效和经济实用的主要方法。     

Surgical treatment of abdominal and thoracic aortic aneurysms in aged patients

A total of 378 patients with aortic aneurysm, consisting of 128 with abdominal aortic aneurysm (AAA) and 250 with thoracic aortic aneurysm (TAA), underwent operation in our institution during the past 20 years. Of these patients, 58 with AAA and 63 with TAA were 65 years old or over. Preoperative complications tended to be observed more frequently in the aged patients than in the younger, 'non-aged' patients. The early mortalities in the aged group were 5% for elective AAA operation, 40% for emergency AAA operation, 11% for elective TAA operation and 41% for emergency TAA operation. The 5-year survival rates in the aged group were 78.3 +/- 5.8% for AAA and 63.4 +/- 4.0% for TAA, which were not significantly different from those in the non-aged group, respectively. Postoperative complications tended to occur more frequently in the aged patients than in the non-aged patients both for AAA and TAA. The present data suggest that aggressive surgical treatment for aortic aneurysm in the aged is warranted unless other serious organ failure exists.     

Is screening of abdominal aortic aneurysm effective in a general practice setting?

AIM: This prospective study was conducted to assess feasibility, patients' acceptability and impact of ultrasound screening on rupture rate of abdominal aortic aneurysms (AAAs). METHODS: A population based sample of men (n=2709), aged over 60 years, covering 11 general practices was offered ultrasound screening between January 1996 and December 2003. The presence of risk factors for arteriosclerosis and annual rupture rates for AAAs were analyzed. RESULTS: Of the 2709 patients approached, 2561 (95%) accepted and 161 (6%) did not attend. A total number of 81 (3.4%) patients (average age: 71 years) were identified with an AAA, of which 59 were small (<5 cm) and 22 large AAAs (>5 cm). The most common risk factors identified in patients with AAA were smoking/ex-smoking (n=68, 84%) and hypertension (n=32, 40%). The overall annual rupture rate was reduced from 47% in 1996 to 14% in 2003. CONCLUSIONS: Ultrasound screening for AAA is feasible, acceptable by elderly male patients in a primary care setting and reduces the incidence of ruptured AAAs.     

The importance of and current trends in the endovascular program – A single center experience

IntroductionOpen vascular surgery and endovascular (EV) interventions are continually developing and their application differs depending on the arterial regions treated. We aim to demonstrate that current EV procedures do not mean a restriction, but on the contrary, an increase in the number of patients who can be successfully treated.MethodsWe have retrospectively followed all open surgery procedures and endovascular interventions done for carotid artery stenosis and subrenal abdominal aortic aneurysms (AAA) from 1990/1993 to 2014 in the Vascular Surgery Department at Na Homolce Hospital.ResultsFrom 1990 to 2014, 1659 open AAA surgery procedures were done in our department. Since 1996, 1023 endovascular abdominal aortic aneurysm repairs (EVAR) have been performed and since the implementation of robotics, 64 aneurysm replacements were robot-assisted. Mortality rates in the OS, EVAR and robotic groups are 1.7%, 1.5% and 0.4%, respectively. The percentage of EVAR stabilized during the last 5 years at about 32% of the total number of treated patients. From 1993 to 2014 there were 5363 open carotid surgery procedures done in our department, 2856 for symptomatic and 2507 for asymptomatic stenosis. The total cohort combined stroke/death rate was 1.6%. Symptomatic, asymptomatic and urgently operated patients had a combined 30-day stroke/death rate of 1.0%, 1.7% and 4.4%, respectively. During the same period 274 carotid bifurcation and 55 common carotid artery percutaneous transluminal angioplasty (PTA) were done. The technical success of endovascular interventions was better than 95%.ConclusionIn the AAA group, the percentage of EVAR stabilized during the last 5 years at about 32% of the total number of treated patients. Given the excellent results of open carotid surgery and the unconvincing results of stenting trials, we consider open carotid surgery to be better than carotid artery primary stenting.     

Growth rate of abdominal aortic aneurysms. Ultrasounds study and clinical outcome

BACKGROUND: The standard treatment for abdominal aortic aneurysms (AAA) >55 mm is actually represented by surgical repair mainly or by endovascular repair, in selected cases; conversely the debate is still open for those ranging 40-55 mm. These last and smaller aneurysms are usually followed-up by ultrasounds (US), in order to detect too fast expansions and to prevent sudden ruptures. Aim of this study is to present the results of the US follow-up of a series of asymptomatic AAAs and the correlation between expansion rate and associated risk factors. METHODS: All patients evaluated for an AAA between March 1991 and December 2000 were included and, according to the maximum diameters of the infrarenal aorta, were divided into 3 groups: A (26-29 mm), B (30-39 mm) and C (>39 mm). Groups A and B underwent US follow up at 6-month intervals, while group C underwent a complete preoperative evaluation. RESULTS: The mean follow up was 36+/-24 months for the entire series (225 AAA); the mean expansion rate was 1 mm/year for group A, <1.5 mm/year for group B for the first 5 years with a sharp increase (5 mm/year) in the following 2 years and 3 mm/year for group C up to 5 years. Among the associated risk factors, hypertension and smoking have confirmed their main role, independent from the initial diameter (p<0.01). Eight ruptures (3.8%) occurred in patients unsuitable for surgery or who refused it and in 7 cases they were lethal. The range between diagnosis and death (19-61 months) and the maximum size (38-93 mm) were absolutely unpredictable. The remaining 40 deaths were related to vascular diseases (MI and stroke 29.8%) or concurrent neoplasms (29.8%) mainly. The surgical treatment was carried out as elective repair on 45 patients (mortality rate 2.2%) and in emergency in 2 cases, both dead, with a mean interval from diagnosis to surgery of 28+/-17 months. CONCLUSIONS: Our results agree with the literature data concerning the dilatative trend and the risk factors and, according to these, elective repair in patients with AAA ranging 45-55 mm should be considered.     

Thoracoabdominal aortic aneurysm repair in high risk cardiac patients: A modified grafting technique

Severe cardiac disease is a major risk for early death following thoracoabdominal aortic aneurysm (TAAA) repair. Proximal aortic cross-clamping during TAAA repair dramatically increases left ventricular afterload risking myocardial ischemia. Although preoperative myocardial revascularization helps protect myocardium at risk during these periods of hemodynamic stress, in some patients myocardial revascularization is not feasible. Similarly, intraoperative shunting or bypass is not always practical. Under these circumstances we employ a modified multigraft technique during TAAA repair to reduce the risk of early death in high-risk cardiac patients. Case #1 is a 59-year-old male with end-stage ischemic cardiomyopathy (ejection fraction 15%), and recurrent admission for CHF, diagnosed with a 6 cm type III TAAA during evaluation for cardiac transplantation. Because of the potential need for intraaortic balloon support, he was not accepted for transplantation unless the TAAA could be repaired first. He underwent successful modified TAAA repair and subsequently had a successful cardiac transplant. He remains alive and well 3 years after TAAA repair. Patient #2 is a 70-year-old male who presented with an 8 cm type III TAAA. Cardiac evaluation revealed a history of prior myocardial infarction, severe nonreconstructable three-vessel coronary artery disease and inducible angina, left ventricular aneurysm, and ischemic wall motion abnormalities during dobutamine stress echocardiogram. Aneurysm size and multiple episodes of radiating central abdominal and back pain suspicious for aneurysm expansion precluded delays inherent to myocardial revascularization. He remains alive and well 10 months following successful modified TAAA repair. Patients with severe cardiac disease are at risk for early death following TAAA repair. Aortic cross-clamping contributes to this risk. The modified, multigraft technique of TAAA repair avoids aortic cross-clamping, minimizes myocardial risk, and may reduce early death.Presented at The 38th Annual World Congress, International College of Angiology, Köln, Germany, June 1996     

Association of a functional inducible nitric oxide synthase promoter variant with susceptibility to biopsy-proven giant cell arteritis

OBJECTIVE: To assess the contribution of 2 polymorphisms within the inducible nitric oxide (NOS2A) promoter region to susceptibility to giant cell arteritis (GCA). METHODS: One hundred three patients with biopsy-proven GCA and 198 ethnically matched controls from the Lugo region (Northwest Spain) were studied. Patients and controls were genotyped using polymerase chain reaction techniques for a multiallelic (CCTTT)n and for the TAAA repeat polymorphism in the promoter region of the NOS2A gene. RESULTS: No significant differences in allele or genotype frequencies for the (CCTTT)n repeat polymorphism in the NOS2A gene between patients with GCA and controls were observed. However, significant differences for the TAAA repeat polymorphism between patients and controls were found. The overall distribution of NOS2A TAAA genotypes in patients with biopsy-proven GCA was significantly different than controls (p = 0.026). Patients with GCA had an increased frequency of the NOS2A TAAA+ allele (16.5%) compared with controls (9.1%) (p = 0.007; OR 1.98; 95% CI 1.20-3.27). This was due to an increased frequency of both heterozygotes (27.2%) and homozygotes (2.9%) for NOS2A TAAA+ observed in patients compared to controls (15.2% and 1.5%, respectively) (p = 0.007; OR 2.15; 95% CI 1.23-3.78). CONCLUSION: Our results suggest a potential implication for NOS2A TAAA gene polymorphism in GCA susceptibility.     

Abdominal aortic aneurysm in patients submitted to chronic hemodialysis for autosomal dominant polycystic kidney disease: Personal experience

A multicenter investigation was carried out, from January 1992 through January 1993, to study the incidence of abdominal aortic aneurysm (AAA) in patients submitted to chronic hemodialysis for end-stage renal disease.AAA affected 8.5% of 129 patients. Risk for AAA was higher in men aged more than 60 years with body height and weight greater than those of the general population.AAA was present in 19.3% (6/31) patients affected with autosomal dominant polycystic kidney disease and in 5.1% (5/98) patients in whom renal insufficiency was due to other pathologies (p<0.02).     

Prevalence of Intracranial Aneurysms in Patients with Infrarenal Abdominal Aortic Aneurysms: A Multicenter Experience

Prior studies suggest high prevalence of intracranial aneurysms (IA) in patients with infrarenal abdominal aortic aneurysms (AAA). We reviewed our multicenter experience in clinical detection/treatment of IAs in AAA patients and estimated the risk of IA in patients with AAA relative to patients without AAA. We reviewed cases of vascular surgery infrarenal AAA repairs at three Mayo Clinic sites from January 1998 to December 2018. Concurrent controls were randomly matched in a 1:1 ratio by age, sex, smoking history, and head imaging characteristics. Conditional logistic regression was used to calculate odds ratios. We reviewed 2,300 infrarenal AAA repairs. Mean size of AAA at repair was 56.9 ± 11.4 mm; mean age at repair, 75.8 ± 8.0 years. 87.5% of the cases ( n = 2014) were men. Head imaging was available in 421 patients. Thirty-seven patients were found to have 45 IAs for a prevalence of 8.8%. Mean size of IA was 4.6 ± 3.5 mm; mean age at IA detection, 72.0 ± 10.8 years. Thirty (81%) out of 37 patients were men. Six patients underwent treatment for IA: four for ruptured IAs and two for unruptured IAs. All were diagnosed before AAA repair. Treatment included five clippings and one coil-assisted stenting. Time from IA diagnosis to AAA repair was 16.4 ± 11.0 years. Two of these patients presented with ruptured AAA, one with successful repair and a second one that resulted in death. Odds of IA were higher for patients with AAA versus those without AAA (8.8% [37/421] vs. 3.1% [13/421]; OR 3.18; 95% confidence interval, 1.62–6.27, p < 0.001). Co-prevalence of IA among patients with AAA was 8.8% and is more than three times the rate seen in patients without AAA. All IAs were diagnosed prior to AAA repair. Surveillance for AAA after IA treatment could have prevented two AAA ruptures and one death.     

巨脾型晚期血吸虫病与HBV及HCV感染的研究

本文作者对１２４例临床诊断为巨脾型晚期血吸虫病（晚血）的患者作了肝组织病理、ＨＢＶ和ＨＣＶ标志检测及随访观察。病理诊断为血吸虫病性肝纤维化７８例（６２．９％），血吸虫病性肝纤维化合并肝炎３１例（２５％），门脉性肝硬化１５例（１２．１％），三组患者ＨＢｓＡｇ及ＨＣＶ标志检出率分别为３５．９％、６４．５％及９３．３％，提示肝细胞病变及其严重程度与肝炎病毒感染有密切关系。以血吸虫病性肝纤维化为基本病变的１０９例中，ＨＢｓＡｇ或ＨＣＶ标志阳性组病死率为２２．９％（１１／４８），显著高于阴性组１．６％（１／６１）。１８例死亡患者中，ＨＢｓＡｇ和／或ＨＣＶ标志阳性１７例，占９４．４％。最常见的死亡原因是肝功能衰竭，第二位是原发性肝癌（ＨＣＣ）。ＨＢＶ及ＨＣＶ感染是发生肝衰竭及ＨＣＣ的关键因素，与晚血患者的死亡密切相关。     

肝动脉化疗栓塞结合外放射治疗大肝癌的预后因素分析

目的 观察肝动脉化疗栓塞（transcatheter arterial chemoembolization,TACE)结合外放射治疗大肝癌的远期效果并分析预后因素。方法 以TACE结合外放射治疗107例大肝癌患者（肝肿瘤最大径5-18cm)。观察近期效果与生存率，并用Cox比例风险模型分析预后因素。结果 48.6%的病例获得肿瘤缓解，1、3、5年累积生存率分别为59.4%、28.4%、15.8%。肿瘤数目、放疗剂量为独立的预后因素。单发肿瘤者的累积生存率（1、3、5年分别为75.8%、43.9%、26.8%）明显高于肝内肿瘤多发者（1、3年分别为31.3%、5.0%,P=0.0005)。放疗剂量40Gy以上者的生存率（1、3、5年分别为95.8%、74.7%、37.4%）明显高于剂量20-40Gy者（分别为60.9%、20.7%、10.3%）与剂量低于20Gy者（分别为26.7%、7.1%、7.1%，P=0.0001)。结论 TACE结合外放射为治疗不能切除大肝癌的有效方法。肿瘤数目为影响预后的最重要的临床因素。在肝脏可耐受的范围内给予最高剂量的放疗是提高疗效的关键。