近肾动脉腹主动脉闭塞症诊断和治疗体会

目的总结近肾动脉腹主动脉闭塞症的诊断和治疗体会。方法对我科在1999年1月～2005年12月6例诊断为近肾动脉腹主动脉闭塞症接受手术治疗的临床资料进行回顾性分析。其中3例作腹主-双髂(股)动脉旁路手术,2例作肾下腹主动脉取栓加腹主-双髂(股)动脉旁路手术,1例单纯作腹主动脉-双侧髂动脉切开取栓手术。结果术后全部病人双足背动脉搏动恢复,双肾功能正常,间歇性跛行消失。结论近肾动脉腹主动脉闭塞症的诊断除根椐临床症状和体征外需进一步行血管造影、MRI、CTA等检查。术中必须行肾动脉以上腹主动脉阻断时,应采用尽可能低的位置阻断,并对受累器官采取保护措施,阻断时间要尽可能缩少。     

复杂主髂动脉闭塞症的治疗选择

主髂动脉闭塞症是血管外科的常见病和多发病,动脉硬化闭塞症是其主要的发病原因。复杂的主髂动脉闭塞大致可分为以下两种情况。1主髂动脉病变复杂:病变累及长段的肾下腹主动脉、腹股沟韧带以远动脉,同时伴有主髂动脉瘤等。这些病变在泛大西洋协作组(Trans-Atlantic Inter-Society Consensus,TASC)Ⅱ分级中多属于D级病变。2病人全身一般情况较差,伴随的系统性疾病多且严     

DebakeyⅢ型夹层动脉瘤远侧破口的腔内封堵

目的 初步总结使用腔内技术处理夹层动脉瘤远侧破口的经验.方法 总结15例DebakeyⅢ型夹层动脉瘤近端破口腔内修复术后腹主动脉以远破口的二期介入处理经验.所有病例远侧破口持续存在,出现腰腹部症状或局部腹主动脉外径增加.本组病例中内脏动脉处破口7个(1个腹腔动脉内破口,6个肾动脉处破口),肾下腹主动脉破口4个,髂动脉破口7个;其中3例为内脏动脉破口合并髂动脉破口.肾下腹主动脉破口均采用一体式覆膜支架封堵;1例近右肾动脉破口使用先心封堵伞;其余内脏动脉和髂动脉破口均采用小覆膜支架封堵.结果 所有病例均顺利完成操作,腹主动脉和髂动脉破口封堵良好,无内漏.使用封堵伞的病例,夹层破口封堵良好,但由假腔供血的右肾动脉同时闭塞;肾动脉破口使用覆膜支架封堵病例中,1例显著内漏,2例微量内漏,其余病例封堵良好,无内漏.病例随访2 ～10个月,平均(5.0±2.0)个月,内漏病例CTA示假腔内部分血栓形成,但破口附近假腔仍有血流,其余病例夹层内均血栓形成.结论 针对适当患者,个体化方案封堵夹层动脉瘤的远侧破口是可行和安全的.     

马凡综合征腹主动脉夹层腔内修复术后支架远端腹主动脉瘤形成：1例报道并文献复习

患者,男,51岁.2年前因"发现腹部搏动性肿块3年余"首次入我院.术前腹部CT血管造影(CT angiography,CTA)提示腹主动脉夹层伴附壁血栓形成,累及双侧髂总动脉;近端破口距肾动脉水平以远约15 mm,双侧髂总动脉各有一破口,内脏动脉均发自真腔(图1),诊断为"马凡综合征、腹主动脉夹层".     

腔内治疗主动脉瘤时锚定区不足的处理

目的 探讨主动脉夹层、胸主动脉瘤、胸腹主动脉瘤腔内治疗远近端锚定区缺乏的现阶段处理体会.方法 2005年8月至2009年2月,我科共治疗主动脉扩张性疾病包括主动脉夹层、胸主动脉瘤、胸腹主动脉瘤129例,其中主动脉夹层近端锚定区不足6例,胸主动脉瘤近端锚定区不足3例,腹主动脉瘤远端锚定区不足4例.分别进行升主动脉一双侧颈总动脉一左锁骨下动脉转流、双侧颈总动脉一左锁骨下动脉转流、腹主动脉一肠系膜上动脉一双侧肾动脉转流、髂内动脉栓塞重建锚定区后成功腔内治疗.结果 患者均获技术和临床成功,无围手术期死亡和重大并发症.随访期间支架人造血管无移位,夹层或动脉瘤腔血栓形成良好,无明显内漏,瘤体未增大;桥血管通畅.结论 对于缺乏锚定区的主动脉扩张性病变,通过人造血管旁路手术或栓塞非必须血管等方法重建或扩大锚定区是扩大腔内治疗适应证的安全、有效的手段.     

正常人降主动脉壁及髂总动脉壁周向张力及平均应力分析

体中段平面及髂总动脉处有创测压,测量收缩压、舒张压、平均压,MRI下测量动脉内径、壁厚.通过公式计算得出动脉壁周向张力与平均应力,以自身不同部位对照.结果:收缩压自胸主动脉至髂总动脉逐渐升高(P<0.01),舒张压胸主动脉与腹主动脉相差不明显(P>0.05),髂总动脉较胸主动脉与腹主动脉低(P<0.01),平均动脉压肾下腹主动脉最高(P<0.01).自胸主动脉至髂总动脉动脉内径逐渐缩小(P<0.01),管壁亦逐渐变薄(P<0.01).动脉壁周向张力自胸主动脉至髂总动脉逐渐减少(P<0.01).肾下腹主动脉平均应力大于其它动脉(P<0.01),且在一个心动周期中变化幅度最大.结果 肾下腹主动脉处平均应力大于肾上腹主动脉、胸主动脉和髂总动脉,且在一个心动周期中变化幅度最大,可能是造成肾下腹主动脉易于受损而形成动脉瘤的原因.     

腔内修复治疗肾下腹主动脉夹层六例经验

目的 探讨肾下腹主动脉夹层腔内治疗的可行性、方法选择和疗效。方法 回顾性分析2000年1月至2006年10月以腔内修复为主的6例肾下腹主动脉夹层患者的临床资料，患者术前均通过螺旋CT或者DSA检查明确诊断。3例采用分叉弄人工血管内支架进行腔内修复；2例植入腹主-单侧髂动脉型人工血管内支架、对侧髂动脉植入封堵器、股股人工血管旁路术；1例植入2枚直管型人工血管内支架，对侧髂动脉结扎、股股人工血管旁路术。患者术后1、3、6个月、1年及以后间隔1年于门诊行彩色B超、X线或者螺旋CT进行随访。结果 所有患者夹层得到完全修复，围手术期4例患者出现一过性发热，无血象异常。术后患者随访6～36个月，5例患者结果满意，1例患者于6个月随访时瘤腔内残留少量血流信号，瘤腔基本血栓化。结论 肾下腹主动脉火层采用以腔内修复为主的方法 安全可行、短期和中期疗效可靠。     

手术治疗近肾动脉腹主动脉闭塞症

为提高近肾动脉腹主动脉闭塞症的疗效，作者采用左肾静脉下控制腹主动脉，腹主动脉切开逆行血栓内膜切除、腹主动脉－双股（髂）动脉人造血管转流术，及腋动脉－双股动脉转流术。１０年来共收治了２７例，病因主要是动脉粥样硬化和大动脉炎所致的主髂动脉狭窄闭塞。诊断主要依据为双下肢缺血、双股动脉搏动缺失、腹主动脉搏动消失、性功能障碍及血管造影阳性结果。２５例作了手术治疗。治愈好转率８４％，死亡４例。作者认为：手术效果决定于合并症及远端流出道的好坏。术前合并症直接影响死亡率。     

髂窝脓肿手术处理错误的经验教训

病历摘要患者男,24岁。因左侧髂窝脓肿行切开引流术,术中大出血,急用纱布压迫后一周内经4次手术止血米能成功,且出现了腹膜炎症状,乃急诊转来本院。立即快速输血补液及抗炎,待情况改善后,在硬膜外麻醉下手术。取出创口内填塞之纱布清除血块和坏死组织时,有大量鲜血涌出,使局部探查难以进行。即用纱布暂时压迫止血,切开左下腹,见腹腔内有多量脓液及血块,左髂窝腹膜后有巨大血肿。吸除腹腔内脓m,游离腹主动脉。在肾动脉下方暂阻断。切断腹股沟韧带,游离股动脉,用血管夹阻断。清除髂窝内血块,发现髂外动脉有一整齐裂口,髂窝内侧的腹膜也订一裂口,脓血由此进入腹腔。用000号无创缝针修补动脉裂口,腹膜破口亦予缝合。彻底冲洗,置多根引流,腹股沟部仅疏松缝合数针以免大血管暴露于外。术后第11天左腹股沟创口又突然大出血,再次紧急     

肝动脉-腹主动脉搭桥在原位肝移植术中的应用

目的探讨供肝动脉与受体肾动脉下的腹主动脉之间用同一供体的骼动脉进行搭桥的方法及其相关并发症的影响因素。方法回顾性分析8例使用同一供体的髂动脉进行肾动脉平面以下肝动脉-腹主动脉搭桥的肝移植术临床资料。结果8例患者术中肝动脉-腹主动脉搭桥用时53～126min，术后发生胆瘘1例，胆道感染并肝内胆汁瘤形成1例，其余6例患者恢复顺利，肝功能1周左右恢复正常；无肝动脉并发症发生。结论使用供体髂血管进行肝动脉-腹主动脉搭桥，对于无法行常规肝动脉吻合的受体是一种安全、有效的方法。     

Spontaneous dissection of the abdominal aorta

Acute dissection of the aorta is a vascular surgical emergency. The majority of dissections originate in the thoracic aorta. Dissection originating in the infrarenal abdominal aorta is very rare and, given the vagueness of presenting symptoms of uncomplicated dissection, diagnosis is very difficult in the early stages. In the absence of a pulsatile abdominal mass, acute uncomplicated aortic dissection should be considered in the differential diagnosis of sudden onset of abdominal and back pain. We report a case of spontaneous infrarenal abdominal aortic dissection occurring in an ostensibly normal aorta, and discuss the diagnostic dilemma and subsequent management of the patient.     

Limited acute dissections of the abdominal aorta. Report of five cases.

Within a two year period, the diagnosis of acute dissection of a segment of the abdominal aorta was made in five cases without aneurysmal dilation or leakage and with virtually no ischaemia. All patients presented with an atypical painful abdominal syndrome and the diagnosis was made by computed tomography. Only one patient, suffering persistent pain was treated by resection and graft interposition of the infrarenal aorta. All the others were treated conservatively and kept under close follow-up. Two of them died from intercurrent disease. The remaining three patients are doing well after 30 and 42 months conservative treatment and 43 months after surgery respectively. A non-complicated dissection of the abdominal aorta must be considered in the differential diagnosis of atypical painful abdominal syndromes. In cases of persistent pain, progression, ischaemia, aneurysmal dilatation or leakage, surgical treatment is mandatory. In uncomplicated cases conservative treatment is recommended, similar to the principles of management for dissections of the descending thoracic aorta.     

Acute and chronic dissections of the abdominal aorta: clinical features and treatment

We report seven cases of dissection of the abdominal aorta. Three patients had acute back pain, whereas four patients had more chronic courses. In six cases, as a result of the palpation of a pulsatile abdominal mass, clinical diagnosis was an atheromatous aneurysm. Angiography and CT scanning demonstrated a dissected abdominal aorta and a normal thoracic aorta. Six patients with an infrarenal dissection were treated by replacement of the aorta with a Dacron prothesis, and one patient with an suprarenal dissection was treated conservatively. With a mean follow-up of 3 years, all patients were alive and free of symptoms. These results favor graft replacement in case of infrarenal aortic dissection and more selective surgical indications in suprarenal aortic dissection.     

Type B aortic dissection with rupture of the left common iliac artery: a case report

Type B aortic dissection involves the appearance of a false lumen distal to the left subclavian artery and extending distally into the descending thoracic aorta and into the abdominal aorta. Complications of the dissection include rupture of the thoracic aorta, leg ischemia, visceral ischemia, and renal failure. A 37-year-old man presented with complaints of sudden onset of chest pain, left leg pain, and numbness. Examination revealed no femoral, popliteal, or distal pulses with decreased sensory and motor function on the left lower extremity. A CT scan revealed an aortic dissection at the proximal descending aorta extending into the iliac arteries with a left retroperitoneal hematoma at the iliac bifurcation. An MRI confirmed the dissection distal to the left subclavian artery into the iliac artery with a distal occlusion. Exploration revealed rupture of the left iliac artery dissection with arterial occlusion and a contained hematoma. The common iliac artery was ligated and an 8-mm Dacron bypass graft from the right common femoral artery to the left femoral artery was performed. Type B aortic dissection can present as rupture of the common iliac artery. Revascularization of the extremity with a femoral-femoral crossover graft is the recommended procedure in the absence of visceral ischemia. The surgeon should have a keen suspicion of this rare complication and its management.     

Robotic-assisted laparoscopic dissection of the infrarenal aorta and iliac artery: a technical description and early results

We report our initial experience with a novel robotic-assisted dissection of the infrarenal aorta and iliac arteries for the treatment of aortoiliac occlusive disease and abdominal aortoiliac aneurysm. Seven patients underwent the procedure using the da Vinci Surgical System. Transabdominal, retroperitonal dissection of the aorta and iliac arteries was completed using the robotic system; then, a mini-laparotomy and hand-sewn aorta-to-graft anastomosis were performed. There was no mortality in this series of patients. This novel technique may overcome the difficulty of aortic dissection in a purely laparoscopic aortic surgery and serves as a bridging step toward totally robotic-assisted aortic surgery.     

Aortic false aneurysms after prosthetic reconstruction of the infrarenal aorta

False aneurysm of the infrarenal aorta was found at the site of proximal anastomosis in 13 patients after vascular reconstruction for lower limb arterial disease. The grafts involved were aortoprosthetic in one patient, aortobiiliac in two patients, and aortobifemoral in 10 patients. They had been implanted eight years prior to reoperation on the average (range six months to 15 years). False aneurysm was diagnosed because of abdominal pain in four cases, embolism in two cases, intestinal hemorrhage in one case, and during routine sonographic or computed tomographic (CT) scan surveillance in the six other cases. Femoral false aneurysm was associated in eight of 10 cases with femoral anastomoses. Aortic false aneurysms were repaired by interposition of a prosthetic tube between the infrarenal aorta and the original prosthetic graft in 11 cases and by changing the aortobifemoral graft in two cases. In one further case, repair was accomplished by implanting an aortobifemoral prosthetic graft laterally on a prosthetic tube interposed between the infrarenal aorta and the body of the original prosthetic graft, which continued to irrigate the internal iliac arteries. There was no mortality. Thrombosis of a prosthetic branch occurred in one case and was treated by thrombectomy. One patient underwent reoperation for intestinal obstruction. Two others had distal embolism responsible for toe necrosis. Anastomotic false aneurysms should be looked for routinely during the surveillance of prosthetic grafts implanted on the infrarenal aorta, especially when femoral false aneurysm is found. Preservation of pelvic vascularization must be an integral part of management.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Spontaneous dissection of the infrarenal abdominal aorta

Spontaneous infrarenal abdominal aortic dissection is rare. We observed enlargement of a spontaneous infrarenal aortoiliac dissection in a 55-year-old hypertensive man. Open surgical repair with a bifurcated polyester graft was successful. A review of the English literature found 41 previously published cases. Mean age was 58 years, 74% of the patients were male, and 62% had hypertension. None had Marfan or Ehlers-Danlos syndrome. More than three fourths of the patients had symptoms, 6 patients (14%) presented with aortic rupture. Dissection was limited to the infrarenal aorta in 50% and extended into the iliac or femoral arteries in 50%. Three patients died before treatment, no death occurred after endovascular repair of after elective open aortic grafting. Mortality following rupture was 67%. Abdominal aortic dissection did not reoccur but 1 patient died at 14 month because of rupture of a thoracic aneurysm. Spontaneous infrarenal abdominal aortic dissections are rare, but usually symptomatic and 14% rupture. Rupture carries high mortality. Elective open repair is recommended, but endovascular repair is a new treatment option for suitable patients.     

Acute dissection of the abdominal aorta

A 64-year-old man presented with sudden lower abdominal pain and diffuse lumbago. He was diagnosed as having primary dissection of the abdominal aorta. Entry closure and aneurysmal wall plication was performed, and the subsequent course was satisfactory. Surgical intervention is recommended for patients with abdominal aortic dissection in the infrarenal segment, where the extent of dissection is limited and access is comparatively easy. Enhanced computed tomography is useful both in diagnosis and follow-up of this aortic disease.     

Midaortic pseudoaneurysm complicating extensive endovascular stenting of aortic disease

We report a case of successful surgical management of a potentially life-threatening complication of aortoiliac stent placement. A 59-year-old man who had Leriche syndrome underwent bilateral iliac artery and infrarenal aortic stent placement at another institution. His history was significant for retroperitoneal lymph node dissection at 19 years of age for testicular cancer. One week after stent placement, the patient was readmitted with abdominal pain, poor oral intake, and diffuse intermittent tenderness. Evaluation with computed tomographic scanning and endoscopy was unremarkable, and the patient was discharged. He was admitted to our institution 1 week later with persistent abdominal pain. A computed tomographic scan of the abdomen revealed a large pseudoaneurysm of the abdominal aorta. The patient underwent urgent exploration, and exclusion of his infrarenal aorta was achieved with aortobifemoral bypass grafting. After the operation, the patient's course was complicated by a large paraduodenal hematoma, which resulted in a gastric outlet obstruction, which was managed without operation. This case illustrates a potential life-threatening complication of extensive stent placement for aortoiliac occlusive disease. Injury to the abdominal aorta must be considered in a symptomatic patient after the placement of stents in the aortoiliac region, beyond the immediate periprocedural period. (J Vasc Surg 1997;26:958-62.)     

Die stentgestützte Aneurysmaausschaltung mit dem TALENT-System

Introduction The TALENT system has made it feasible for the first time to use endovascular stent placement in the treatment of infrarenal aneurysms of the abdominal aorta with neck diameters greater than 26 mm. The following paper presents the experience of 29 German vascular surgical centers using the TALENT system. Materials and Methods Between October 1996 and September 1997, a total of 123 aortic aneurysms in 122 patients were treated endovascularly. Ninety-five infrarenal aneurysms of the abdominal aorta were treated using bifurcated stents, while in 28 cases tube stents were implanted. In nine cases, tube stents were used to treat aneurysm of the thoracic aorta. A total of 111 patients (112 aneurysms) presented for follow-up. The average proximal diameter of the bifurcated stents in infrarenal aneurysms was 30 mm (range 24–36 mm), while the average iliac stent diameter was 14 mm (range: 10–20 mm). In tube stents, diameters ranged from 24–30 mm in abdominal stents and from 32–40 mm in thoracic stents, respectively. In this series, each stent was individually manufactured for the patient on the basis of findings from computed tomography (CT) and calibrated angiography. Results Endovascular treatment of aneurysms was successful technically in 96% of patients. During a follow-up period averaging 4.3 months, the following complications were observed: 5 perioperative death (4.1%), 4 conversions to open surgical therapy (3.3%), 7 endoleaks (5.7%), 2 stent dislocations, 2 iliac stent thromboses, 2 perforations of iliac arteries, 1 inguinal hematoma, and 1 inguinal infection. Conclusions These preliminary findings show that aneurysms with larger neck diameters are amenable to endovascular treatment. Despite the wide distribution of participating vascular surgery centers with varying degrees of experience and many first-time implantations, the results of the present multicenter study hardly differed from those reported in larger series in established institutions. Through the use of larger-diameter stents, up to 50% of all infrarenal aneurysms of the abdominal aorta may be possibly successfully treated using endovascular methods.