腔内血栓降低大鼠腹主动脉瘤壁残余应力对瘤壁保护作用的评价

目的：用测量张开角的方法研究大鼠单纯腹主动脉瘤（AAA）和腔内血栓AAA模型的应力分布，对比两种模型瘤壁的顺就生，评估腔内血栓对瘤壁的保护作用。方法：用猪弹力蛋白酶灌注Wistar大鼠腹主动脉建立梭形肾下AAA模型，相似的方法并机械破坏内腹建立腔内血栓AAA模型，测量并对比单纯AAA和腔内血栓AAA动脉环的蠕变速度，残余应力，对比两组AAA同一瘤体不同部位的残余应力，动脉环内径和瘤壁厚度。结果：单纯AAA模型建立的成功率90%，腔内血栓AAA模型建立的成功率为60%，单纯AAA动脉环蠕变速度较腔内血栓AAA慢，单纯AAA入口和出口的残余应力值最大，内径和瘤壁厚度最小；腔内血栓AAA的残余应力分布规律相似，但总体残余应力较低。结论：残余应力量化反映AAA瘤壁的顺应性，腔内血栓AAA较单纯AAA的顺应性大；单纯AAA和腔内血栓AAA入口和出口附近应力最大，腔内血栓通过降低血管的残余应力对AAA起保护作用。     

腔内修复术后腹主动脉瘤破裂对策

腔内修复（EVAR）术后腹主动脉瘤（AAA）破裂是严重的主动脉疾病，危及生命。随着EVAR手术的推广和病人预期生命延长，发现其术后远期发生率显著高于预期。提高EVAR术后长期随访率，同时重视动脉粥样硬化和系统性炎性疾病对EVAR手术远期预后的意义，有助于早期发现AAA破裂风险，降低发生率。该疾病须根据病人病情制定个体化的手术治疗方案，但总体的围手术期病死率高。腔内手术是首选的手术治疗方法，以“Cuff开窗技术”、“裙套技术”为代表的腔内手术能够快速、有效地隔绝内漏；开放手术是治疗复杂病变的重要手段，以“球囊阻断技术联合主动脉缩缝术”为代表的开放手术，能够迅速稳定血流动力学状态，彻底纠正主动脉破裂的病变，有较高的救治成功率。     

腹主动脉瘤腔内修复术后内漏的诊断与治疗

腹主动脉瘤（AAA）腔内修复术（EVAR）是目前大动脉病变腔内治疗最成熟的技术之一。AAA EVAR术后内漏指支架型血管置入后，在支架型血管腔外、被旷置的瘤体及邻近血管腔内出现持续性血流的现象。内漏是AAA EVAR术后最为常见、对疗效影响很大的并发症，其发生率大约15％～50％。内漏可导致瘤体进一步增大甚至破裂。目前，内漏的机理尚不完全明确，诊断与治疗方面也存在争议。现根据我院临床经验，结合近年来相关文献报道探讨AAA EVAR术后内漏的诊治。     

腔内修复术后腹主动脉瘤破裂对策

腔内修复（EVAR）术后腹主动脉瘤（AAA）破裂是严重的主动脉疾病，危及生命。随着EVAR手术的推广和病人预期生命延长，发现其术后远期发生率显著高于预期。提高EVAR术后长期随访率，同时重视动脉粥样硬化和系统性炎性疾病对EVAR手术远期预后的意义，有助于早期发现AAA破裂风险，降低发生率。该疾病须根据病人病情制定个体化的手术治疗方案，但总体的围手术期病死率高。腔内手术是首选的手术治疗方法，以“Cuff开窗技术”、“裙套技术”为代表的腔内手术能够快速、有效地隔绝内漏；开放手术是治疗复杂病变的重要手段，以“球囊阻断技术联合主动脉缩缝术”为代表的开放手术，能够迅速稳定血流动力学状态，彻底纠正主动脉破裂的病变，有较高的救治成功率。     

腹主动脉瘤腔内治疗进展

腹主动脉瘤(abdominal aortic aneurysms,AAA)是指腹主动脉的局部或普遍扩张,主动脉直径较正常直径增大50％以上的病理改变.随着瘤体的不断增大,其破裂风险不断增高[1].1951年Dubost首次成功进行了AAA切除术,成为AAA外科治疗的里程碑.1991年阿根廷血管外科医生Parodi首次采用支架-人工血管复合体治疗AAA并取得成功[2];开创了AAA腔内治疗的新纪元.随后腔内技术治疗AAA在世界范围内迅速开展,使AAA的治疗发生了根本的变革.本文对AAA最新的腔内治疗热点及进展进行综述.     

腹主动脉瘤腔内治疗的现状

1991年阿根廷Parodi等第一次成功地实施了腹主动脉瘤(AAA)的腔内治疗。一开始关于这个领域出现了很多命名，有具体指一项技术的，比如腹主动脉瘤的“人工血管支撑(stenting graft)”和“腔内旷置术(endovascular exclusion，也称‘隔绝术’)”；有指这一类新方法的，比如“血管腔内外科(endovascular surgery)”和“腔内技术(endovascular technic)”等等。国际腔内血管外科医师协会在美国亚力桑纳凤凰城创办了专业杂志《Journal of Endovascular Surgery》于2000年更名为《Journal of Endovascular Therapy》，     

腹主动脉瘤腔内修复术并发内漏的防治

腹主动脉瘤(abdominal aortic aneurysm,AAA)是指腹主动脉局限性扩张,直径为邻近正常动脉1.5倍以上的病理性改变,其致命的并发症是破裂.自1952年以来,动脉瘤切除和人工血管原位移植术曾是治疗AAA唯一有效的方法.1990年,阿根廷学者Parodi制成直型腔内移植物(stent-graft,SG),首次对AAA患者进行腔内治疗.1991年,俄罗斯医师Volodos报道了29例AAA腔内隔绝术获得成功.1994年Yusof等报道了分叉型覆膜支架治疗AAA.1997年,景在平教授成功实施了国内首例腹主动脉瘤的腔内修复术(endovascular aneurysm repair,EVAR).EVAR至今已有20年的历史,国内已广泛开展此项技术;由于其创伤小,恢复快的特点,已逐步取代了一部分AAA的传统开腹手术.但是,内漏(endoleak)仍是一个有待解决的难题.     

巨噬细胞浸润在腹主动脉瘤发病中的作用

腹主动脉瘤(abdominal aortic aneurysm，AAA)是一种主动脉局限性扩张性疾病。虽然临床上能通过主动脉重建手术或腔内隔绝术对其进行有效治疗，但因为其发病机制尚未完全清楚，将直接影响对AAA的早期防治效果。目前在AAA的病因学研究中，炎性细胞浸润与AAA发病的关系正受到国内外学者的广泛重视。本文对炎性细胞中的一种主要成分——巨噬细胞参与AAA形成的各种作用作一概述。     

腹主动脉瘤合并需外科手术的消化系统疾病六例的临床分析

目的：探讨腹主动脉瘤（AAA）合并需外科手术之消化系统疾病（DSD）的治疗方法。方法：总结自1999年3月至2001年10月6例AAA合并需手术治疗之DSD的处理经验。AAA直径为4.8-11cm，平均7.1cm。AAA和DSD同期手术治疗3例（胆囊切除2例，乙状结肠癌根治1例），AAA腔内隔绝术后行结肠肝曲癌和食道下端癌根治术2例。先行胃癌根治术后行AAA修复1例。结果：食管胃吻合口瘘术后第2天死亡1例，胃瘫1例经治疗30d后胃功能恢复，未发生移植人工血管感染。5例存活，随访6-42个月，平均19个月，无吻合口动脉瘤及支架内漏发生。结论：只要患者全身及局部情况许可，AAA和DSD可同期手术，反之分期进行，AAA腔内隔绝术可作为该类患者首先进行治疗之有效措施。     

腹主动脉瘤的治疗

目的 探讨腹主动脉瘤(AAA)的治疗方法。方法 回顾性分析26例AAA的临床资料。结果 26例中夹层动脉瘤3例，真性动脉瘤21例，动脉瘤破裂后再形成的假性动脉瘤1例，动脉瘤穿破十二指肠空肠曲形成腹主动脉肠瘘1例。病变累及肾动脉平面以上者3例，肾动脉平面以下者23例：病变仅累及腹主动脉者4例，病变除累及腹主动脉外，尚合并有单侧或双侧髂总动脉瘤者／2例，合并双侧髂总动脉瘤及一例或双侧髂内动脉瘤者5例，合并一侧髂总、髂内、髂外动脉瘤1例，合并有双侧髂总、髂内、髂外动脉瘤1例。施行紧急手术治疗3例，择期手术治疗14例，施行支架型人工血管腔内微创治疗7例，未手术2例。术后发生并发症3例，无瘫痪、下肢动脉栓塞等发生。术中及术后30d死亡率为3．8％(1例)。支架型人工血管治疗的7例无漏血、移位等并发症发生，均痊愈出院。22例随访3个月至4年，均存活良好。结论 AAA的腔内血管外科治疗具有创伤小，术石恢复快，并发症少等优点，有条件行支架型人工血管作腔内治疗的应优先考虑腔内治疗，传统手术方法在技巧等方面的改进有利于提高手术的成功率，并能为不具备腔内治疗条件的患者解除疾患。     

肾动脉下腹主动脉瘤腔内治疗后并发症的防治

目的　总结肾动脉下腹主动脉瘤腔内治疗后常见并发症的预防与处理。　方法对已施行腔内治疗的 71例肾下腹主动脉瘤患者的临床资料进行回顾性分析 ,讨论常见并发症发生的原因、处理、结果及预后。　结果　 71例接受腔内治疗的肾动脉下腹主动脉瘤患者技术成功率1 0 0 % ,无中转开腹手术者。原发性内漏 8例 ,神经并发症合并急性血栓形成 1例。一过性缺血性肠炎 2例。无肾动脉梗死、肢体栓塞等并发症。平均随访时间 (2 6± 5)个月。围手术期病死率 1 3 % (1 /71 ) ,总病死率 4 2 % (3/ 71 )。死亡原因 2例为急性心肌梗死 ,1例为急性心功能衰竭。随访过程中发现 3例原发性内漏转为持续性内漏 ,另发现继发性内漏 4例。本组患者 1个月后内漏发生率 9 8%(7/ 71 )。 2例继发性Ⅰ型内漏随访中瘤体增大 ,1例进行二期腔内治疗。　结论　动脉瘤的腔内治疗具有创伤小、技术操作可行、效果肯定的优点 ,内漏血是该技术主要并发症。对漏血量及瘤体有增大趋势的内漏应积极处理     

Endovascular repair of infrarenal abdominal aortic aneurysms in high-risk-surgical patients.

PURPOSE: Following the publication of a prospective randomized trial (EVAR2) that questioned the benefit of endovascular repair of abdominal aortic aneurysms (AAA) for high-surgical-risk patients, we evaluated our own initial and long-term results with endovascular AAA repair for this patient population. MATERIAL AND METHODS: Between January 2000 and December 2005, 115 patients with an AAA managed by an aortic endograft were entered in a registry. Data concerning diagnosis, operative risk, treatment, and follow-up were analyzed on an intention-to-treat basis for all patients considered to be poor candidates for surgery. Patients with a ruptured AAA and those who were good surgical candidates were excluded from analysis. The main goal was evaluation of the operative mortality and the long-term survival of these patients. Secondary goals were determination of the frequency of secondary operations, the outcome of the aneurysm sac, and primary and secondary patency rates after aortic endograft placement. RESULTS: A total of 92 high-surgical-risk patients treated by an endograft were entered in this study. Sixty-seven patients (73%) were classed ASA III and 18 (20%) were ASA IV (20%). Mean aneurysm diameter was 58 mm+/-9 mm. The technical success rate was 99%. Operative mortality was 4.3% (4 cases). Four patients required re-intervention during the mean follow-up of 18 months. The survival rate at 3 yr was 85%. One type I endoleak (1%) and 9 type II endoleaks (9.7%) occurred during the follow-up period. Primary and secondary patency rates at 3 yr were respectively 96% and 100%. CONCLUSION: Our initial and long-term results with endograft repair of AAA in high-surgical-risk patients were satisfactory. These results appear to justify endovascular repair for this patient population.     

Abdominal aortic endograft proximal collapse resulting in aortic aneurysm rupture

An 82-year-old man was transferred to our emergency department due to acute abdominal pain. He had undergone an endovascular abdominal aortic aneurysm repair (EVAR) six years ago. An intravenous contrast-enhanced abdominal computed tomography revealed the rupture of the abdominal aortic aneurysm (AAA) with a large retroperitoneal hematoma. A Talent (Medtronic, Santa Rosa, CA, USA) modular bifurcated endoprosthesis had vertically collapsed approximately 7 cm after losing its infrarenal fixation. As a result, it led to the repressurization of the aneurysm sac and rupture. The patient was successfully treated by placing three Talent (Medtronic) aortic cuffs. To our knowledge, this is the first reported case of endograft collapse that has manifested with aortic aneurysm rupture. Although they are gradually declining, considerable rates of complications create the 'Achilles' heel' of endovascular repair of AAAs. A lifelong follow-up strategy for patients treated for AAA with EVAR is essential for the early detection and treatment of complications of the procedure.     

Endovascular repair of abdominal aortic aneurysm: one-year results of the French AneuRx trial

The purpose of this prospective study was to evaluate the results of abdominal aortic aneurysm (AAA) repair using the Medtronic AneuRx endovascular stent graft. Forty-seven patients presenting with asymptomatic AAA were recruited in 17 French vascular centers. The mean age of these patients was 72.2 ± 7.8 years (range, 54 to 85.2 years). Indications were validated by an independent committee and all procedures were supervised by a trained medicotechnical assistant. Clinical data and follow-up imaging were also reviewed by an independent committee. The primary end point was successful implantation, defined as exclusion of the aneurysm without mortality, morbidity, or reintervention. The secondary end point was durable exclusion at 1 year, assessed by serial computed tomography (CT scan). Implantation of the AneuRx endovascular stent graft in this series of highly selected patients was associated with no mortality and low morbidity. One-year follow-up findings showed reduction in aneurysm diameter in 45% of patients. This finding indicates that endovascular treatment is effective. However, observation of stable aneurysm diameter in 50% and increased aneurysm diameter in 5% suggests that careful, indefinite follow-up surveillance is necessary.     

Abdominal aortic aneurysm repair

Options for abdominal aortic aneurysm (AAA) repair include both open and endovascular approaches. Patient selection for each of these requires careful consideration relating to patient health, fitness and anatomy. This article aims to provide an overview of the essential aspects of both open surgical repair (OSR) and endovascular AAA repair (EVAR), focussing upon decision making, the procedures, follow-up and long-term outcomes. Consideration is also given to more complex AAA repairs, including fenestrated/branched stent grafts and open juxta-renal aneurysm repairs. AAA epidemiology, screening, and work up for repair are covered in the previous article.     

Sac enlargement without endoleak: when and how to convert and technical considerations

The primary goal of endovascular treatment of abdominal aortic aneurysms (AAA) is prevention of death from rupture. Even in the absence of an endoleak, the AAA may continue to enlarge. The pathogenesis of this phenomenon remains unclear. Therefore, surveillance after endovascular AAA treatment must include regular evaluation of aneurysm size, or even better, aneurysm volume. Aneurysm sac enlargement without an endoleak is not a benign condition. Recurrent or persistent pressurization of the AAA sac will eventually result in rupture. Besides that, continued expansion of the AAA sac can result in dilatation of the infrarenal neck and/or iliac arteries, which may threaten the integrity of proximal and distal anastomotic seals. Many centers will take a pragmatic approach in case of endotension and a growing AAA, and convert to open surgery with removal of the endograft and placement of a regular vascular graft. Direct puncture and pharmacological intervention in the cause of sac enlargement by local instillation seems logical, but has failed so far. The third option for aneurysm sac enlargement without an endoleak is laparoscopic or open fenestration of the aneurysm. Until permanent solutions for endotension and endoleaks are found, endovascular aneurysm repair will remain an imperfect long-term treatment and continued follow-up will be mandatory.     

���Ӹ����������淶������

??Emphasis on standardized treatment of abdominal aortic aneurysm WU Qing-hua. Department of Vascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing100029 , China
Abstract The mortality rate was high when the abdominal aortic aneurysm (AAA) ruptured, so early detection and standardized treatment are critical. Compared with traditional open surgery (OR), AAA endovascular aneurysm repair (EVAR) developed rapidly due to the continuous improvement of equipment in recent years. For minimally invasive of EVAR procedure, it has been developed rapidly in some countries and medical centers. But there are still some problems such as indications inconsistent in different centers, ignoring the traditional surgery of the AAA, not strictly regulate the course of treatment, follow-up needs to be strengthened and so on. For the healthy and rapid development of the AAA treatment, it requires a substantial strengthening of the standardized treatment of AAA.     

Does endovascular grafting represent a giant step forward?

Endovascular repair of abdominal aortic aneurysms was first reported in 1991 by Parodi et al. Since then, there has been widespread development of many stent-grafts for abdominal aortic aneurysm (AAA) repair. Available data support the proposition that stent-grafts are generally safe, although their long-term efficacy remains completely unknown. Importantly, endovascular AAA repair has neither fewer complications nor lower mortality rates than open repair; in fact, the opposite appears true. Along with most new techniques come new complications, and endovascular repair of AAA has brought forth the concept of both "endoleak" and device failure. Although it is uncommon, delayed AAA rupture after seemingly successful endovascular repair of AAA has been reported. In our opinion, these faults unique to endovascular repair mandate a cautious approach to the clinical application of stent-grafts. Until ongoing phase 2 and future phase 3 studies are completed with a minimum of 2 to 3 years' follow-up, we shall not know whether endovascular repair of AAA represents a giant step forward or merely an industry-driven overuse of proprietary technology.