CTA融合导航技术在腹主动脉瘤腔内修复及保留髂内动脉治疗中的应用北大核心CSCD

目的探讨CTA融合导航技术在腹主动脉瘤腔内修复(EVAR)术中的应用价值,评价CTA融合导航在髂内动脉保留策略中的技术优势。方法选取2020年12月至2021年6月在珠海市人民医院接受CTA融合导航EVAR术治疗的12例肾下型未破裂出血腹主动脉瘤患者。术前CTA扫描确诊,术中配准术前CTA与术中DynaCT扫描重建图像后,将融合图像叠加至术中透视影像,作为导丝等器械的路径导引。融合图像可作为双肾动脉支架锚定的参照。融合导航下根据髂动脉受累程度行髂内动脉单侧或双侧保留治疗。结果12例融合导航手术均获得成功。其中5例单侧髂内动脉栓塞并保留一侧髂内动脉,1例双侧髂内动脉重建,6例支架远端固定于髂总动脉远端并保留双侧髂内动脉。术后均未发现严重并发症。结论CTA融合导航技术辅助EVAR手术安全可行,无需使用对比剂,有助于保留髂内动脉,技术优势明显,值得临床推广。     

三明治技术在腹主动脉瘤累及髂总动脉腔内治疗中保留髂内动脉的疗效分析

【摘要】 目的 分析三明治技术应用于腹主动脉瘤（AAA）累及髂总动脉腔内治疗保留髂内动脉的近期疗效。 方法 回顾性分析重庆医科大学附属第二医院2016年6月至2018年7月采用主动脉腔内修复术（EVAR）治疗的9例AAA累及髂总动脉患者（累及单侧髂总动脉3例，双侧6例），术中均接受髂内动脉三明治重建。术后观察和随访围手术期死亡率、腔内修复效果、内漏、支架一期通畅情况及手术相关并发症发生情况。 结果 9例患者EVAR术和髂内动脉三明治重建技术均获成功，围手术期无死亡。术中即刻造影显示9例支架均获通畅，瘤腔均成功修复。出现1例Ⅰ型内漏，2例Ⅲ型内漏，随访时自行消失；1例左上肢急性缺血，再次予急诊肱动脉修复术；3例左肱动脉切口处血肿形成，2例右股动脉穿刺点处血肿形成。术后1周、3个月、6个月复查CTA分别显示支架通畅9例、8例、8例，均无肠缺血、脊髓缺血或瘫痪症状。 结论 三明治技术在AAA累及髂总动脉腔内治疗中保留髂内动脉安全可行，术后臀肌跛行发生率低，近期随访支架通畅率可，值得临床推广，但远期效果尚需进一步随访及更大临床样本验证。     

腹主动脉瘤腔内修复术22例围手术期处理回顾性总结

目的 总结腹主动脉瘤腔内修复术(EVAR)围手术期处理的临床经验.方法 回顾分析22例腹主动脉瘤患者EVAR临床经过,通过术前对主要脏器功能进行评估和保护,CTA测量近远侧瘤颈长度、直径、角度和构型,瘤体与分支动脉的关系,最低肾动脉开口至腹主动脉分叉的距离,导入途径的直径、扭曲和钙化程度.根据CTA测量结果,选择覆膜支架和手术方式.术时采用局麻20例,中转全麻l例,1例通过髂总动脉重建导人途径采用硬膜外麻醉,1例合并Stanf.0rd A型主动脉夹层,术时采用全麻.在支架释放前准确定位最低肾动脉位置,至少保留一侧通畅的髂内动脉,若双侧需要覆盖,分期覆盖或髂内动脉重建.支架植入后复查造影,有无内漏.正确判断内漏类型并进行相应处理.支架近端Ⅰ内漏2例,球囊扩张1例,植入Cuff 1例;支架远端Ⅰ内漏1例,球囊扩张时,动脉破裂,行人工血管补片修补术;Ⅲ型内漏3例,球囊扩张后支架植入1例.1例合并Starford A型主动脉夹层先行胸主动脉腔内修复术,后行EVAR.术后7一10 d复查CTA,以后每年复查1次.结果 EVAR手术全获成功.主要并发症为单侧髂肢扭结继发血栓形成,Fogarty导管取栓并支架植人1例;腹壁切口裂开1例,清创缝合;无手术死亡,随访6个月～5年,患者均存活.结论 CTA图像质量高、测量准确,是EVAR术前评估和术后随访的金标准.EVAR是高危、高龄腹主动脉瘤患者有效的治疗方法.     

腔内治疗肾下型腹主动脉瘤8例临床疗效观察

目的:探讨肾下型腹主动脉瘤的腔内治疗技术与疗效.方法:收集随访我院2014年3月至2017年8月收治的8例接受腔内治疗的腹主动脉瘤(abdominal aortic aneurysm,AAA)患者的临床资料,统计并分析术后疗效.结果:腔内治疗8例AAA,手术全部成功.3例SchumacherⅡB型,4例SchumacherⅡC型,1例SchumacherⅢ型;2例扭曲成角Ⅰ级,4例扭曲成角Ⅱ级,2例扭曲成角Ⅲ级.8例患者术后出现1例髂动脉急性血栓形成,置管溶栓后血管通畅;1例术中髂动脉出现Ⅰ型内漏,经植入支架延长段和球囊扩张后内漏消失;1例术中双侧髂内动脉栓塞,术后未出现相应症状;其中5例使用烟囱技术,术后随访肾动脉通畅;结论:EVAR结合烟囱技术治疗AAA是安全、有效的,提高了成功率,降低了并发症及病死率.     

局部麻醉穿刺下完全无对比剂腔内修复腹主动脉瘤1例

目的 探讨对比剂过敏高危腹主动脉瘤患者接受局部麻醉穿刺下完全无对比剂主动脉腔内修复术(EVAR)的可行性.方法 对1例对比剂过敏腹主动脉瘤患者,在不使用对比剂、局部麻醉穿刺条件下实施EVAR术.结果 手术获成功.术后MRI随访结果显示,患者腹主动脉瘤完全隔绝,无内漏,覆膜支架内血流通畅,双侧肾动脉显影良好.结论 局部麻醉穿刺下完全无对比剂EVAR术治疗对比剂过敏伴全身麻醉禁忌高危腹主动脉瘤患者安全有效,但严格掌握适应证、术前充分评估是手术成功的关键.     

腹主动脉瘤腔内隔绝术后缺血性结肠炎的诊治①

为探讨腹主动脉瘤术后并发缺血性结肠炎的诊断和治疗,作者回顾性分析了1997年3月～2000年1月间施行的腹主动脉瘤腔内隔绝术40例,其中30例保留双侧髂内动脉(双侧组),10例保留单侧髂内动脉或移植物远端固定于双侧髂外动脉、手术重建单侧髂内动脉(单侧组).统计两组患者的术后肠蠕动恢复时间及肠道并发症.两组患者中仅双侧组1例于术后第28天始出现持续性中下腹隐痛,经纤维结肠镜检查确诊为缺血性结肠炎,经CTA发现术后继发双侧髂内动脉闭塞,经扩血管、促进侧支循环建立等保守治疗缓解;其余患者除并发其他并发症的3例外,均于术后第二天恢复普食及排气排便.提示腔内隔绝术中保留单侧髂内动脉可避免术后缺血性结肠炎的发生;继发于术后双侧髂内动脉阻塞的慢性缺血性结肠炎,在肠镜随访观察下进行有效的保守治疗是首选治疗方法.     

肾下型腹主动脉瘤瘤体参数对腹主动脉瘤腔内修复术后内瘘发生情况影响

目的 探讨肾下型腹主动脉瘤瘤体参数对腹主动脉瘤腔内修复术(EVAR)后内瘘发生情况的影响.方法 回顾性分析华北石油管理局总医院自2015年1月至2020年5月收治的108例接受EVAR的肾下型腹主动脉瘤患者的临床资料.根据术后是否发生内瘘,将患者分入内瘘组和无内瘘组.记录两组患者的一般资料、手术前后瘤体相关参数及术后动...     

腹主动脉瘤腔内修复术后Ⅱ型内漏的栓塞治疗

内漏是腹主动脉瘤腔内修复术后并发症之一,本院血管外科应用钢圈栓塞治疗Ⅱ型内漏1例,就其经验总结如下. 患者为女性,81岁.于2006年4月24日因肾下腹主动脉瘤(图1)行腔内修复术,置入分叉型人工血管内支架(Zenith,Cook,USA),远端锚定于髂总动脉,保留两侧髂内动脉.患者恢复顺利,术后5 d出院.术后1年随访CTA显示支架形态位置满意,瘤腔内未见明显对比剂充盈,但瘤体直径与术前相比,无明显缩小(最大径仍为6 cm).2008年3月24日因下腹饱胀并扪及搏动性肿块1个月余来诊.     

腹主动脉瘤腔内修复术后Ⅱ型内漏的诊治经验

Ⅱ型内漏是腹主动脉瘤腔内修复术(endovascular aneurysm repair,EVAR)后最常见的并发症.目前对Ⅱ型内漏的形成机制尚不完全明确,对于诊断与治疗方面也存在争议.自1997年报道经动脉栓塞治疗EVAR术后Ⅱ型内漏以来[1],该方法已成为治疗EVAR后Ⅱ型内漏的主要方法.     

腹主动脉瘤腔内隔绝术后缺血性结肠炎的诊治

为探讨腹主动脉瘤术后并发缺血性结肠炎的诊断和治疗,作者回顾性分析了1997年3月－2000年1月间施行的腹主动脉瘤腔内隔绝术40例,其中30例保留双侧髂内动脉（双侧组）,10例保留单侧髂内动脉或移植物远端固定于双侧髂外动脉、手术重建单侧髂内动脉（单侧组）。统计两组患者的术后肠蠕动恢复时间及肠道并发症。两组患者中仅双侧组1例于术后第28天始出现持续性中下腹隐痛,经纤维结肠镜检查确诊为缺血性结肠炎,经CTA发现术后继发双侧髂内动脉闭塞,经扩血管、促进侧支循环建立等保守治疗缓解;其余患者除并发其他并发症的3例外,均于术后第二天恢复其普食及排气排便。提示腔内隔绝术中保留单侧髂内动脉可避免术后缺血性结肠炎的发生;继发于术后双侧髂内动脉阻塞的慢性缺血性结肠炎,在肠镜随访观察下进行有效的保守治疗是首选治疗方法。     

Large Diameter Limbs for Dilated Common Iliac Arteries in Endovascular Aneurysm Repair. Is It Safe?

In this prospective study we examined whether dilated common iliac arteries (CIAs) can provide a safe distal seal in endovascular aneurysm repair (EVAR) with the use of bifurcated stent grafts with large diameter limbs. Sixteen patients with 26 dilated CIAs with a diameter of 6 mm who were offered EVAR using stent grafts with large diameter limbs were included in the study (Group A). Forty-two patients who also underwent EVAR without iliac dilatation, matched for age, sex and surgical risk were used for comparison (controls-Group B). In group A mean CIA diameter was 18.2 mm (16–28) and mean abdominal aortic aneurysm (AAA) diameter was 6.87 ± 1.05 cm; mean age was 77.2 ± 4.8 yrs (67–81). Mean follow-up was 33.6 months (2.8 yrs). CIA diameter changes and development of endoleaks were assessed by CT angiography (CTA). Overall iliac dilatation was present in 16/58 of our patients (27.6%). In 10 patients dilatation was bilateral (17.3%). Partial or complete flow to the internal iliac artery (IIA) territories was preserved in all patients post-EVAR. On follow-up, stable caliber of the dilated CIAs was observed in 21 patients (84%), enlargement of 1mm in 3 (16%), and failure of the distal attachment in 1 (6.2%). Compared to the control group there was no statistical significance in the incidence of complications. Dilated common iliac arteries provide a safe distal seal in patients who have undergone EVAR, thus obviating the need for additional endovascular procedures and sparing flow in the IIA vascular bed.     

Endovascular Aneurysm Repair and Sealing (EVARS): A Useful Adjunct in Treating Challenging Morphology

An 81-year-old male with previous open abdominal aortic aneurysm repair presented with asymptomatic large pseudoaneurysms at both ends of an open surgical tube graft. Endovascular aneurysm sealing (EVAS) in combination with the iliac limbs of a standard endovascular aneurysm repair (EVAR) successfully excluded both pseudoaneurysms from circulation. We describe the combination of elements of EVAS and EVAR and have termed this endovascular aneurysm repair and sealing (EVARS). EVARS has the advantage of harnessing the benefits of endobag sealing in aortic necks unsuitable for standard EVAR whilst providing the security of accurate stent placement within short common iliac arteries. In conclusion, EVAS may be combined with standard endovascular iliac limbs and is a possible treatment option for pseudoaneurysm following open aneurysm repair.     

Notes on the application of the Matsui-Kitamura stent-graft for endovascular repair of abdominal aortic aneurysm

Abdominal aortic and left common iliac aneurysms in a 79-year-old man who had undergone Miles' operation for rectal carcinoma were treated with endovascular repair of an abdominal aortic aneurysm (EVAR), taking into consideration the age, surgical history, and wishes of the patient and his family. The Matsui-Kitamura stent-graft (MK-SG) was designed based on preoperative angiographic mapping. At EVAR, the right leg of the MK-SG was caught at the aortic bifurcation because of unexpected contraction of the MK-SG. To resolve the problem, the body of the MK-SG was dilated with a balloon, slightly lifted while being gradually shortened, and eventually successfully connected to the leg of the MK-SG. Made of nitinol mesh, the MK-SG is stable and flexible enough to make it one of the best stent-grafts for EVAR. A serious drawback, however, is the high contraction rate of the MK-SG itself. It is difficult to estimate the appropriate length of the stent-graft owing to unpredictable contraction. It is important to understand its characteristics and to carefully design and acquire sufficient skills in manipulating MK-SG.     

Endovascular Treatment of Concurrent Bilateral Common and Internal Iliac Artery Aneurysms with Preserved Pelvic Circulation: Bilateral Iliac Branch Devices with Opposing Single Division Internal Iliac Artery Sparing

An 83-year-old man with bilateral common iliac artery aneurysms (right, 3.0 cm; left, 2.7 cm), bilateral internal iliac artery aneurysms (right, 3.4 cm; left, 2.6 cm), and an abdominal aortic aneurysm (3.8 cm) was treated with an aortobi-iliac stent graft and bilateral iliac branch devices. The internal iliac components were extended into opposing posterior (left) and anterior (right) divisions of the internal iliac artery using stent grafts. Computed tomography angiography demonstrated that all aneurysms decreased or were stable in size with patent stent grafts at 1 month. The patient was asymptomatic without complications of pelvic ischemia at the last clinical follow-up at 6 months.     

Endovascular abdominal aortic aneurysm repair: how many patients are eligible for endovascular repair?

PURPOSE: The purpose of this study was to determine how many patients with abdominal aortic aneurysm (AAA) are eligible for endovascular abdominal aortic aneurysm repair (EVAR). MATERIALS AND METHODS: We retrospectively reviewed computed tomography (CT) angiograms obtained between January 2002 and June 2003 in 182 patients with suspected AAA. Indication for surgical or endovascular treatment was based on clinical and radiological criteria. The percentage of patients eligible for EVAR was evaluated. RESULTS: Out of a total of 182 patients with suspected AAA studied by CT angiography, after combined radiological-surgical assessment, 130 were considered eligible for surgical or endovascular treatment (71.4%). EVAR was indicated in 51 patients (39.3%, group A) and surgical repair was indicated in 79 patients (60.7%, group B). The reasons for ineligibility for EVAR were the following: unfavourable anatomy of the proximal neck in 41 patients (51.9%), diameter of the aneurysm sac >7 cm in 13 patients (16.4%), markedly tortuous/dilated iliac axis in six patients (7.6%), age <65 years in 17 patients (21.5%) and patient refusal in two cases (2.5%). There were no statistically significant differences in aneurysm diameter (52.7+/-0.8 versus 49.8+/-1.2 mm, p=ns), patients' age (73.2+/-1.2 versus 70.6+/-2.02 years, p=ns) or proximal neck length (2.95+/-1 versus 3.03+/-1.2 cm, p=ns) between groups A and B. CONCLUSIONS: Endovascular repair of abdominal aortic aneurysms through the placement of aortic stent-grafts has now become a viable alternative to open surgery. In recent years, the number of patients treated with EVAR has steadily risen as a result of increased physician experience, availability of new and more versatile devices and improvements in noninvasive imaging techniques. Unfavourable neck anatomy is the primary factor for exclusion from endovascular repair.     

Endovascular stent graft repair of abdominal aortic aneurysms: Current status and future directions

Endovascular stent graft repair of abdominal aortic aneurysm (AAA) has undergone rapid developments since it was introduced in the early 1990s. Two main types of aortic stent grafts have been developed and are currently being used in clinical practice to deal with patients with complicated or unsuitable aneurysm necks, namely, suprarenal and fenestrated stent grafts. Helical computed tomography angiography has been widely recognized as the method of choice for both pre-operative planning and post-operative follow-up of endovascular repair (EVAR). In addition to 2D axial images, a number of 2D and 3D reconstructions are generated to provide additional information about imaging of the stent grafts in relation to the aortic aneurysm diameter and extent, encroachment of stent wires to the renal artery ostium and position of the fenestrated vessel stents. The purpose of this article is to provide an overview of applications of EVAR of AAA and diagnostic applications of 2D and 3D image visualizations in the assessment of treatment outcomes of EVAR. Interference of stent wires with renal blood flow from the hemodynamic point of view will also be discussed, and future directions explored.     

Endovascular aortic aneurysm repair with stent-grafts: experimental models can reproduce endoleaks

PURPOSE: To develop canine aneurysm models that can reproduce type II endoleaks after endovascular aneurysm repair (EVAR) with stent-grafts. MATERIALS AND METHODS: A fusiform infrarenal abdominal aortic aneurysm model (AAA) was surgically created with a jugular vein patch, while preserving collateral vessels (n = 3). To allow comparative studies within the same animal, a bilateral iliac aneurysm model was also constructed with venous patches and surgical re-implantation of the sacroiliac trunk (n = 3). Stent-grafts were implanted by femoral approach at least 2 months later in both aortic and iliac models. Follow-up imaging was performed by Doppler ultrasound (US) and angiography until animals were killed 3 months after EVAR. RESULTS: Angiography revealed immediate type II leaks in all cases. Leaks were still present at autopsy 3 months after EVAR in all cases, and were revealed at pre-death angiography in all but one case. At autopsy, leaks were characterized by the presence of large endothelialized channels that formed within the thrombus between the stent-graft and the aneurysmal wall. CONCLUSION: As shown in this pilot study, persistent type II leaks after EVAR can be reproduced in aortic and iliac animal models. The iliac model can be created bilaterally in the same animal, thus allowing for comparative evaluation of different therapies. These models could be used to better understand the mechanisms of endoleak, and to assess future developments aimed to improve the outcomes after EVAR.     

Delayed complications following EVAR

More than a decade after the first clinical attempts, two large randomized studies have proven that endovascular aortic aneurysm repair (EVAR) provides immediate advantages over open repair. In the long run, however, a relatively high number of reinterventions is necessary to improve the long-term efficacy of EVAR, which may outweigh the early benefits. Since EVAR is gaining popularity in the medical community and in patients with abdominal aortic aneurysm (AAA), it is expected that a growing number of patients will present with delayed complications requiring some kind of reinterventions. For the patient's safety, vascular surgeons and interventional radiologists involved in EVAR must be well aware of these complications and the ways to overcome them. We began our endovascular program for AAA in 1994 and currently follow 485 patients with a variety of manufactured grafts. In this article we describe the delayed complications observed with EVAR, their mechanisms, favoring factors, and ways to treat them.     

Single-Center Experience and 1-Year Follow-up Results of “Sandwich Technique” in the Management of Common Iliac Artery Aneurysms During EVAR

Purpose

Abdominal aortic aneurysm (AAA) accompanied by common iliac artery (CIA) aneurysms requires a more demanding procedure owing to the difficulties in obtaining an adequate distal landing zone for the stent-graft limb(s), a potential site of endoleak. The “sandwich technique” is a procedure to increase EVAR feasibility in the setting of adverse or challenging CIA anatomy. Its main advantages include no restrictions in terms of CIA diameter or length or internal iliac artery (IIA) diameter, no need to wait for a specific stent-graft. Our purpose is to describe our single-center experience and one year follow-up results of this new procedure.

Materials and Methods

From April 2009 to June 2010, the sandwich technique was performed in our institution in 7 patients treated for AAA and unilateral CIA aneurysms (n. 5) or bilateral CIA aneurysms (n. 2). Inclusion criteria were the presence of unilateral or bilateral CIA aneurysm (independently from its diameter), IIA artery measuring up to 9?mm in its maximum diameter, not dilatation of IIA and EIA.

Results

The mean follow-up length was 15?months (range: 14–20 months). All stent-implanted iliac branches remained patent on 1?year follow-up and IIA flow was preserved. None of the patients had symptoms of pelvic ischemia. CT scan follow-up showed aneurysm shrinkage in five patients, without any sign of endoleaks in all cases.

Conclusions

In selected cases, the “sandwich technique” showed good outcomes confirming to be a safe and easy to perform way to overcome anatomical constraints and expanding the limits of EVAR.