脾动脉起始部动脉瘤的切除及血管重建的手术探讨

目的探讨脾动脉起始部动脉瘤的切除及脾动脉重建的手术方法。方法回顾性分析1996年1月~2007年3月收治的8例脾动脉起始部动脉瘤患者的临床资料,经彩色超声、CT和血管造影检查证实脾动脉起始部真性动脉瘤;均在全身麻醉下首先阻断腹腔干起始部,远端脾动脉阻断后切除动脉瘤,1例行腹腔干-脾动脉自体静脉移植,4例行肾下主动脉-脾动脉人工血管转流,3例同时切除动脉瘤和脾脏。结果均于手术后10~14 d治愈出院。随访0.5~10年;其中1例人工血管转流术后2年死于急性心肌梗塞,余7例均健康生活,无动脉瘤复发。结论动脉瘤切除、脾动脉重建是一种较好的脾动脉起始部真性动脉瘤的治疗方案。     

紧邻腹腔干脾真性动脉瘤的手术治疗：附7 例报告

目的：探讨紧邻腹腔干脾动脉瘤的治疗方法。 方法：回顾性分析2000年1月—2012年6月收治的7例紧邻腹腔干脾动脉瘤患者临床资料。 结果：7例术前均经彩超、CT及血管造影检查确诊,均在全身麻醉下手术治疗,包括动脉瘤切除、肾下主动脉—脾动脉人工血管转流4例;动脉瘤切除、脾脏切除2例;多发动脉瘤切除、脾动脉结扎、脾切除1例。手术后10~14 d治愈出院,随访2~14年,存活5例,死亡2例,其中1例主-脾转流术后2年死于急性心肌梗死,1例动脉瘤切除+脾切除术后5年死于急性脑出血。存活5例中3例为主-脾动脉转流者（1例术后2年吻合口逐渐狭窄,术后6年完全闭塞,但未见脾脏梗塞,余2例未出现吻合口狭窄或假性动脉瘤）;2例为动脉瘤切除+脾脏切除者。 结论：动脉瘤切除+脾动脉重建是治疗紧邻腹腔干脾真性动脉瘤的有效方法。     

腹腔干动脉瘤九例的诊断与治疗

目的 探讨腹腔干动脉瘤的诊断与治疗方法。方法 回顾总结9例腹腔干动脉瘤的诊治情况。结果 本组腹腔干动脉瘤9例,位于起始部2例。主干2例,分叉处5例,术前经CTY下实5例,行磁共振造影（MRA）检查证实2例,数字减影动脉造影（DSA）证实5例,均予手术治疗,其中肝动脉重建例,肝动脉及脾动脉结扎、脾切除2例,腹腔干重建4例,本组围手术期无死亡。结论 腹腔干动脉诊断一旦明确,应尽早手术治疗,行腹腔干或肝动脉重建术是最佳的手术方式。     

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.     

迷走脾动脉瘤12例报道并文献复习

目的 探讨迷走脾动脉瘤的治疗方法及疗效评价.方法 回顾性分析新疆维吾尔自治区人民医院血管外科2012年1月-2014年5月收治的12例迷走脾动脉瘤患者,其中男性4例,女性8例,对其治疗方法进行临床分析.迷走脾动脉瘤均起源于肠系膜上动脉,瘤体均为单发,直径1.5 ～2.8 cm,平均2.1 cm.12例均行手术治疗,4例行开放手术切除瘤体,5例行脾动脉介入栓塞治疗,3例行瘤体内栓塞+肠系膜上动脉内覆膜支架植入.结果 12例治疗均获成功,2例出现腹痛、发热等不适反应.未出现脾动脉瘤复发、增大或破裂.12例均获随访,每隔3个月复查彩色多普勒超声或CT血管成像,随访时间6～24个月,1例术后1年死于腹腔大出血;11例情况良好,无复发.结论 对于具有适合解剖条件的迷走脾动脉瘤,腔内治疗安全有效,对于累及肝动脉的迷走脾动脉瘤,需开放手术进行血管重建.     

三维增强核磁共振血管造影在内脏动脉瘤诊治中的应用

目的 探讨三维增强核磁共振血管造影在内脏动脉瘤诊治中的临床价值.方法 对43例内脏动脉瘤患者行三维增强MR血管造影检查,19例同期行数字减影血管造影(digital subtraction angiography,DSA).三维增强MR血管造影用屏气超快速三维梯度回波序列,图像减影后进行三维重建.结果 43例共50个内脏动脉瘤,涉及脾动脉32个(其中5例脾动脉异位起源于肠系膜上动脉),占64%;肠系膜上动脉7个(14%),腹腔动脉干5个(1例为腹腔系膜干),肾动脉4个,肝动脉2个.三维增强MR血管造影能清楚显示动脉瘤部位、大小、形态,并在立体直观显示动脉瘤及其与周围血管脏器关系方面优于DSA.43例中,行栓塞治疗15例,手术9例,保守观察19例.结论 三维增强MR血管造影能尤创、准确诊断内脏动脉瘤,所提供的三维解剖细节有助于临床治疗方案的制定,可作为内脏动脉瘤的首选检查方法.     

升主动脉-颈内动脉自体静脉转流治疗累及左颈总动脉起始部的巨大真性动脉瘤

目的探讨累及左颈总动脉起始部的巨大真性动脉瘤的手术方法。方法回顾性总结1997年2月至2004年6月间3例该病患者的临床资料，均行手术治疗：胸部正中切口显出前纵隔，切开心包及其返折，显露心脏及其大血管，联合颈部切口显出动脉瘤全貌，升主动脉-颈内动脉自体静脉转流后，于主动脉弓上切除动脉瘤。结果3例均于术后7d治愈出院，分别随访8月、5年、7年无动脉瘤复发。结论利用自体静脉行升主动脉-颈内动脉移植技术，经胸部正中切口根治累及左颈总动脉起始部的巨大动脉瘤，具有显露清晰、操作方便、无须切开胸腔、创伤小、恢复快的优点，是一种较好的手术方案。     

脾动脉起始部真性动脉瘤的手术治疗(附7例报告)

目的：探讨脾动脉起始部真性动脉瘤的手术治疗方法，总结临床治疗经验。方法：回顾性总结1996年1月至2006年8月收治的7例病人，经彩色超声、CT和血管造影检查证实脾动脉起始部真性动脉瘤；均在全身麻醉下行动脉瘤切除，5例行脾动脉血管重建，2例同时行脾脏切除。结果：手术后10—14d治愈出院。随访1—9年，1例人工血管转流术后2年死于急性心肌梗塞，余6例均健康生活。无复发。结论：脾动脉起始部真性动脉瘤切除、脾动脉重建是—种较好的治疗方案。     

胰头部动脉优先离断在根治性胰十二指肠切除术中的运用

目的探讨胰头部动脉优先离断在肠系膜上静脉或门静脉受侵犯的胰头部恶性肿瘤行根治性胰十二指肠切除术中的运用价值。方法回顾性分析2012年1月至2013年5月华中科技大学同济医学院附属同济医院完成的58例胰头部恶性肿瘤行根治性胰十二指肠切除术患者的临床资料。58例患者术前薄层CT检查均显示肠系膜上静脉或门静脉受侵犯或受压,均行胰头部动脉优先离断的根治性胰十二指肠切除术,即在处理胰头部静脉血管之前优先离断胰头部的所有动脉供血,即三大动脉血管的分支,主要步骤包括：在十二指肠水平部或横结肠系膜根部暴露和悬吊肠系膜上动、静脉;解剖肝总动脉从而离断胃十二指肠动脉和胃右动脉,同时沿肝总动脉根部解剖腹腔动脉干上方;离断胰腺和脾动脉的胰头分支;沿暴露的肠系膜上动脉前方、右侧和后方解剖,完全离断胰头钩突部与肠系膜上动脉和腹腔动脉干间的神经结缔组织,与腹腔动脉干的上方贯通,此时可清楚地显示腹主动脉前方;最后通过预置的静脉血管阻断带安全剥离、切除或重建肠系膜上静脉或门静脉,完整切除肿瘤。结果术前影像学检查判断局部肿瘤可切除患者37例,可能切除患者21例。58例患者均顺利施行胰头部动脉优先离断的根治性胰十二指肠切除术,手术时间为4．5～8．1h,术中出血量为200—900mL,术中及术后胰腺钩突部无出血。行肠系膜上静脉侧壁部分切除修补术21例,肠系膜上静脉受累段切除端端吻合术10例,血管受压迫成功将肿瘤从血管上剥离行标准的胰十二指肠切除术27例。术后患者出血、胰液漏和胆汁漏的发生率分别为5．2％（3／58）、6．9％（4／58）和1．7％（1／58）。围手术期无患者死亡。结论胰头部动脉优先离断方式能保障肠系膜上静脉或门静脉受侵犯或受压的胰头部恶性肿瘤行根治性胰十二指肠切除术的安全性,减少术中出血。     

256层螺旋CT对腹腔镜结直肠癌手术前肠系膜血管解剖结构评估的价值

目的探讨CT三维血管重建技术对结直肠癌患者术前进行肿瘤血管评估的临床价值．为腹腔镜结直肠癌手术提供参考。方法2010年2月至2010年12月间,对11例准备行腹腔镜结直肠癌根治术的患者术前进行256层螺旋CT扫描．通过三维血管重建技术观察其肠系膜血管解剖及变异情况．并将结果与腹腔镜术中所见进行对照。结果256层螺旋CT三维血管重建均清晰地显示出肠系膜血管解剖及变异情况．并与腹腔镜手术中所见吻合。3例右半结肠切除术患者中,1例回结肠动脉走行于肠系膜上静脉的腹侧．2例回结肠动脉走行于肠系膜上静脉的背侧：2例右结肠动脉和回结肠动脉分别直接起源于肠系膜上动脉．另1例未见右结肠动脉而由结肠中动脉右支参与供血。1例横结肠切除患者的结肠中动脉发自肠系膜上动脉。3例乙状结肠切除患者中,2例乙状结肠动脉与左结肠动脉共干起源于肠系膜下动脉．另1例乙状结肠动脉直接起源于肠系膜下动脉。4例直肠癌患者均由肠系膜下动脉延续的直肠上动脉供血。结论256层螺旋CT血管重建技术可以满足腹腔镜结直肠癌根治术前对肠系膜血管解剖及变异情况的观察．为手术提供重要参考。     

Endoaortic stent grafting of a giant infected hepatic-celiac pseudoaneurysm

A 72-year-old man was admitted because of progressive right upper-abdominal distension and pain as well as concurrent remittent fever for 5 months. He had undergone a radical gastrectomy and catheter intubation in the common hepatic artery for chemotherapy 12 months before admission. The diagnosis of giant infected hepatic-celiac artery pseudoaneurysm was established. Coils embolotherapy was given in another hospital, but it failed. After admission, a computed tomographic aortogram showed a mass 10.3 x 8.5 x 8.1 cm in size in the right upper abdomen that originated from the common hepatic artery and the celiac artery. A celiac-super mesenteric artery (SMA) double catheter simultaneous digital subtraction angiography (DSA) further revealed that the entrance of the aneurysm opened directly from the abdominal aorta, the distance between the orifice of SMA and celiac axis was only 0.5 cm, and the diameter of the celiac trunk had been aneurysmally enlarged to 2.0 cm. A blood culture was positive for Bacillus pyocyaneus. After detailed discussion and preparation, a stent-graft complex was negotiated through the left femoral artery and deployed successfully into the abdominal aorta to seal the orifice of celiac trunk under the dynamic supervision of DSA. Completion angiography revealed that the hepatic-celiac pseudoaneurysm was completely excluded from aortic flow by the endoluminal stent-graft complex, while the SMA and renal arteries remained perfectly patent. The patient recovered uneventfully and was discharged without any residual symptoms. At a 5-year follow-up, the patient remained asymptomatic and was leading a normal life.     

MSCTA观察腹腔干与肠系膜上动脉的解剖学变异

目的采用MSCTA评价腹腔干与肠系膜上动脉及其主要分支的解剖变异。方法收集1000例患者的MSCTA,进行VR、MIP和MPR,观察腹腔干与肠系膜上动脉及其主要分支的起源和走行。结果1000例患者中,880例（88．00％）属于正常解剖学类型（Michels I型）,120例（12．00％）存在不同类型的解剖变异,其中72例（7．20％）属于Mi-chelsⅡ～X型;48例（4．80％）不属于Michels分型,包括腹腔干-肠系膜上动脉共干31例（3．10％）,脾动脉起源于肠系膜上动脉5例（O．50％）,胃十二指肠动脉起源于肠系膜上动脉和脾动脉各3例（O．30％）、肝左动脉1例（O．10％）,腹腔干缺如2例（O．20％）,胃左动脉起源于腹主动脉、脾动脉和肝固有动脉各1例（O．10％）。结论腹腔干与肠系膜上动脉存在广泛的解剖学变异;MSCTA有助于了解变异情况,对腹部血管外科手术具有指导意义。     

Riolan动脉弓的MSCT血管成像表现

目的探讨MSCT血管成像（MSCTA）Riolan动脉弓的影像表现。方法收集6例Riolan动脉弓病变患者,3例男性患者为高血压动脉粥样硬化性疾病,3例女性患者均为多发性大动脉炎。采用16层（4例）、64层（2层）螺旋CT扫描行腹部CTA检查,对病变血管行VR、MIP和MPR重建。结果 6例Riolan动脉弓血管直径为3.5～10.0mm,平均（6.7±0.4）mm。3例腹主动脉粥样硬化性病变中,肠系膜上动脉（SMA）近端闭塞2例,远端与肠系膜下动脉（IMA）形成Riolan动脉弓,其中1例伴有腹主动脉瘤,同时SMA、IMA与腹腔动脉干形成动脉吻合弓;IMA近端闭塞1例,远端与SMA形成Riolan动脉弓。3例多发大动脉炎中,2例SMA狭窄,SMA与IMA间形成Riolan动脉弓,1例SMA、IMA同时与腹腔动脉干形成动脉吻合弓;1例IMA近端狭窄,IMA与SMA间形成Riolan动脉弓。结论 MSCTA可以显示SMA与IMA间Riolan动脉弓结构,其特征性影像表现是SMA与IMA间的纡曲扩张的血管弓。出现Riolan动脉弓提示SMA或IMA管腔闭塞或狭窄。     

Successful treatment of a visceral artery aneurysm with a celiacomesenteric trunk: Report of a case

A celiacomesenteric trunk is an anomaly in which the celiac and superior mesenteric arteries have a common origin from the aorta. This structure accounts for less than 1% of all visceral artery anomalies, and is estimated to have an incidence of 0.25%. Aneurysms involving a celiacomesenteric trunk are exceptionally rare. We herein report our treatment modality for an 82-year-old man with a visceral artery aneurysm involving a celiacomesenteric trunk. The aneurysm was resected, and the superior mesenteric, splenic, and common hepatic arteries were successfully reconstructed.     

支架型人工血管腔内治疗复杂主动脉瘤

目的：总结15例应用支架治疗复杂动脉瘤的初步经验。方法：Ⅲ型夹层动脉瘤者主动脉极度扭曲1例；破口在弓部的Ⅲ型夹层动脉瘤1例，需先行左右颈-颈和左右腋．腋动脉人工血管搭桥后再封闭左侧颈总动脉和锁骨下动脉：Ⅲ型夹层动脉瘤近侧破口来自于变异发出的右锁骨下动脉1例；Ⅲ型夹层动脉瘤合并肠系膜上动脉几乎完全闭塞和肠缺血1例；Ⅲ型夹层动脉瘤真假腔难判断者4例；腹主动脉瘤瘤颈长度〈1cm需开窗型支架治疗1例；破裂腹主动脉瘤1例：5枚支架治疗胸腹主动脉瘤1例；腹主动脉瘤瘤颈夹角为90。2例；主动脉溃疡紧邻腹腔动脉，需开窗型支架开窗型人工血管治疗1；肝动脉瘤腹腔动脉瘤合并动静脉瘘1例。结果：15例病人经支架治疗均获得成功。结论：支架型人工血管治疗复杂动脉瘤为微创方法，但需严密设计。     

胃癌患者手术前胃左动脉的CT三维血管重建检查

目的 术前了解胃癌患者胃左动脉的解剖,指导术中N07组淋巴结的清扫.方法 利用64排螺旋CT三维血管重建技术在术前检查胃癌患者胃左动脉的起始位置.结果 本组共观察731例.胃左动脉起于腹腔动脉干者635例,其中起于肝总动脉和脾动脉分支处者176例,起于腹腔干前1/3者292例,起于中1/3者135例,起于后1/3者32例.起于其他地方者共78例,其中起于腹腔干与腹主动脉夹角处者9例,起于腹主动脉者28例,起于胃脾动脉干者27例,起于脾动脉者4例,起于肝总动脉者4例,起于肝左动脉者1例,起于肝胃动脉干者4例,起于肠系膜上动脉者1例.15例胃左动脉缺如.3例特殊变异.结论 术前掌握胃癌患者胃左动脉起始位置及变异情况对顺利清扫其周围淋巴结,避免血管损伤有重要意义.     

Aneurysms of anomalous splenomesenteric trunk: Clinical features and surgical management in two cases

Aneurysms of the splenic artery that anomalously arise from a splenomesenteric trunk are a rarity. Aneurysmal disease of visceral arteries is found in only 0.2% of the general population. The celiac trunk and superior mesenteric artery (SMA) are involved in less than 10% of all visceral aneurysms. Although rupture seems to occur in 20% to 22% of patients, the related mortality rate can rise as high as 100%. Anomalies of the celiac trunk and SMA, more common than previously claimed, include the splenic artery arising from the SMA, which occurs in only 1% of patients. We present two cases of young patients who had 4-cm aneurysms behind the pancreas that involved an anomalous splenic artery. The first patient required dissection of the entire splenopancreatic bloc through a transverse abdominal incision to excise the aneurysm and repair the SMA. The second patient was treated by the classic approach, through a median incision and by entering the mesenteric root. There do not seem to be reports of similar cases, except for two cases of aneurysms involving the celiomesenteric trunk. The cause of these aneurysms can be attributed to mesenchymal alterations during the embryonic formation of aortic collateral branches. A correct surgical approach to splanchnic aneurysms calls for awareness of potential vascular variations of the arteries and their collateral pathways. (J Vasc Surg 1996;24:687-92.)     

A Ruptured Pancreaticoduodenal Artery Aneurysm Repaired by Combined Endovascular and Open Techniques

Aneurysms of the pancreaticoduodenal arteries (PDA) are rare, accounting for <2% of all visceral aneurysms. An association with celiac artery stenosis has been reported. Many present with rupture, and a high mortality can be expected. Treatment is therefore challenging. Arterial ligation, anuerysmectomy, or bypass has been the mainstay of treatment. We recently treated a patient (who had no celiac axis) with a ruptured PDA aneurysm with combined open and endovascular techniques. A 46-year-old man was transferred to our hospital with a 1-day history of abdominal pain and syncope. On admission, an abdominal and pelvis computerized tomographic (CT) scan identified a large mesenteric hematoma, a 1.9 cm PDA aneurysm, and an occluded celiac axis. Mesenteric angiography revealed no active aneurysm leak and a stenotic superior mesenteric artery (SMA) origin. All hepatic blood flow originated from the stenotic SMA via markedly enlarged PDA collaterals. The patient was brought to the operating room, where absence of the celiac axis was confirmed. An aorto-to-proper hepatic and SMA bypass was performed using a bifurcated polyester graft. The next day, the patient was brought to the angiography suite, where the PDA aneurysm was coiled. Postprocedure CT scans confirmed thrombosis of the aneurysm. Ruptured mesenteric artery aneurysms are a challenging problem for the vascular surgeon. PDA aneurysms are rare and often occur in an unfavorable location. There appears to be an association with anatomic anomalies of the mesenteric circulation. Prompt invasive and noninvasive diagnostic studies aid in the definitive management of this often fatal problem. Combined endovascular and open techniques can be used for successful treatment.     

Ulzerierende, ischämische Gastritis

Ischemic ulcerative gastritis caused by mesenteric artery insufficiency is rare because of the high collateral blood flow between the celiac trunk and the superior mesenteric artery (SMA). Nearly 50% of patients with ischemic gastritis have been treated for an ulcerative pathology prior to revascularization. The diagnosis should be considered in cases of occlusive atherosclerotic disease, previous surgery for acute or chronic intestinal ischemia and heavy smokers. The SMA is the predominant artery in chronic visceral ischemia and should be revascularized first. In cases of isolated supramesocolic ischemia celiac trunk revascularization should be considered as a priority. We report about a patient with ischemic ulcerative gastritis and ischemic colitis which could be successfully treated by endarterectomy of the infrarenal aorta and an aortomesenteric bypass.