17例腘动脉瘤外科治疗临床经验

目的总结腘动脉瘤外科治疗的临床经验。方法回顾性分析2005年5月至2015年12月期间17例腘动脉瘤患者的临床资料。结果 17例均行手术治疗,后侧入路行腘动脉瘤切除+自体静脉间置术10例,应用人工血管重建腘动脉1例;内侧入路行股腘动脉或股-胫后动脉自体大隐静脉旁路术5例,行腘动脉假性动脉瘤切除+自体大隐静脉补片成形术1例。平均随访时间为(4.5±3.3)年,1例术后2个月行截趾术;另1例因自体静脉桥血栓形成导致远端缺血坏死,术后6个月行膝上截肢术。因心脑血管疾病死亡3例,未发生动脉瘤相关的死亡。结论腘动脉瘤有症状者或瘤体直径大于2cm者应尽早手术,后侧入路行腘动脉瘤切除及自体静脉重建临床效果满意,应作为腘动脉瘤的首选治疗方案。     

肢体假性动脉瘤的临床诊治(附30例报道)

目的 探讨肢体假性动脉瘤的病因、发病机理以及手术方式的选择,评价各种手术的治疗效果,以提高对假性动脉瘤的诊治水平.方法 30例假性动脉瘤患者(股动脉18例,腘动脉7例,肱动脉2例,桡动脉3例),其中8例为感染或破裂性假性动脉瘤,1例肢体坏死.30例患者均行外科手术治疗,其中11例行假性动脉瘤破口修补术,2例行股动脉结扎术,2例行血管端端吻合术,8例行自体大隐静脉移植术,6例行人工血管移植术,1例行截肢术.结果 30例患者术后恢复顺利,除1例行下肢截肢术外,其余29例术后效果良好.随访7个月～8年,平均(4.4±2.3)年;行人工血管移植术者4例移植段发生血栓,经溶栓治疗后好转,其余血供状况良好.结论 外科手术治疗肢体假性动脉瘤是一种有效的方法.     

脾动脉瘤血管腔内治疗的临床疗效分析

目的探讨血管腔内治疗脾动脉瘤的安全性和有效性。方法回顾性分析2010年1月至2014年12月本科收治的48例脾动脉瘤患者的资料,腔内治疗方法:弹簧圈动脉瘤(14例)或载瘤动脉栓塞术(19例),覆膜支架隔绝术(2例),支架辅助弹簧圈瘤体内填塞(5例)和多层裸支架隔绝术(8例)。术后1、3、6、12个月采用CT血管造影检查随访,记录并评价围手术期和随访期的临床结果指标。结果本组病例瘤体均治疗成功,支架植入患者的脾动脉均通畅。围手术期无手术相关死亡,8例患者弹簧圈栓塞后出现栓塞后综合征,均于3~5天后缓解。随访时间23.9(3~59)个月,采用弹簧圈栓塞瘤体或载瘤动脉33例:4例患者发现有部分脾脏梗死,但无明显临床症状,2例患者因瘤体内再灌注接受再次手术;采用覆膜支架植入或裸支架辅助弹簧圈栓塞7例:动脉瘤隔绝或栓塞良好,无内漏,支架通畅;采用多层裸支架隔绝术8例:术后12个月6例(75%)患者瘤腔达到完全血栓化,分支动脉通畅。其余病例未出现严重并发症。随访期患者均未观察到动脉瘤增大、破裂或复发。结论血管腔内治疗脾动脉瘤安全,疗效显著。     

大脑中动脉动脉瘤的显微外科治疗

目的 探讨大脑中动脉(MCA)动脉瘤手术治疗的临床疗效。方法 回顾分析29例外科手术治疗的MCA的临床资料。结果 所有病例均施行显微外科手术，其中行动脉瘤夹闭20例，动脉瘤切除4例，夹闭加包裹5例，其中1例巨大动脉瘤(直径7cm)切除后同时行MCA端一端吻合。术后随访6～30个月，优良27例，中残2例(术前为Ⅳ级)。结论 显微外科手术可明显提高大脑中动脉动脉瘤的治疗效果。     

颅内外动脉狭窄合并颅内动脉瘤同期血管内治疗的效果分析

目的探讨同期治疗颅内外动脉狭窄合并颅内动脉瘤的策略及临床效果。方法回顾性分析2013年4月至2018年9月于北京大学第一医院神经外科行同期血管内治疗的15例颅内外动脉狭窄合并颅内动脉瘤患者的临床资料。男性6例,女性9例,年龄(63.9±9.1)岁(范围:43~79岁);动脉狭窄部位共15处,狭窄程度为75%~95%,其中前循环8处,后循环7处;动脉瘤共17个,最大径(5.3±1.2)mm(范围:3~7 mm),其中前循环动脉瘤11个、后循环动脉瘤6个。患者均行同期动脉狭窄支架成形及动脉瘤栓塞术治疗。记录患者围手术期及术后临床症状、影像学资料及并发症情况。结果15处动脉狭窄均成功置入支架(残余狭窄<30%);17个动脉瘤中,10个行单纯弹簧圈栓塞,7个行支架辅助弹簧圈栓塞,均完全栓塞。围手术期1例患者出现轻微脑梗死症状,其余未发生手术相关并发症。术后随访(43.8±8.2)个月(范围:24~85个月),患者术后6~12个月均复查数字减影血管造影,其中2例出现无症状性支架内再狭窄,所有动脉瘤未见复发。截至末次随访时,患者均未出现颅内出血、缺血性卒中等相关症状。结论颅内外动脉狭窄合并颅内动脉瘤应根据血管狭窄的部位、程度及动脉瘤的大小、形态、位置、数量及两者的位置关系等因素综合分析,制定个体化的治疗策略,给予同期血管内治疗可能是一种安全、有效的治疗方法。     

主动脉腔内隔绝术治疗DeBakey Ⅲ型主动脉夹层动脉瘤:附63例报告

目的:分析主动脉腔内隔绝术(EVAR)治疗De Bakey Ⅲ型主动脉夹层动脉瘤的临床效果。方法:回顾性分析2008—2014年采取EVAR手术治疗的63例De Bakey Ⅲ型主动脉夹层动脉瘤患者临床资料,总结EVAR的手术方法、手术成功率、术后夹层假腔直径的变化。结果:De Bakey Ⅲ型主动脉夹层动脉瘤63例置入支架66个,其中有3例患者分别置入支架2枚,平均手术时间(159.1±21.7)min,手术中出现3例内漏,其中1例患者出现极少量内漏、术后CTA复查未发现,1例在支架置入后发现近端内漏、1例患者发现支架远端内漏,分别予以增加支架封堵,术后CTA复查仍然存在少许内漏;全组手术的技术成功率95.24%(60/63),临床成功率为92.06%(58/63);患者术后6个月左锁骨下动脉真腔开口直径、近端破口真腔水平直径mm、瘤体最大真腔直径、膈肌水平真腔最大直径均较术前明显增大(均P0.05),假腔大直径测定值均较术前明显减小(均P0.05),整体腔径最大值差异均无统计学意义(均P0.005)。结论:EVAR治疗De Bakey Ⅲ型主动脉夹层动脉瘤效果显著,安全可靠。     

胰十二指肠动脉瘤合并腹腔干动脉狭窄的介入治疗：附6例报告

目的:探讨胰十二指肠动脉瘤(PDAA)合并腹腔干动脉狭窄的治疗时机及方式的选择。方法:回顾性分析6例PDAA患者临床资料,其中4例因动脉瘤破裂出血,2例未出血被偶然发现,6例均合并腹腔干动脉狭窄或闭塞,所有患者行腔内动脉瘤栓塞治疗。结果:6例患者中,男5例,女1例;年龄42～81岁,平均59.8岁;瘤径8～21 mm,平均14.6 mm;2例为真性动脉瘤,4例为假性动脉瘤;4例位于胰十二指肠下后动脉,2例位于胰十二指肠下前动脉;5例患者有腹腔干动脉狭窄,狭窄率68%～92%,平均81%,1例完全闭塞。6例患者均行PDAA弹簧圈栓塞术,腹腔干动脉狭窄均未处理,手术时间60～110 min,平均(76.7±13.5)min;4例破裂患者栓塞治疗后出血停止,2例未破裂动脉瘤栓塞后瘤体消失,术后患者住院时间7～13 d,平均(10±2.3)d。随访9～15个月,未出现动脉瘤复发及内脏缺血表现。结论:PDAA合并腹腔干动脉狭窄单独行动脉瘤栓塞治疗是安全有效的,腹腔干动脉狭窄不处理并未出现内脏缺血表现,也未增加动脉瘤复发的风险。     

胸主动脉腔内修复术治疗近端锚定区不良的胸主动脉钝性伤疗效评价

目的探讨胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)治疗覆膜支架近端锚定区不良的胸主动脉钝性伤(blunt thoracic aortic injury,BTAI)的临床疗效。方法回顾分析2007年12月-2014年12月采用TEVAR治疗的13例覆膜支架近端锚定区不良的BTAI患者临床资料。其中男10例,女3例;年龄24~64岁,平均44岁。术前影像学检查提示Stanford B型主动脉夹层7例,假性动脉瘤3例,动脉瘤1例,穿透性溃疡2例。根据支架近端锚定区Mitchell分区位置不同,单纯行覆膜支架置入覆盖左锁骨下动脉(left subclavian artery,LSA)8例;烟囱技术重建LSA 3例;烟囱技术重建左颈总动脉2例(其中1例采用弹簧圈栓塞LSA起始部以避免Ⅱ型内漏,1例采用原位开窗技术重建LSA)。结果手术均顺利完成,手术时间1~3 h,平均1.8 h;术中出血量30~200 m L,平均120 m L;住院时间7~37 d,平均15 d。无围手术期死亡、截瘫发生。13例均获随访,随访时间3~30个月,平均18个月。术中发生Ⅰ型内漏1例(7.7%),未予以特殊处理,于术后6个月自愈;1例术后3周出现穿刺部位皮下血肿,伴正中神经压迫症状,超声检查提示肱动脉假性动脉瘤并血栓形成,行肱动脉假性动脉瘤切除术,术后恢复尚可。所有患者术后未见明显胸背痛、憋气、左上肢乏力、麻木及头晕等症状;影像学检查提示主体及分支支架血流通畅;未见支架移位,无病变处扩张和破裂等;无新发死亡及细菌感染等严重并发症。结论根据Mitchell分区法设计个性化方案,采用TEVAR治疗覆膜支架近端锚定区不良的BTAI具有良好的近期临床效果,远期结果有待进一步随访。     

内脏动脉瘤的外科治疗

目的 探讨内脏动脉瘤的外科治疗方法。方法 回顾性分析2002年2月至2010年6月收治的19例内脏动脉瘤患者外科治疗的临床资料,包括脾动脉瘤7例、肝右动脉瘤1例、胃左动脉瘤1例、胰十二指肠动脉瘤3例、胃十二指肠动脉瘤2例、肠系膜上动脉瘤、结肠中动脉瘤和左结肠动脉瘤各1例、肾动脉瘤2例。其中破裂12例。按照手术方式分为两组,介入栓塞治疗组13例,开放手术组6例。结果 4例栓塞后再出血,2例行手术探查止血、2例行二次栓塞后都得以成功止血。8例动脉瘤破裂伴休克患者术后均停止出血。1例胰十二指肠动脉瘤栓塞后出现十二指肠不全梗阻。2例脾动脉瘤患者术后出现部分脾梗死。术后随访18例,随访2 ～ 103个月,无动脉瘤复发。结论 以支配脏器和动脉解剖的特点作为内脏动脉瘤选择手术方案的主要依据。腔内治疗和开放手术在治疗内脏动脉瘤方面均有效,而对于假性动脉瘤破裂患者,腔内治疗效果满意。     

经皮肝穿刺胆管引流术后胆道大出血的介入治疗

目的探讨介入疗法治疗经皮肝穿刺胆管引流术（PTCD）后胆道大出血的临床应用价值。 方法回顾性分析2008年3月至2015年1月621例因胆道梗阻行PTCD,共发生术后胆道大出血8例（1.29%）,7例患者首选经选择性血管造影及引流管造影,证实责任血管后行介入治疗。1例先行手术探查,术后再发大出血,予血管造影检查证实假性动脉瘤后行介入治疗。 结果6例患者经造影证实为医源性血管损伤,其中2例为动脉胆管瘘,3例为假性动脉瘤,1例为门静脉胆管瘘。2例动脉胆管瘘及3例假性动脉瘤患者予栓塞责任血管近端、远端后治愈,门静脉胆管瘘患者经保守治疗后死亡。剩余2例为胆管癌栓松动后自发出血,经肝动脉栓塞后止血。 结论血管介入治疗为胆道大出血的首选治疗方法,具有安全性高、创伤小、疗效确切的优势。     

Characteristics and surgery of aneurysms of the proximal (A1) segment of the anterior cerebral artery

AIM: Proximal anterior cerebral artery (A1) aneurysms are considered to be rare or even unique. Proper surgical planning around A1 segment is particularly essential in order to avoid injury of tiny perforating arteries. METHODS: In 17 patients with angiographically or intraoperatively diagnosed A1 aneurysms, representing 0.8% of 2 124 aneurysm patients treated surgically at our institution between 1991 and 2003, clinical presentation, neuroradiological findings, surgical treatment methods and outcome were retrospectively analyzed. RESULTS: Sixteen patients presented with subarachnoid hemorrhage; A1 aneurysms were ruptured in 13 cases. Five patients (29%) had multiple aneurysms. In all cases A1 aneurysms were saccular and their maximum diameter ranged from 4 to 25 mm, average, 7.2 mm; in 4 cases they projected from the origin of the perforating artery, in 6 at the bifurcation of the internal carotid artery, in 5 at the anterior communicating artery and in 2 from the convexity of the parent artery. In 15 patients aneurysms were clipped via ipsilateral pterional approach and in the remaining 2, including a case with a second middle cerebral artery aneurysm, through contralateral approach. Eleven patients had excellent outcome, three good, and three died. CONCLUSIONS: Angiograms must be thoroughly analyzed to correctly assess origin of the aneurysmal neck, and to plan the operative procedure as radiological presentations of distal or proximal A1 lesions resemble those of anterior communicating artery and internal carotid artery bifurcation aneurysms, respectively. Contralateral approach may facilitate surgical elimination of selected A1 aneurysms or enable one-stage clipping in patients with multiple bilateral aneurysms.     

Surgery of Proximal Anterior Cerebral Artery Aneurysms

Summary.  Background: Aneurysms of the proximal segment of anterior cerebral artery (A1) are uncommon, but present a unique challenge to surgeons because of the risk of injury to the nearby perforating arteries. Surgical issues and treatment options, however, have not been detailed in the previous literature.  Method: We report a consecutive series of 11 patients with A1 aneurysms focusing on the surgical considerations. The A1 aneurysms represented 3.4% of the 322 cerebral aneurysms treated in our hospital in the last 6 years. All patients presented with subarachnoid hemorrhage, and 8 patients (73%) had multiple aneurysms.  Findings: All aneurysms were secured by neck clipping via pterional craniotomy without any surgery-related morbidity. All of the aneurysms projected superiorly or posteriorly from the origin of the perforating artery of the A1 segment. The aneurysm dome was tightly adherent to the perforating arteries in 7 cases (64%) and the base extended broadly along the axis of the parent artery in 4 cases (36%).  Interpretation: Separating the perforating arteries from the neck or dome of the A1 aneurysm and preserving the vessel presents a substantial challenge to the surgeon, because the aneurysm is almost always behind the parent artery in the surgical field, making it difficult to achieve good access for this particular type of dissection. Consideration should be given to additional orbitotomy, wide opening of the Sylvian fissure, mobilization of the MCA and ICA, selection of aperture clip and intra-operative shortening of the clip blades. Published online December 5, 2002  Correspondence: Akihiko Hino, M.D., Department of Neurosurgery, Saiseikai Shigaken Hospital, Ohashi 2-4-1, Ritto, Shiga 520-30, Japan.     

Craniotomy side for neck clipping of the anterior communicating aneurysm via the pterional approach

The safety and reliability of neck clipping of the anterior communicating artery (Acom) aneurysm via the pterional approach was evaluated in terms of craniotomy side in 39 consecutive cases operated on by the senior surgeon from April 1991 through March 2000. These aneurysms were approached in principle via the side where the proximal A2 portion of the anterior cerebral artery was located posteriorly, for the purpose of easier identification of all five arteries involved, i.e., A1 and A2 portions of the anterior cerebral arteries of both sides and Acom. All aneurysms were clipped safely irrespective of the approach side because it was possible prior to aneurysmal dissection to prepare both A1 portions of the anterior cerebral arteries for temporary clipping, but not as far as the place where the aneurysm projects inferiorly and its fundus adheres firmly to the optic chiasm. The security of perforating arteries, however, could not be confirmed even after the completion of neck clipping in 9 cases. Clipping was impossible in the other 2 cases. In 2 of these 11 aneurysms the difficulty in clipping was not based on what side was used for craniotomy but on their large size. In the remaining 9 aneurysms, the necks of which were all situated on the posterior wall of the Acom, the craniotomy side turned out to be inappropriate when they were approached via the side where the proximal A2 portion of the anterior cerebral artery was located posteriorly. It was concluded that the craniotomy side should be selected so that the surgeon can observe directly the neck of the aneurysm.     

Characteristics of aneurysms arising from the horizontal portion of the anterior cerebral artery

BACKGROUND: Aneurysms arising from the proximal portion of the anterior cerebral artery (A1: horizontal portion) are quite rare and are considered to be unique, because they are usually connected with other vascular anomalies and are sometimes part of a multiple aneurysm occurrence. A1 aneurysm cases experienced over the past seven and a half years are summarized in this paper. METHODS: A total of 413 patients were surgically treated including 142 patients with subarachnoid hemorrhage (SAH); the remaining 271 patients had unruptured aneurysms. Among them, nine cases were categorized as constituent A1 aneurysms, three with SAH and six with unruptured aneurysms. RESULTS: The shape of the aneurysm was saccular in all nine cases. Three of the nine cases had associated vascular malformations. The average aneurysm diameter in the three cases with SAH was 4.0 mm, which is smaller than other common aneurysms presenting with SAH. Eight aneurysms developed at the takeoff point of perforating arteries-the medial lenticulostriate artery in five cases and the recurrent artery of Heubner in three cases. In the remaining case, the aneurysm originated from the proximal end of the associated A1 fenestration. All nine patients had an excellent outcome after surgery. CONCLUSION: A1 aneurysms require surgical elimination even if they are small. We emphasize the importance of preserving the blood flow of these perforating arteries by avoiding compression with either the clip blade or the clip body itself.     

The limitations of three-dimensional CT angiography (3D-CTA) in the diagnosis of cerebral aneurysms

OBJECT: The purpose of this study is to show some limitations of 3D-CTA to diagnose cerebral aneurysms. METHODS: Sixteen saccular aneurysms less than 10 mm in diameter were included. Large and complicated aneurysms were excluded. RESULTS: Although information about perforating arteries from the posterior cerebral artery is very important for surgery of basilar bifurcation aneurysms, 3D-CTA could not delineate the perforating arteries. A small posterior communicating artery (Pcom.A.) was not detected, and it was very difficult to differentiate infundibular dilatation of the Pcom. A. from an aneurysm. A small aneurysm of the distal middle cerebral artery could not be detected. Flow direction can not be determined by 3D-CTA, and nor could the side of the neck of the anterior communicating artery aneurysm be determined. Fenestration of the anterior communicating artery and the origin of the triple anterior cerebral artery were both misdiagnosed as anterior communicating artery aneurysms. CONCLUSION: It is premature to consider 3D-CTA as a replacement for conventional angiography.     

Aneurysms of the proximal anterior cerebral artery

The authors report eight cases of aneurysm of the anterior cerebral artery proximal to the anterior communicating artery (A1 segment). In six of these cases, the aneurysms arose from the proximal anterior cerebral artery at the origin of either a cortical branch (on case), the accessory middle cerebral artery (one case), or a perforating branch (four cases). In another case the aneurysm arose at the proximal end of the fenestration, whereas in the one remaining case no branch was present at the site of the aneurysmal neck.     

Aneurysms located at the proximal anterior cerebral artery and anterior communicating artery associated with middle cerebral artery aplasia: case report

BACKGROUND: Aneurysms arising from the proximal anterior cerebral artery (ACA) are quite rare. Here, we report upon such a case of aneurysms located at the proximal ACA and anterior communicating artery associated with middle cerebral artery (MCA) aplasia. CASE DESCRIPTION: A 64-year-old woman complained of severe headache. Brain computed tomography scans demonstrated acute subarachnoid hemorrhage. Angiograms showed 2 aneurysms located at the anterior communicating artery and proximal ACA, but did not show an MCA shadow on the lesion side. Instead, multiple collateral vessels ran toward the sylvian fissure and supplied the MCA territory, together with hypertrophied perforating branches. The operative findings confirmed that the cordlike rudimentary MCA had no internal blood flow. The 2 aneurysms were secured by neck clipping. CONCLUSION: The combined effects of these anomalies on the hemodynamic equilibrium of the arteries and the genesis of the aneurysms are noteworthy.     

The three-dimensional CT angiography findings of ruptured aneurysms hardly detectable by repeated cerebral angiography

We reported three cases of cerebral aneurysms hardly detectable by cerebral angiography, but easily detected by three-dimensional CT angiography (3D-CTA). These cases were ruptured aneurysms with subarachnoid hemorrhage. After detection of subarachnoid hemorrhage on CT scan, cerebral angiography was performed at first, but aneurysms were not detected. Subsequently 3D-CTA was carried out, and aneurysms were detected. In all cases, cerebral angiography was repeated, after the aneurysms had been found by 3D-CTA. This time aneurysms were all detected by cerebral angiography, but each case needed photographs from special direction. The aneurysms were small by usual cerebral angiography and they were almost invisible behind the artery near which they existed. 3D-CTA was very useful for detection of small aneurysms, but small perforating arteries around the aneurysms were invisible by 3D-CTA. To find these perforating arteries, cerebral angiography was needed.     

Aneurysms arising from the proximal (A1) segment of the anterior cerebral artery. A study of 38 cases.

This study reviews aneurysms of the proximal segment (A1) of the anterior cerebral artery in 38 patients (23 men and 15 women) and their surgical, angiographic, and clinical management. Thirty-seven aneurysms were saccular and one was fusiform. The incidence of A1 aneurysms among a total of 4295 aneurysm cases treated was 0.88%. Multiple aneurysms occurred in 17 patients (44.7%) of the 38 cases; in 10 (58.8%), there was bleeding from the A1 aneurysm. The aneurysms were classified into five categories according to the mode of origin of the aneurysm in relation to the A1 segment: in 21 cases, aneurysms originated from the junction of the A1 segment and a perforating artery; in eight, from the A1 segment directly; in six, from the proximal end of the A1 fenestration; and in two, from the junction of the A1 segment and the cortical branch. One patient had a fusiform aneurysm. Computerized tomography (CT) of these aneurysms revealed bleeding extending to the septum pellucidum similar to that of anterior communicating artery aneurysms. When performing radical surgery it is very important to recognize the characteristics of A1 aneurysms, including multiplicity, a high incidence of vascular anomalies (especially A1 fenestration), and their similarity to anterior communicating artery aneurysms on CT.     

Microanatomy of the anterior cerebral artery

The microanatomic features of the anterior cerebral artery were studied in 30 unfixed human brains which were injected with tinted polyester resin via cannulation of the internal carotid arteries under microscopic dissection. The outer diameter, length, and number of perforating branches were measured for each of the following vessels: anterior cerebral artery (proximal A1 segment, distal A2 segment), anterior communicating artery, and recurrent artery of Heubner. The perforating branches of the proximal segment of the anterior cerebral artery penetrated the brain at the anterior perforated substance, lateral chiasm, and optic tracts. The perforating branches of the anterior communicating artery penetrated the brain at the lamina terminalis, anterior perforated substance, and medial chiasm. The first 5 mm of the distal anterior cerebral artery (A2) had perforating branches penetrating the brain at the gyrus rectus and olfactory sulcus. The recurrent artery of Heubner originated from the A2 segment of the anterior cerebral artery in 57% of the cases, from the anterior cerebral artery-anterior communicating artery junction in 35%, and from the A1 segment in 8%. The depth of the interhemispheric fissure at the genu was 36.0 +/- 0.5 mm and at the midbody of the corpus callosum, 35.0 +/- 0.5 mm. Extension of the dissection to approach the anterior communicating artery from the genu of the corpus callosum using the anterior interhemispheric route was an additional 31.7 +/- 0.7 mm. The callosal arterial supply from the anterior cerebral artery showed short callosal branches in all brain specimens and long callosal vessels in 10% of the specimens.