外科手术在肾下腹主动脉瘤治疗中的地位(附187例手术经验)

目的：就肾下型腹主动脉瘤的治疗经验，讨论外科手术的实用性和前途。方法：回顾分析1992年1月至2004年2月择期行肾下型腹主动脉瘤切除术187例，将其结果与经腔内治疗者作比较。结果：围手术期死亡1例(0．54％)，死亡原因是术后6h出现频发室性早搏、室颤，诱发大面积心肌梗死。手术时间平均为3．8h；出血量平均470ml．输血量445ml。ICU内恢复时间为12～24h。围手术期并发症包括心力衰竭17例，呼吸衰竭8例，急性心肌梗死2例，急性脑梗死1例，急性肾功能衰竭3例，无术后严重出血或失血性休克发生，也无下肢动脉栓塞发生。术后1、3、5年生存率分别为97．0％、84．6％及78.3％，随访期间病人死亡者的原因与腹主动脉瘤和手术无关。经腔内治疗手术目前仍有较高的中、远期并发症。结论：瘤体直径不能作为手术适应证的唯一指标。术前同时应确切评价全身重要脏器功能。影响腹主动脉瘤手术的危险因素主要是高龄、严重心、肺疾患及肾功能不全等。迄今，经腹手术仍是治疗腹主动脉瘤的主要方法。     

187例肾下腹主动脉瘤的手术治疗经验

目的　总结肾下型腹主动脉瘤手术经验。方法　回顾性分析 1 992年 1月至 2 0 0 4年2月 1 87例择期行肾下型腹主动脉瘤切除术 (或同时切除髂动脉瘤 )的临床资料。结果　围手术期心梗死亡 1例 ,死亡率为 0 . 5 4 %。手术时间 3～ 6h ,平均 3 8h ;出血量 2 0 0～ 1 5 0 0ml,平均 4 70ml;输血量 0～ 1 5 0 0ml,平均 4 4 5ml。ICU停留时间 1 2～ 2 4h。围手术期并发症包括心力衰竭 1 7例 ,呼吸衰竭 8例 ,急性心肌梗死 2例 ,急性脑梗死 1例 ,急性肾功能衰竭 3例 ,无术后严重出血或失血性休克发生 ,无下肢动脉栓塞发生。术后 1、3、5年生存率分别为 97. 0 %、84. 6 %、78 . 3%,患者随访期间的死亡与腹主动脉瘤和手术无关。结论　瘤体直径不能作为手术指征。腹主动脉瘤手术的危险因素主要是高龄、严重的心肺疾患和肾功能不全等。手术切除腹主动脉瘤疗效是满意的。     

肾下型腹主动脉瘤的外科治疗

目的总结26例肾下型腹主动脉瘤的手术治疗经验。方法回顾性分析近5年多来手术治疗26例肾下型腹主动脉瘤的临床资料，全组26例，术前均经影像检查证实诊断。行择期手术21例，破裂型腹主动脉瘤急诊手术5例。26例均行腹主动脉瘤切除，人工血管重建术。结果围手术期死亡2例，均为急症手术患者，总病死率7．7％，急诊手术病死率40．0％。随访时间1-5年。术后1，3，5年生存率分别为96％，88％，75％。死亡原因均与腹主动脉瘤和手术无关。结论CTA检查是诊断腹主动脉瘤的可靠方法。手术治疗仍是治疗腹主动脉瘤的重要方法。瘤体直径不是决定手术的唯一指征。影响手术的危险因素主要是高龄、严重的心肺疾病和肾功能不全。     

腹主动脉瘤腔内修复术单中心治疗经验

目的 评价腔内修复术(endovascular aneurysm repair,EVAR)治疗肾下型腹主动脉瘤(abdominal aortic aneurysm,AAA)的围术期和中远期效果.方法 回顾性分析131例AAA行EVAR的临床资料,评价EVAR治疗AAA的安全性和中远期疗效.结果 手术时间(137±29) min,术中出血(142±20) ml、输血(46±26) ml、ICU恢复时间为(17±4)h.围术期主要并发症包括重度心功能不全8例、心肌梗死2例、肺部并发症5例,内漏4例等;随访中发现内漏15例,Ⅰ型8例,Ⅱ型5例,Ⅲ型和Ⅳ型各1例,死亡2例;Kaplan-Meier生存分析无并发症生存率及再次处理率提示60个月后仍有并发症发生,其中40％是需要再次处理的并发症.结论 EVAR是AAA的安全治疗方法,但需要长期严格随访并及时处理并发症.     

破裂腹主动脉瘤的外科治疗

目的探讨急诊腹主动脉瘤切除人工血管移植术治疗破裂腹主动脉瘤的经验。方法总结1999年4月至2005年4月外科手术治疗破裂腹主动脉瘤20例，采用钳夹阻断膈下腹主动脉或Foley氏球囊管腔内阻断瘤颈上腹主动脉后行急诊腹主动脉瘤切除人工血管移植术，应用分叉型人工血管12例，直型人工血管8例。结果急诊腹主动脉瘤切除人工血管移植手术30d围手术期死亡率40％（8例），死亡原因包括急性肾功能衰竭4例，多器官功能衰竭2例，呼吸循环衰竭2例。存活12例，术后合并症包括急性肾功能不全、肺部感染、凝血机制障碍和腹泻等共11例，均经治疗后痊愈。随访观察6～60个月，无人工血管血栓形成和感染等并发症以及随访期死亡发生。结论破裂腹主动脉瘤外科手术治疗死亡率仍然很高，早期确定诊断，紧急外科手术治疗，术后加强围手术期管理是降低破裂腹主动脉瘤死亡率的关键。     

30例腹主动脉瘤的外科诊疗结果分析

目的 交流腹主动脉瘤的诊断和外科治疗方法。方法 对1991年2月至2002年7月我院外科治疗的30例肾下型腹主动脉瘤的临床资料进行回顾性分析。结果 数字减影血管造影术诊断1例．MR1诊断2例。其余27例均经CT确诊。该30例中．腹主动脉瘤破裂6例．行急诊手术，死亡2例(死亡率33.3％)；24例未破裂者中．22例行腹主动脉瘤切除和原位人造血管移植术．术后死亡2例(死亡率9.1％)．另2例行腹主动脉瘤腔内人造血管移植术。结论 及早术前诊断．恰当地选择手术时机、手术方式及正确的围手术期处理是提高手术成功率，减少术后并发症和死亡率的关键。     

八十岁以上高龄腹主动脉瘤患者的外科治疗

目的探讨八十岁以上高龄腹主动脉瘤患者的传统手术及腔内治疗的疗效。方法回顾性分析20例年龄在80～90岁腹主动脉瘤患者的外科治疗经验,其中12例接受传统手术,8例行腔内治疗。结果20例患者围手术期有2例死亡,均为手术组患者。腔内组的手术及术后并发症情况均显著优于手术组。随访3～69个月,2例手术组患者失访,手术组和腔内组各有2例远期死亡。手术组和腔内组的累计生存率分别为6／10和6／8。结论对于八十岁以上高龄腹主动脉瘤患者的外科治疗可行,在合适病例首选腔内治疗。     

九例腹主动脉瘤破裂死亡原因分析

目的分析总结腹主动脉瘤破裂的死亡原因与救治经验。方法回顾性分析2001-2005年23例腹主动脉瘤破裂手术治疗后9例死亡病例的临床资料。结果23例中死亡9例,术前均伴有休克,总死亡率约39．1％。术前伴发高血压7例、COPD 1例、慢性肾功不全1例。其破裂类型包括向前壁开放性破裂5例;向脊柱左侧方破裂3例;向后方破裂1例。破裂部位分别为肾动脉3例、肾下腹主动脉领域6例。术后分别死于ARDS 4例、急性肾衰2例、人工血管感染2例、DIC 1例。结论死亡率与就诊时的休克状态、破裂部位和类型、术后并发症、人工血管感染密切相关,及时正确地诊断救治、加强围手术期监护有利于降低死亡率。     

支架型人工血管临床应用的初步经验

目的探讨支架型人工血管治疗各类动脉瘤的临床效果。方法本组包括夹层动脉瘤 4 8例 ;腹主动脉瘤 13例 ;降主动脉、左锁骨下动脉、肾下和肾上腹主动脉假性动脉瘤分别为 4例、1例、2例和 1例 ;左、右髂动脉瘤各 1例。对夹层动脉瘤和假性动脉瘤均行破口封堵术 ,真性腹主动脉瘤行隔绝术。结果本组均获技术成功。围手术期死亡 2例。 5例夹层动脉瘤术后近侧有少量残余漏 ,但 4例半年后近侧渗漏消失 ,9例残存远侧破口少量返流。腹主动脉瘤 6例术后即时有轻度内漏 ,3个月后 5例内漏消失。结论支架型人工血管治疗夹层动脉瘤、假性动脉瘤和真性动脉瘤手术微创、安全 ,但其远期疗效需进一步观察。     

腔内修复术治疗肾下型腹主动脉瘤合并糖尿病的中远期疗效观察北大核心CSCD

目的观察腔内修复术（EVAR）治疗肾下型腹主动脉瘤（AAA）合并糖尿病（DM）患者的临床疗效,并分析影响中远期疗效的因素。方法对2004年1月至2014年6月符合纳入标准的103例AAA合并DM患者行EVAR治疗并进行随访。结果88例（85．43％）患者完成最终有效随访,中位随访时间3．59年,最长随访时间10．32年。随访期间共发生25例死亡,远期全因死亡率为24．3％。随访期间共发生介人相关并发症6例（5．8％）。随访期问二次干预2例,二次干预率为1．9％。术后5年累积生存率为70％,术后10年累积生存率为6l％。结论EVAR手术对AAA合并DM患者是安全的。     

Preoperative glomerular filtration rate and outcome following open abdominal aortic aneurysm repair

Estimated glomerular filtration rate (eGFR) can be readily calculated from serum creatinine values. It is a more sensitive prognostic indicator than serum creatinine alone in patients undergoing thoracoabdominal or endovascular abdominal aortic aneurysm repair. The value of eGFR in patients undergoing open abdominal aortic aneurysm repair remains unclear. The preoperative eGFR was calculated for patients undergoing elective open infrarenal aortic aneurysm repair. Postoperative complications, perioperative mortality, and long-term survival were compared across eGFR and serum creatinine quartiles. The eGFR identified preoperative renal dysfunction in 33% of patients, whereas serum creatinine identified renal impairment in only 11%. The eGFR correlated with perioperative morbidity and long-term survival. Serum creatinine did not correlate with perioperative mortality or long-term survival. However, it did correlate with postoperative morbidity. The eGFR is a more sensitive index of preoperative renal function than serum creatinine and correlates with survival. It should replace serum creatinine as the standard index of renal function before open abdominal aortic aneurysm repair.     

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     

腹主动脉瘤腔内修复与开放手术疗效比较

目的 比较腹主动脉瘤开放手术和腔内治疗的效果.方法 对2002年1月至2007年7月收治的223例分别行开放手术和腔内修复的腹主动脉瘤患者进行网顾性分析.手术组141例,男性118例,女性23例;腔内治疗组82例,男性66例,女性16例.对手术相关情况、围手术期并发症发生率、病死率、随访中并发症发生率等进行对比分析.结果 腔内修复组手术时间、术中出血量、输血量均少于开放手术组(P<0.01),围手术期并发症两组无显著差异(P>0.05),SF-36量表评估显示术后6个月开放手术组优于腔内治疗组,术后2年生存率两组无明显差异(P>0.05),但腔内修复组并发症发生率高于开放手术组(P<0.01).住院费用腔内修复组明显高于开放手术组(P<0.01).结论 腹主动脉瘤腔内修复具有手术时间短、微创的特点,但具有较高的远期并发症,开放手术组6个月健康生存质量优于腔内修复组.     

腹主动脉瘤96例的诊断与手术治疗

摘要：目的 探讨腹主动脉瘤(AAA)的诊断、手术方式的选择及并发症的防治。方法 回顾性分析14年余收治的96例AAA的诊断和手术治疗的临床资料。对82例肾动脉水平以下型AAA行动脉瘤切除人工血管置换术，12例肾下型行涤纶片动脉瘤体包裹术，2例肾动脉上型腹主动脉假性动脉瘤行側壁瘤体切除修补术。结果 主动脉造影、MRA或EBT可确定动脉瘤上界与肾动脉间的距离。93例获得临床治愈。手术死亡3例，手术病死率3.1%(3/96)；其中急诊手术病死率50.0%(2/4)，限期手术病死率1.1%(1/92)，两者差异显著（P<0.05）。6例术后出现乙状结肠缺血症状，2例肢体远端有缺血症状，2例急性肾功能不全，均经非手术治疗痊愈。手术并发症发生率21.3％。82例获随访，随访时间6个月至15年。术后5年生存率为81.7%。 结论 AAA切除人工血管置换术是治疗AAA的基本方法。     

237例肾动脉水平以下腹主动脉瘤手术治疗经验

目的提高腹主动脉瘤手术的安全性。方法总结了自１９６０年１月到１９９６年１２月２３７例肾动脉水平以下腹主动脉瘤切除人造血管移植手术治疗的经验。结果随着腹膜后途径的应用,动脉瘤近端血流控制、动脉瘤切除以及缝合修补等方法的改进,使手术的危险性明显降低,手术时间缩短（２～３ｈ）。随访２２７例,手术死亡率低（３．８％）。５年存活率达７４．４％。结论手术技术和麻醉监护的进步,使腹主动脉瘤修补手术变得更迅速、安全和方便。     

Open repair of aortic aneurysms involving the renal vessels

This retrospective review examines the open surgical repair of intact juxtarenal (JRAAs) and suprarenal (SRAAs) aortic aneurysms to estimate effects on survival and renal function. Patients undergoing open repair of JRAA and SRAA were identified. Preoperative medical comorbidities and perioperative and late outcomes were recorded. Primary end points were survival (perioperative and long-term survival) and changes in renal function (acute tubular necrosis [ATN], acute dialysis, and late functional decline). Associations between outcomes and clinical variables were examined using univariate and multivariate techniques. Between December 1996 and September 2006, 678 patients underwent open repair of aortic aneurysms, including 150 aneurysms involving the renal vessels (134 JRAAs, 16 SRAAs). Perioperative mortality was 3% and long-term survival was 69% at 5 years. Fourteen percent of patients experienced ATN, and 7% required acute in-hospital dialysis. Late renal function remained unchanged or improved in 75%. These results demonstrate a perioperative mortality and renal complication rate in keeping with previous reports of open abdominal aortic aneurysm repairs involving the renal vessels. Future implementation of branch and fenestrated aortic endografts to treat similar aneurysms should approximate these results prior to widespread acceptance.     

Fate of the excluded abdominal aortic aneurysm sac: Long-term follow-up of 831 patients

Purpose: Nonresective treatment of the infrarenal abdominal aortic aneurysm by proximal and distal ligation of the aneurysm sac (exclusion) combined with aortic bypass has been previously reported. A 10-year experience with 831 patients undergoing this procedure was reviewed.Methods: From 1984 to 1994, 831 (761 elective, 70 urgent) of 1103 patients being treated for abdominal aortic aneurysm underwent repair with the retroperitoneal exclusion technique. Perioperative morbidity and mortality, estimated blood loss, transfusion requirements, natural history of the excluded aneurysm sac, and long-term survival were all assessed.Results: The operative mortality rate for patients undergoing exclusion and bypass was 3.4%. The incidence of nonfatal perioperative complications was 5.2%. Colon ischemia requiring resection occurred in 2 (0.2%) of the 831 patients. Estimated blood loss was 638 ± 557 cc (50 to 330 cc). On follow-up 17 (2%) patients were found to have patent aneurysm sacs as detected by duplex examination. Fourteen patients required surgical intervention. No cases of graft infection or aortoenteric fistula have been noted.Conclusion: Retroperitoneal exclusion and bypass is a viable alternative to traditional open endoaneurysmorraphy in surgery for abdominal aortic aneurysm. Most excluded aneurysm sacs have thrombosis without any long- or short-term complications; however, in a small number of patients delayed rupture of patent aneurysm occurs, thus emphasizing the need for diligent follow-up and appropriate intervention. (J Vasc Surg 1996;24:851-5.)     

Short- and long-term outcomes of aortic root repair and replacement in patients undergoing acute type A aortic dissection repair: Twenty-year experience

ObjectiveThe study objective was to evaluate the perioperative and long-term outcomes of aortic root repair and aortic root replacement and provide evidence for root management in acute type A aortic dissection.MethodsFrom 1996 to 2017, 491 patients underwent aortic root repair (n = 307) or aortic root replacement (n = 184) (62% bioprosthesis) for acute type A aortic dissection. Indications for aortic root replacement were intimal tear at the aortic root, root measuring 4.5 cm or more, connective tissue disease, or unrepairable aortic valvulopathy. Primary outcomes were in-hospital mortality, long-term survival, and reoperation rate for root pathology.ResultsPatients' median age was 61 years and 56 years in the aortic root repair group and aortic root replacement group, respectively. The aortic root replacement group had more renal failure requiring dialysis, previous cardiac intervention or surgery, heart failure, coronary malperfusion syndrome, acute myocardial infarction, and severe aortic insufficiency, as well as concomitant coronary artery bypass grafting, tricuspid valve repair, and longer cardiopulmonary bypass and aortic crossclamp times but similar arch procedures. Perioperative outcomes were similar in the aortic root repair and aortic root replacement groups, including in-hospital mortality (8.5% and 8.2%), new-onset renal failure requiring permanent dialysis, stroke, myocardial infarction, and sepsis. Kaplan–Meier 10-year survival was 62% and 65%, and the 15-year cumulative incidence of reoperation was 11% and 7% in the aortic root repair and aortic root replacement groups, respectively. The primary indication for root reoperation was aortic root aneurysm in the aortic root repair group and bioprosthetic valve deterioration in the aortic root replacement group.ConclusionsAortic root repair and aortic root replacement are appropriate surgical options for acute type A aortic dissection repair with favorable short- and long-term outcomes. Aortic root replacement should be performed for patients with acute type A aortic dissection presenting with an intimal tear at the aortic root, root aneurysm 4.5 cm or greater, connective tissue disease, or unrepairable aortic valvulopathy.