Endovascular Repair of a Traumatic Thoracic Aortic Injury Resulting in Late Aortic Dilatation

We present an unusual complication following endovascular repair of traumatic thoracic aortic injury using a homemade stent-graft. Although an initial technical success was apparently obtained, the aorta showed remarkable dilatation without shortening or migration of the stent skeleton in late follow-up period. The possible cause of the dilatation was considered to be the expansion and gathering of the crimped, loosely attached, graft fabric in addition to the incomplete exclusion due to the insufficient landing zone and the limited radial force. Thus, the specific feature of stent-graft, considered to provide an advantage to treatment, has adversely affected the native aorta.     

Early and midterm outcomes of open stent-graft treatment for distal aortic arch aneurysm

PURPOSE: The aim of this study was to investigate early and late outcomes for open stent-graft treatment, which was introduced as a less-invasive technique for thoracic aortic aneurysm of the distal arch, and to clarify the validity of and indications for this treatment. MATERIALS AND METHODS: We retrospectively investigated 38 patients with thoracic aortic aneurysm of the distal arch who underwent open stent-graft placement at our hospital between June 2000 and September 2006. RESULTS: Five patients died in hospital (hospital mortality 13.2%). Age at the time of surgery and onset of postoperative paraplegia were identified as risk factors. Four patients (10.5%) had postoperative paraplegia, but no significant risk factors were seen. The size of the aneurysm was clearly reduced in 18 of the 25 patients (75.8%), in whom computed tomography was performed after discharge, and late outcomes were good. Mural thrombus thickness on the stent landing zone of <4 mm was a predictor for aneurysm shrinkage. Seven patients died during the late period, and the 5-year survival rate among hospital survivors was 80.1%. CONCLUSION: Early outcomes for open stent-graft are not necessarily good, and late survival is also not excellent. Open stent-graft thus cannot be regarded as an ideal technique for all patients with distal aortic arch aneurysm. However, after aneurysm shrinkage was confirmed during the early period, late outcomes were good. Absence of thick mural thrombus on the stent landing zone may represent a good indication for open stentgraft surgery.     

覆膜支架腔内治疗急性胸主动脉综合征

目的 评价覆膜支架腔内治疗急性胸主动脉综合征的有效性和安全性。方法 2001年5月至2005年12月应用覆膜支架治疗57例急性胸主动脉综合征患者,其中急性主动脉B型夹层45例,穿透性粥样硬化性溃疡（PAU）或假性动脉瘤9例,创伤性胸主动脉瘤3例。建立数据库,分析其临床特点、疗效及随访结果。结果 57例患者覆膜支架置入技术成功率100％。5例有近端内漏,1例术中出现升主动脉夹层,未予特殊处理,随访结果良好;1例术后7天出现升主动脉夹层并发心包填塞死亡。5例PAU或主动脉夹层合并冠心病患者,在应用覆膜支架成功完全封闭破口后立即行冠状动脉介入治疗成功。1例出现术后一过性双下肢无力,经静脉滴注山莨菪碱和甘露醇2天后痊愈。1例支架覆盖左锁骨下动脉开口导致左椎动脉缺血,嗜睡2天后自行好转。术后重症监护病房时间1～8（平均3．5）天,术后平均住院10天。术后30天内死亡2例,1例死于升主动脉夹层破裂,1例死于急性肾衰竭。术后30天内死亡率3．5％。术后平均随访（25．3±13．1）（13—55）个月。1例于术后3个月死于大咯血,1例死因不明。1例因近端内漏行二次腔内修复术。5例患者因降主动脉覆膜支架远端再发现破口,行二次腔内修复术。术后截瘫发生率为0,无支架移位、狭窄等并发症。术后住院及随访期内总死亡率为7．0％。与传统手术相比,腔内治疗急性胸主动脉综合征具有创伤小、严重并发症少、住院时间较短的优势。结论 覆膜支架是治疗急性胸主动脉综合征优良且有效的方法,也可用于外科手术高风险患者,近中期随访结果良好,远期结果有待于进一步随访。     

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.     

The use of femoropopliteal stent-grafts for critical limb ischemia

Peripheral vascular disease of the femoropopliteal segment is one of the most common anatomic locations leading to patient symptoms. Traditional open surgical bypass has started to be supplanted by a surge in lower risk endovascular procedures. Though midterm results of endovascular therapy have been acceptable, longer term results, especially in long diffuse disease, appear to be less durable than their surgical alternatives. Recently the Viabahn, a percutaneously placed PTFE stent-graft, has been approved for use in the femoropopliteal artery. Though the majority of the data for this stent-graft has been derived from patients with complex (>10 cm length) lesions, most of the patients have been claudicants. The population with critical limb ischemia is at particularly high risk for cardiovascular mortality and may benefit from this less invasive approach. However, stent-graft utilization is more complex and many variables must be evaluated before and during the procedure to allow for optimal procedural outcomes.     

改良支架"象鼻"手术治疗Stanford A型主动脉夹层的临床应用

目的:探讨改良支架"象鼻"手术治疗主动脉夹层的方法和效果.方法:20例Stanford A型主动脉夹层患者,年龄23～71岁,中位年龄50.7岁.其中急性夹层14例,慢性夹层6例.应用深低温停循环(DHCA)和上腔静脉逆行灌注或右腋动脉顺行灌注(SCP)进行脑保护,施行改良支架"象鼻"手术(即升主动脉和半弓置换及降主动脉腔内支架植入).同期行Ben-tall手术11例,Cabrol 2例.停循环时间36～86 min,平均34.5 min.结果:术后住院死亡2例(10%).存活患者获随访3个月～2年,无死亡,其中10例于术后3个月定期行主动脉多层螺旋CT检查,8例降主动脉夹层内有血栓形成,2例有部分血栓形成.结论:改良支架"象鼻"手术简单,停循环时间短,可以达到支架"象鼻"手术的同样效果,远期降主动脉假腔封闭率仍有待进一步的临床随访观察.     

Spaltfuß mit Y-förmigem Os metatarsale (Bifurcated metatarsal bone)

Summary Goal of Surgery Correction of the deformity of the third metatarsus and of the malposition of the toes to improve form and function of the foot. Indications Problems with shoe wear. Aesthetic appearance. (Limitation of function.) Contraindications None. Preoperative Work Up Drawing of surgery to be performed. Positioning and Anaesthesia Supine. General anaesthesia. Surgical Technique Excision of the distal half of the hypoplastic second metatarsus through a curvilinear dorsal incision. Osteotomy of the third metatarsus at the Y-junction and implantation of the mediodistal part into the proximal half of the second metatarsus. Corrective osteotomy of the third metatarsus at the Y-junction. Internal fixation of both metatarsi with transosseous, transarticular Kirschner wires. Four weeks later correction of the hallux valgus using the technique recommended by Kramer. Postoperative Management Below knee plaster of Paris. Removal of K'wires after consolidation of osteotomies. Progressive increase in weight bearing. Arch supports. Possible Complications Injury to nerves, vessels or tendons. Wound infection. Delayed consolidation. Nonunion. Growth disturbances. Results 30 months postoperatively, when the patient was 13 years of age, both osteotomies had healed in good position: the foot looked nearly normal. At 21 years of age the patient has no problems. She is involved in sports and is satisfied with the result.

     

A canine model to study the significance and hemodynamics of type II endoleaks

OBJECTIVE: The clinical significance of Type 2 endoleak after endovascular repair of abdominal aortic aneurysms (AAA) remains incompletely delineated. This study describes the development of a novel canine model that allows for continuous monitoring of intraaneurysmal pressure in the setting of Type 2 endoleak. METHODS: Infrarenal AAA were created in 10 mongrel dogs by implanting a prosthetic aneurysm containing an intraluminal, solid-state, strain gauge pressure transducer which is able to measure pressures in both solid and liquid media. A segment of native aorta with two or more patent side branch vessels was reimplanted into the prosthetic aneurysm using a Carrel patch. Four animals had two lumbar vessels implanted; two had two lumbar vessels and the caudal mesenteric artery implanted, and four control animals had no vessels reimplanted. Retrograde flow in the aneurysmal side branches caused a Type 2 endoleak after the aneurysm was excluded from antegrade flow by deploying a stent graft. Both systemic and intra-sac pressures were measured daily for up to 90 days after endovascular exclusion and indexed to systemic pressure. Endoleak patency and flow were assessed with digital subtraction angiography, duplex ultrasound, and cine-magnetic resonance angiography (MRA). Histological characterization of the intraaneurysmal contents was performed. RESULTS: Before endovascular exclusion, the systolic, mean arterial, and pulse pressure within the aneurysmal sac closely matched that of the systemic circulation (systolic, 0.96 +/- 0.22; mean, 0.94 +/- 0.21; pulse pressure, 0.97 +/- 0.22) (R value, 0.97). Endovascular exclusion in animals with no collateral side branch vessels resulted in no endoleak and significantly reduced intraaneurysmal pressure when compared to systemic pressure, with systolic, mean arterial, and pulse pressure 0.172 +/- 0.05, 0.137 +/- 0.05, and 0.098 +/- 0.02, respectively (P < 0.001). In animals with Type 2 endoleaks, the pressures were lower than systemic pressure, but statistically significant in their difference from the control group. The systolic pressure of those with Type 2 endoleaks was 0.702 +/- 0.048; mean arterial pressure was 0.784 +/- 0.028, and pulse pressure was 0.406 +/- 0.031 when indexed to systemic pressure (P < 0.001). Cine-MRA and Duplex ultrasound documented persistent patency of the Type 2 endoleaks throughout the study period in animals with multiple side branches. CONCLUSION: Intraaneurysmal pressure in the setting of Type 2 endoleaks may be accurately determined using this canine model. Intraaneurysmal pressure is maintained at a significant level in the context of this retrograde collateral perfusion, suggesting that persistent Type 2 endoleaks are of clinical significance. This model may serve to allow further evaluation and characterization of Type 2 endoleaks.     

人造血管覆盖支架腔内治疗胸主动脉夹层动脉瘤

目的 总结人造血管覆盖支架腔内治疗胸主动脉夹层动脉瘤的经验。方法 术前行CTA或MRA检查进行影像学评估。手术在DSA监视下进行，对29例StanfordB型胸主动脉夹层动脉瘤施行了人造血管覆盖支架腔内治疗，封闭夹层入口。术后随访期间行CT检查观察手术效果、假腔内血栓形成情况、有无内漏及支架移位等并发症。结果 29例手术均获成功，术后均无内漏、无截瘫，术后第10d猝死1例，随访期间猝死1例，其余病例均健康生存，假腔内血栓形成．无支架移位情况发生。结论 人造血管覆盖支架腔内治疗胸主动脉夹层动脉瘤具有微创、有效、严重并发症少，恢复快的优点。其近期一中期疗效令人满意，远期效果有待继续随访观察。