摘要
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1例,1例通过髂总动脉重建导入途径采用硬膜外麻醉,1例合并StanfordA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Cuff1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StanfordA型主动脉夹层先行胸主动脉腔内修复术,后行EVAR。术后7～10d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导管取栓并支架植入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。
Objective To summarize the clinical experience of perioperative management in performing endovascular abdominal aortic aneurysm repair （EVAR）.Methods EVAR was performed in 22 patients with abdominal aortic aneurysm.The clinical data were retrospectively analyzed.Before treatment the functions of main organs were evaluated and certain measures were adopted in order to protect them.Useful parameters,including the length,diameter,angle and configuration of the proximal and distal aneurysmal neck,the relationship of the aneurysm to aortic branches,the distance from the lowest renal artery to the bifurcation of abdominal aorta,and the quality of access vessels （such as diameter,tortuosity and calcification degree） were determined and assessed with CTA.According to the parameters thus obtained,the suitable stent-graft with ideal diameter and length was selected,and the optimal surgery pattern was employed.Local anesthesia was employed in 20 patients,among them the local anesthesia had to be changed to general anesthesia in one.Epidural anesthesia was carried out in one patient through the surgically-reconstructed iliac artery access,and general anesthesia was employed in one patient who had Stanford type A aortic dissection.The lowest renal artery must be accurately localized before deployment of stent-graft was started.At least one patent internal iliac artery should be reserved when bilateral internal iliac arteries needed to be covered,to be covered by stages or to be reconstructed.After stent-graft placement,angiography must be performed to find out if there was any endoleak and,if any,to determine the type of endoleak and to deal with it properly.Two cases had proximal type I endoleak,so balloon dilation was employed in one and cuff implantation in another one.Distal type I endoleak occurred in one case,but,unfortunately,the iliac artery ruptured when balloon dilation was employed,therefore the patient had to receive vascular repair with prosthesis.Three cases developed type Ⅲ endoleak.Balloon dilation followed by additional stent-graft placement was adopted in one case.Thoracic endovascular aortic repair with subsequent EVAR was carried out in another patient with Stanford type A aortic dissection.Re-examination with CTA was performed 7-10 days after the treatment,and once a year thereafter.Results EVAR was successfully completed in all patients.The main complications included thrombosis due to vascular kinking （n=1） and disruption of abdominal incision （n=1）.No death due to surgery occurred.During the follow-up period of 6 month to 5 years all patients remained alive.Conclusion With the advantages of high imaging quality and usefulness for accurate measure of parameters,CTA is the gold standard for preoperative and postoperative evaluation.EVAR is a safe and effective treatment for abdominal aortic aneurysm in aged patients with high-risk.
出处
《介入放射学杂志》
CSCD
北大核心
2010年第11期858-861,共4页
Journal of Interventional Radiology
关键词
主动脉瘤
腹
主动脉瘤腔内修复术
CTA
围手术期处理
aortic aneurysm
abdomonal
endovascular aortic aneurysm repair
computed tomography angiography
perioperative management
