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主动脉壁间血肿的诊断与治疗

目的探索主动脉壁间血肿的诊断与治疗要点。 方法回顾性分析北京大学人民医院心外科2011年1月至2013年4月共收治5例主动脉壁间血肿患者的临床资料，其中男4例、女1例，年龄35～70岁。2例行药物治疗，1例行介入治疗，2例行外科手术治疗，其中1例行二次手术。分析其疗效和安全性。 结果全组患者住院时间11～34 d，均痊愈出院。2例行外科手术患者的住院时间分别为18 d与34 d。对全组随访1～20个月，随访结束时，患者均痊愈。 结论主动脉壁间血肿是一种需要积极治疗的急性主动脉病变，CT增强造影具有较高诊断价值。A型主动脉壁间血肿应积极外科手术替换病变血管，B型主动脉壁间血肿可以在严密随访下行药物治疗。如果患者同时合并主动脉溃疡等高危病变，可以选择腔内隔绝治疗。

Management of Endoleak after Endovascular Exclusion for Aortic Dissection

腔内隔绝术（endovascular exclusion, EVE）最早用于治疗腹主动脉瘤，1994年Dake报道将其用于B型主动脉夹层（aortic dissection, AD）的治疗，国内自1998年开展。在EVE治疗AD的10余年历史中，内漏的预防和处理始终是一个备受关注的问题，现结合笔者的经验讨论AD术后内漏相关的问题。......

Causes and Risk Factors of Multiple-interventions in Endovascular Repair for Aortic Dissection

ObjectiveTo assess the causes and risk factors of multiple-intervention in endovascular aortic repair (EVAR) for type B aortic dissection (TBAD). MethodsWe retrospectively analyzed the clinical data of 347 TBAD patients initially treated with EVAR in our hospital between January 1999 and December 2013. The patients were stratified into a multiple-intervention group (34 patients) and a single-intervention group (313 patients). We analyzed the differences of clinical data of the two groups. ResultsThere were 9 patients with endoleak, 10 patients with new dissection, 8 patients with incomplete thrombosis of the false lumen, 4 patients with new aneurysm, 2 patients with retrograde dissection, and 1 patient with iliac artery occlusion in the multiple-intervention group. Higher proportions of chronic dissection and smoking occurred in the multiple-intervention group (79.4% versus 50.8%, 61.8% versus 40.3%, P=0.002, 0.018, respectively). Both of the degree and proportion of hyperglycemia were higher in the multiple-intervention group (6.9±2.3 mmol/L versus 5.7±1.8 mmol/L, P=0.027; 44.1% versus 22.7%, P=0.011). There were statistical differences in oversizing rate of grafts (14.6%±3.2% versus 11.3%±2.5%, P<0.001), operation time (172 min versus 82 min, P<0.001), and blood loss (280 ml versus 100 ml, P=0.006) between the two groups. ConclusionEndoleak, new dissection, and incomplete thrombosis of the false lumen are the main causes of multiple-intervention. While in chronic phase, smoking, hyperglycemia, too big oversizing, and complicated lesion or operation are the potential risk factors.

主动脉弓部夹层动脉瘤手术治疗

目的 总结通过人工血管旁路术延长锚定距离后，腔内隔绝术（endovascular graft exclusion，EVGE）治疗主动脉弓部夹层动脉瘤的疗效。 方法 2005 年9 月－ 2007 年9 月，采用血管旁路术后二期行EVGE 治疗主动脉弓部夹层动脉瘤10 例。男9 例，女1 例；年龄33 ～ 55 岁，平均38 岁。合并高血压病8 例，尿毒症1 例。DSA 示近端破口位于左颈总动脉与左锁骨下动脉之间4 例；破口距左锁骨下动脉开口lt; 1.5 cm 且左椎动脉为优势动脉6 例，合并无名动脉瘤1 例，升主动脉及主动脉弓部壁内血肿1 例。 结果 除1 例患者由于真腔闭塞未能行EVGE 治疗外，9 例均顺利完成EVGE 治疗。术后即刻造影示Ⅰ型内漏、Ⅱ型内漏（左锁骨下动脉未结扎所致）各1 例，分别于治疗后1、3 个月经计算机X 线断层扫描血管造影术证实内漏消失。8 例破口封堵良好，1 例并发降主动脉周围血肿而失访。8 例获随访，随访时间12 ～ 36 个月，降主动脉假腔内血栓形成。 结论 人工血管旁路术延长锚定距离，不仅可扩大EVGE 的适应证，还能降低Ⅰ型内漏。

Advances in surgical indications and morphological rupture-risk assessment of abdominal aortic aneurysms

ObjectiveThis paper aimed to summarize the new progress in surgical indications regarding as maximum diameter from evidence-based medical evidence and morphological rupture-risk assessment of abdominal aortic aneurysms (AAA) and its clinical application value.MethodThe rupture-risk and its mechanism of AAA in specific population and morphological characteristics were reviewed.ResultsAsymptomatic patients in specific subgroups may also benefit from AAA repair by lowering the intervention threshold. Besides the maximum diameter of aneurysm, other morphological factors, such as the true geometric shape, the wall thickness, and mural thrombus also had important predictive value for AAA rupture risk.ConclusionRupture-risk assessment based on the actual individual situation of AAA patients can further facilitate the clinical diagnosis and treatment.

覆膜支架腔内隔绝术治疗Stanford B型主动脉夹层

目的　总结采用覆膜支架腔内隔绝术治疗Stanford B型主动脉夹层的临床经验。 方法　2008年8月至2012年10月安庆市立医院对26例Stanford B型主动脉夹层患者行覆膜支架腔内隔绝术治疗，男21例，女5例；年龄（52.4±10.3）岁。术后定期复查CT血管成像。 结果　所有患者支架释放全部成功，无死亡、中转开胸和截瘫。术后发现支架覆盖腹腔干及肠系膜上动脉1例，急诊行旁路移植术；多发性脑梗塞1例，轻度Ⅰ型内漏2例，未予特殊处理；股动脉狭窄3例，其中1例严重狭窄者行大隐静脉移植术，2例中度狭窄者给予保守治疗。随访22例，随访时间（23.5±15.9）个月。随访期间CT血管成像显示所有患者支架无移位，主动脉真腔较术前明显扩大，假腔血栓形成。 结论　覆膜支架腔内隔绝术创伤小、效果佳、并发症少，是治疗Stanford B型主动脉夹层的有效方法。

Predictive value of the neutrophil-to-lymphocyte ratio in peripheral blood for complications after elective endovascular repair of abdominal aortic aneurysm

Objective To explore the predictive value of neutrophil-to-lymphocyte ratio (NLR) in peripheral blood for postoperative complications of elective endovascular repair for abdominal aortic aneurysm (AAA). Methods From August 2016 to November 2021, the clinical data of patients with AAA who received endovascular isolation repair for the first time in the Department of Vascular Surgery of Beijing Hospital were retrospectively analyzed, including the basic information of the patients, comorbid diseases, and the largest diameter of AAA, preoperative blood labotry test, postoperative complications, long-term survival rate and other indicators. The optimal NLR in peripheral blood was determined, and the differences in postoperative complications and long-term survival rates between the high NLR group and the low NLR group were analysed. Results A total of 120 patients with AAA underwent endovascular isolation for the first time were included in this study, including 105 males and 15 females. The age ranged from 52 to 94 years, with an average of (73.3 ± 8.26) years. The largest diameter of abdominal aortic aneurysm was 35 to 100 mm, with an average of (58.5 ± 12.48) mm. The best cut-off value of NLR for predicting postoperative complications of AAA was 2.45 by using Yoden index screening. Those with NLR ≥2.45 were in the high NLR group (n=66), and those with NLR <2.45 were in the low NLR group (n=54). There was no statistically significant difference between the two groups in the incidence of overall complications and the incidence of sub-complications (P>0.05). The results of logistic regression analysis suggested that NLR was an independent risk factor for complications after endovascular repair of AAA (P<0.05). The median survival time of patients in the high NLR group and the low NLR group was 31.47 months and 35.28 months, respectively, and there was no statistically significant difference between the two groups (P>0.05). Conclusion NLR can be used as a reference predictor of complications after elective endovascular repair of AAA, but more research results are still needed to confirm.

COMPARISON OF ENDOVASCULAR REPAIR AND OPEN REPAIR FOR RUPTURED ABDOMINAL AORTIC ANEURYSM

Objective To compare the effectiveness between conventional open repair (OR) and endovascular repair (EVRAR) for ruptured abdominal aortic aneurysm. Methods Between March 2000 and July 2011, 48 cases of ruptured abdominal aortic aneurysm were treated by conventional OR in 40 cases (OR group) or by EVRAR in 8 cases (EVRAR group). There was no significant difference in age, sex, the neck length (less than 2 cm), the neck angulation of aneurysm (more than60°), il iac severe tortuosity, preoperative systol ic pressure, and preoperative comorbidity between 2 groups (P gt; 0.05). The blood transfusion volume, operation time, intensive care unit (ICU) stay, postoperative complications, reinterventions, and mortality were analyzed. Results There was no significant difference in 24-hour and 30-day mortality rates and non graft-related complications between 2 groups (P gt; 0.05). EVRAR group was significantly better than OR group in blood transfusion volume, operation time, and ICU stay (P lt; 0.05), but OR group was significantly better than EVRAR group in reinterventions and graftrelated complications (P lt; 0.05). Conclusion EVRAR has obvious advantages in blood transfusion volume, operation time, and ICU stay, so it is feasible for ruptured abdominal aortic aneurysm in patients with precise anatomical suitability.

腔内隔绝术抢救Stanford B型主动脉夹层动脉瘤破裂一例

Improvement of Visceral Arterial Blood Supply after Thoracic Endovascular Aortic Repair for Stanford Type B Aortic Dissection

ObjectiveTo investigate the improvement of visceral arterial blood supply after thoracic endovascular aortic repair (TEVAR) for patients with Stanford type B aortic dissection (AD). MethodsWe retrospectively analyzed clinical data of 35 patients with Stanford type B AD undergoing TEVAR in Mianyang Central Hospital from January 2013 to March 2014. There were 30 male and 5 female patients with their age of 45-82(62.5±10.0) years. Among the 140 main visceral arteries (celiac artery, superior mesenteric artery, left and right renal arteries) of the 35 patients, blood supply of 79 arteries were compromised, including 36 arteries with stenosis and blood supply via the true lumen, 18 arteries with blood supply via both true and false lumen, 18 arteries with blood supply via the false lumen, and 7 arteries without blood supply. Improvement of blood supply of main visceral arteries was analyzed. ResultsAll the operations were successfully performed without in-hospital death. Operation time was 97.8 (68-147) minutes, length of ICU stay was 12-34 h, and length of hospital stay was 10-21 days. None of the patients had cerebral infarction, acute renal failure, AD rupture or stent migration after TEVAR. Blood supply of the compromised visceral arteries showed improvement in various degrees. ConclusionFor the treatment of Stanford type B AD, TEVAR can not only successfully block the rupture of AD, but also improve blood supply of main visceral arteries, avoid or reduce the complications resulting from compromised visceral arterial blood supply and visceral ischemia.