腹主动脉瘤腔内治疗后随访期并发症及处理

2020-11-30 《门诊》杂志 门诊新视野

EVAR因具有创伤小、出血少、术后恢复快等优点,已成为腹主动脉瘤的主要治疗方法。随着经验的积累和器材的逐步完善,操作技术的日臻成熟,治疗适应证也更加广泛。

EVAR因具有创伤小、出血少、术后恢复快等优点,已成为腹主动脉瘤的主要治疗方法。随着经验的积累和器材的逐步完善,操作技术的日臻成熟,治疗适应证也更加广泛。尽管EVAR患者围手术期的风险大大降低,但随访期出现的问题仍较多,需要密切随访,必要时需要再次手术干预。在长沙举行的第八届湘雅血管论坛上,来自四川大学华西医院血管外科的赵纪春教授就腹主动脉瘤腔内治疗后随访期并发症及处理作了精彩的演讲。

EVAR术后并发症包括内漏、髂支闭塞、支架移位、支架扭曲、支架感染以及瘤体破裂等,其中以内漏最为常见。内漏的影响因素包括瘤颈长度、瘤颈钙化程度、瘤颈角度、支架相关因素等。对于Ⅰa型内漏,可先观察,内漏消失或者内漏量无增加且瘤体无增大继续临床观察;若内漏持续且瘤体直径较手术时增大,再干预,干预方式包括再次行瘤颈球囊扩张并增加Cuff支架,或予以弹簧圈栓塞。O’Neill等发表的研究显示使用延长性支架,可以使得Ⅰ型内漏的发生率下降65%。对于Ⅰb型内漏均可再次手术延长腿支。对于Ⅱ型内漏,随访期间瘤体进行性增大,可行弹簧圈栓塞治疗。Ⅱ型内漏的解剖学风险包括持续通畅的IMA、通畅的腰动脉数量、最大的动脉瘤直径。2013年的一项研究显示Ⅱ型内漏发生率为10.2%,其中35.4%自行闭合,0.9%的Ⅱ型内漏会导致动脉瘤破裂。经动脉穿刺栓塞是Ⅱ型内漏最常见的处理手段,常用的栓塞填充物包括弹簧圈、不锈钢弹簧圈、蛋白胶等。

EVAR术后支架内血栓形成的原因包括主动脉分叉部的钙化或狭窄、髂总动脉近端成角或狭窄、髂动脉解剖路径扭曲、支架打折或受压、支架直径重叠面积过多、动脉夹层或锚定区远端位于髂外动脉等。其处理手段包括腔内溶栓、吸栓、球囊扩张+支架植入或动脉切开取栓、动脉旁路搭桥术。一项回顾性研究显示延长腿支架延伸至髂外动脉可带来较高腿支血栓和截肢的风险。

单中心临床资料

回顾性分析了四川大学华西医院血管外科2011年6月~2018年12月间完成的567例肾下腹主动脉瘤腔内修复术的患者,术后1、3、6、12个月以及其后每年进行了门诊随访腹部彩超、CT血管重建复查。随访时间为1~96个月,总体死亡为8.3%、动脉瘤相关死亡率2.4%、再干预率为3.7%,主要并发症是内漏(以Ⅱ型内漏最多)和肾动脉重度狭窄(表1)。

表1 EVAR术后并发症的情况

病例分享

病例1(男性,78岁)

现病史:EVAR术后3年。

造影:近端和远端内漏。

手术策略:弹簧圈栓塞瘤腔和右髂内动脉。

术后造影:内漏明显好转。

病例2(女性,55岁)

现病史:EVAR术后8个月,CT发现Ⅰa型内漏21天。

造影:近端内漏。

手术策略:在近端瘤颈植入Cuff支架。

术后造影:内漏消失。

病例3(男性,70岁)

现病史:EVAR术后1年。

CT:髂动脉闭塞。

手术策略:双侧股动脉搭桥。

总结

EVAR在围手术期的微创优势突出。术前详细评估腹主动脉瘤和制定个体化、精确的手术方案是手术成功的首要因素。但EVAR术后随访期并发症较开放手术为多,其中以内漏和支架移植物血栓最常见。如果不及时处理将影响远期疗效,因此术后定期终身随访并及时处理相关并发症十分必要。

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    2021-04-01 1881ef655dm

    学习啦

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    2021-04-09 丁鹏鹏
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    2020-12-02 ms3000001399365829

    学习了

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    2020-12-01 392534278

    学习

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