对于复杂腹主动脉瘤的治疗,开放手术不可或缺

2020-09-25 《门诊》杂志 门诊新视野

腹主动脉瘤是血管外科常见疾病之一,一旦破裂,病死率高达70%~95%,严重威胁患者的健康和生命。对于腹主动脉瘤患者的治疗,首先应予以药物保守治疗以抑制腹主动脉瘤的生长。

2020年8月29日,西北第八届主动脉疾病高峰论坛以线上直播+线下相结合的形式成功举办,广大血管外科医师对主动脉疾病领域的热点问题进行了深入讨论和经验分享。据统计,腹主动脉瘤发病率约为每年20~40例/10万人,因该疾病导致65~74岁人群死亡率约为1.7%,破裂腹主动脉瘤死亡率高达80~90%,严重威胁着患者的生命。其中近肾腹主动脉瘤处理时同样必须考虑内脏器官血供。而瘤颈极度扭曲的腹主动脉瘤的腔内治疗也是一大难点。《门诊》杂志特邀西安交通大学第一附属医院血管外科的禄韶英教授就复杂腹主动脉瘤的治疗策略接受采访。

《门诊》:腹主动脉瘤是血管外科常见疾病之一,一旦破裂,病死率高达70%~95%,严重威胁患者的健康和生命。请您分享一下腹主动脉瘤的治疗策略?以及如何选择?

禄韶英教授:对于腹主动脉瘤患者的治疗,首先应予以药物保守治疗以抑制腹主动脉瘤的生长。早期,瘤体直径<5 cm或4.5 cm(亚洲女性患者),可以通过控制血压、血糖、血脂、戒烟等危险因素达到抑制瘤体增长的目的。若出现瘤体在短期内快速增长、或发生严重并发症时,诸如存在破裂倾向、远端栓塞、脏器缺血等,则需要手术干预。

目前,手术治疗方式主要包括开放手术和腔内手术。针对这两种术式选择,仍没有统一的标准。一般情况下,对于耐受较强的青年患者,倾向采用开放手术治疗;而耐受差、心、肺、脑功能差的高龄患者,建议采用腔内手术。需要注意的是,对于部分瘤颈扭曲、狭窄、过短、累及内脏动脉、入路血管条件差等复杂腹主动脉瘤,采用腔内手术治疗困难重重;若换成开放手术治疗,则复杂解剖问题迎刃而解。因此,手术策略的选择应综合考虑医师的经验、患者的情况和个人意愿以及就诊医院的硬件条件等因素。

《门诊》:针对近端瘤颈较短的近肾腹主动脉瘤,涉及内脏动脉区,常规的腹主动脉瘤腔内修复术疗效并不理想。针对此类病变的治疗,可选择的治疗技术有哪些?

禄韶英教授:对于累及内脏区的腹主动脉瘤的治疗,常规EVAR术在支架的释放过程中会覆盖内脏动脉,导致内脏缺血。因此,一般可以通过采用特殊的腔内技术活改进医疗器具的方式、达到治疗的目的。常用的技术包括烟囱支架、开窗支架、定制开窗支架等:

1)烟囱技术(平行支架技术):即通过在肾动脉、腹腔干或肠系膜上动脉放置烟囱支架保证内脏供血。虽然该技术操作简单、手术器具受限较小,但是易发生Ia型内漏;

2)体外预开窗技术:由血管外科医师在术前根据患者的影像数据对现有的支架进行改制;同样可以获得很好的临床效果,但存在医学伦理问题,容易产生医疗纠纷。

3)定制开窗支架:通过在主体支架对应的内脏区精准的开窗孔并,定位更加准确、内漏更少,同时解决了锚定不足的问题。但是定制开窗支架费用昂贵、等待时间长。

需要注意的是,窗孔越多发生内漏的风险越高,且分支支架内有血栓形成的风险。对腔内医疗器具的不断改造以适应更复杂的腹主动脉瘤,是血管外科医师和医疗器具厂家共同努力的目标。随着腔内技术和器具的发展,多分支支架、多开窗支架的应用前景会更加广阔,腔内手术成功率也将提升。

对于复杂腹主动脉瘤的治疗,若采取腔内技术,手术操作复杂、时间长、费用高,且医师和患者需要长时间暴露在放射线下。另一方面,来我院就诊的很多患者的经济状况普遍较差。因此若患者心肺功能合适,一般会采用开放手术进行救治。此外,杂交手术可以利用人工血管将内脏动脉转流处理,进而使用覆膜支架全程覆盖病变,也是一项被广泛使用的术式。总的来说,每位医师的经验不同,只要在术前对患者进行充分的评估,采用自己最熟练的术式就是合理的治疗策略。

《门诊》:一直以来,瘤颈极度扭曲的腹主动脉瘤是治疗的难点。请您分享一下治疗此类病变有哪些手术技巧?

禄韶英教授:瘤颈极度扭曲的腹主动脉瘤是治疗的难点之一。需要强调的是,瘤颈极度扭曲的腹主动脉瘤是腔内治疗的禁忌,一旦出现并发症,后果不堪设想。对于无法耐受其他术式、仅能采用腔内技术进行治疗的患者,建议:1)选择可塑性强、锚定牢靠的支架;2)为防止释放支架过程中出现弹跳情况,可采用半释放技术,同时多次、多角度造影,多次定位、调整等;3)利用双导死技术、牵张导丝、肾下锚定技术等辅助完成治疗。

对于此类病变的治疗,采用开放手术进行处理能够获得良好的远期效果,并且操作简单、费用低。近年来,外科手术相关医疗器具和麻醉技术得到了长足的发展,现在的开放手术并不意味着巨创。与此同时,康复理念的进步也加快了患者术后的恢复速度。

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    2021-03-30 ms8000000973263526

    能介又能开,方才稳妥

    0

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    2020-10-31 lovetcm

    #腹主动脉瘤#开放手术还是腔镜,要看复杂程度,以及技术本身

    0

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