Shames Murray L, Sanchez Luis A, Rubin Brian G, Sicard Gregorio A
Division of Vascular Surgery, Washington University School of Medicine, St Louis, MO 63110, USA.
Vasc Endovascular Surg. 2002 Jan-Feb;36(1):77-82. doi: 10.1177/153857440203600113.
The FDA approval of endovascular grafts for the treatment of abdominal aortic aneurysms has been associated with a dramatic increase in the use of these devices. Major referral centers are reporting the treatment of 75% to 80% of their patients with infrarenal abdominal aortic aneurysms with endovascular devices. The large quantity of endovascular devices being used has produced a growing number of management issues that are often not predictable during the preoperative assessment. These issues require complex intraoperative decision making and innovative techniques for their management as reflected by the subsequent case report. An 82-year-old patient presented with a 7.8-cm abdominal aortic aneurysm. The aneurysm extended into the common iliac arteries bilaterally. The right common iliac artery was 6.5 cm and the left common iliac artery was 2.0 cm in maximal diameter. The preoperative work-up, including a computed tomography scan and arteriogram, suggested that he would be a potential candidate for endovascular repair. The plan was to extend the graft into the right external iliac artery after embolization of the right hypogastric artery and to seal the left limb in the ectatic left common iliac artery using an aortic extender cuff. During the endovascular repair of the aortoiliac aneurysms using the AneuRx bifurcated graft, the main device became dislodged from its infrarenal attachment site and migrated into the large right common iliac artery aneurysm with the iliac limb ending in the distal external iliac artery. A new bifurcated device was deployed from the left side to attempt an endovascular salvage of the difficult situation. The new graft was partially deployed down to the iliac limb. This allowed cannulation of the contralateral stump through the original endovascular graft that had migrated distally. The two grafts were connected with a long iliac limb. This allowed stabilization of the endovascular reconstruction by increasing its columnar strength. The deployment of the second bifurcated graft was completed and the central core with the runners removed safely without migration of the second bifurcated component. The reconstruction was completed with an aortic cuff in the left common iliac artery. The use of the aortic cuff was useful to preserve the left hypogastric artery. No intraoperative endoleak was noted. The patient did well and was discharged the day following the procedure. The follow-up computed tomography scan shows the abdominal aortic aneurysm excluded by the endovascular graft with a defunctionalized portion of one bifurcated graft within the right common iliac aneurysm. There is no evidence of endoleak and the abdominal aortic aneurysm had decreased in size at 6 months. This case demonstrates one of the unique management problems that may arise during endovascular graft placement. Events that initially would suggest failure of the endoluminal treatment may be corrected using advanced endovascular techniques by an experienced surgeon. However, there will be times that the prudent decision will be conversion to open repair. Only good clinical judgement and adequate training will prevent catastrophic outcomes.
美国食品药品监督管理局（FDA）批准血管内移植物用于治疗腹主动脉瘤后，这些装置的使用量急剧增加。主要转诊中心报告称，其75%至80%的肾下腹主动脉瘤患者采用血管内装置治疗。大量使用血管内装置产生了越来越多的管理问题，这些问题在术前评估时往往无法预测。这些问题需要复杂的术中决策和创新技术来处理，后续病例报告即反映了这一点。一名82岁患者，患有7.8厘米的腹主动脉瘤。该动脉瘤双侧延伸至髂总动脉。右侧髂总动脉最大直径为6.5厘米，左侧髂总动脉最大直径为2.0厘米。术前检查，包括计算机断层扫描和动脉造影，提示他可能是血管内修复的潜在候选人。计划是在栓塞右下腹动脉后将移植物延伸至右股外动脉，并使用主动脉延长袖套封闭左下肢在扩张的左髂总动脉中的部分。在使用AneuRx分叉移植物进行主-髂动脉瘤的血管内修复过程中，主要装置从其肾下附着部位脱落，移入右侧大髂总动脉瘤，髂支末端位于股外动脉远端。从左侧部署了一个新的分叉装置，试图通过血管内方法挽救这一困难局面。新移植物部分部署至髂支。这使得能够通过已向远端移位的原血管内移植物对侧残端进行插管。两个移植物通过一个长的髂支连接。这通过增加其柱状强度实现了血管内重建的稳定。第二个分叉移植物的部署完成，带有输送器的中心核心安全移除，第二个分叉部件未发生移位。在左髂总动脉中使用主动脉袖套完成重建。使用主动脉袖套有助于保留左下腹动脉。术中未发现内漏。患者情况良好，术后第二天出院。随访计算机断层扫描显示腹主动脉瘤被血管内移植物排除，右侧髂总动脉瘤内一个分叉移植物的一部分失去功能。没有内漏的证据，腹主动脉瘤在6个月时尺寸减小。该病例展示了血管内移植物置入过程中可能出现的独特管理问题之一。最初可能提示腔内治疗失败的情况，经验丰富的外科医生可通过先进的血管内技术予以纠正。然而，有时谨慎的决定将是转为开放修复。只有良好的临床判断和充分的培训才能防止灾难性后果。
