Kotsis T, Scharrer-Pamler R, Kapfer X, Liewald F, Görich J, Sunder-Plassmann L, Orend K H
Department of Thoracic and Vascular Surgery, University of Ulm, Ulm, Germany.
Int Angiol. 2003 Jun;22(2):125-33.
The conventional approach for the repair of thoracoabdominal aneurysms remains complex and demanding and is associated with substantial morbidity and mortality. Moreover, in cases of reoperation the impact can be dramatic either in survival or in quality of life of the patients, albeit the use of adjuncts. A combined endovascular and surgical approach with retrograde perfusion of visceral and renal vessels has been realized in order to minimize intraoperative and postoperative complications.
Within an experience of 231 aortic stent-grafts between 1995-2000, 4 of the patients with thoracoabdominal aneurysms were treated with a combined endovascular and surgical approach. Three procedures were electively conducted and 1 on emergency basis. Two women, 59 and 68 years old, and 2 men, 68 and 73 years old (maximum aneurysm's diameter was 10, 6, 8 and 9 cm, respectively) were operated with the combined method (the first 2 patients had a previous open repair of a thoracoabdominal aneurysm). The surgical approach was executed in all patients without thoracotomy or re-do retroperitoneal exposure. Revascularization of renal, superior mesenteric (and celiac in 2 cases) arteries was accomplished via transperitoneal bypass grafting. Aneurysmal exclusion was performed by stent-graft deployment.
The entire procedure was technically successful in all patients. The 1(st) patient was discharged 6 weeks after the operation, while the postoperative studies revealed the patency of the vessels and no evidence of leak or secondary rupture of the aneurysm; the patient died 3 months after the repair, due to rupture of an aneurysm of the ascending aorta. In the 2(nd) patient, 30 months after the operation, spiral-CT scanning revealed distinct shrinkage of the aneurysm, no graft migration or endoleak and patency of all revascularized vessels. The 3(rd) patient died on the 6th postoperative day due to multiorgan failure after having developed ischemic-related pancreatitis, albeit the successful combined repair. The 4(th) patient followed an uneventful course. No patient experienced any temporary or permanent neurological deficit.
The combined endovascular and surgical approach is feasible, without cross-clamping of the aorta and with minimized ischemia time for renal and visceral arteries, and seems the appropriate strategy for high risk and previously operated, with a thoracoabdominal trans-diaphragmatic approach, patients.
传统的胸腹主动脉瘤修复方法仍然复杂且要求高，并且伴有较高的发病率和死亡率。此外，在再次手术的病例中，尽管使用了辅助手段，但对患者的生存或生活质量的影响可能很大。为了尽量减少术中和术后并发症，已经实现了一种结合血管腔内和外科手术的方法，即对内脏和肾血管进行逆行灌注。
在1995年至2000年期间使用231个主动脉支架移植物的经验中，4例胸腹主动脉瘤患者采用了血管腔内和外科手术相结合的方法进行治疗。3例为择期手术，1例为急诊手术。两名女性，年龄分别为59岁和68岁，两名男性，年龄分别为68岁和73岁（最大动脉瘤直径分别为10厘米、6厘米、8厘米和9厘米）接受了联合手术方法（前两名患者曾接受过胸腹主动脉瘤的开放修复）。所有患者均未进行开胸手术或再次进行腹膜后暴露，而是采用了手术入路。通过经腹旁路移植术实现肾动脉、肠系膜上动脉（2例为腹腔动脉）的血运重建。通过部署支架移植物进行动脉瘤排除。
所有患者的整个手术在技术上均获成功。第1例患者术后6周出院，术后检查显示血管通畅，没有动脉瘤渗漏或二次破裂的迹象；该患者在修复后3个月因升主动脉瘤破裂死亡。第2例患者术后30个月，螺旋CT扫描显示动脉瘤明显缩小，没有移植物移位或内漏，所有血运重建血管通畅。第3例患者在术后第6天因发生缺血性胰腺炎后多器官功能衰竭死亡，尽管联合修复手术成功。第4例患者病程顺利。没有患者出现任何暂时或永久性神经功能缺损。
血管腔内和外科手术相结合的方法是可行的，无需主动脉交叉钳夹，肾动脉和内脏动脉的缺血时间最短，似乎是高风险且先前采用胸腹经膈入路手术的患者的合适策略。
