Tshomba Yamume, Kahlberg Andrea, Marone Enrico Maria, Setacci Francesco, Logaldo Davide, Chiesa Roberto
Division of Vascular Surgery, "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy.
J Vasc Surg. 2006 Aug;44(2):408-11. doi: 10.1016/j.jvs.2006.04.040.
We previously described the case of a 47-year-old man who experienced perioperative graft occlusion after infrarenal aortic endarterectomy and aortobifemoral expanded polytetrafluoroethylene bypass graft for occlusive disease. The patient was treated with local graft thrombolysis and stenting of an intimal flap at the level of the endarterectomized aorta next to the aortic anastomosis. An urgent laparotomy performed 6 years later showed aortic wall perforation by the stent with a large aortoenteric fistula. Surgical treatment included removal of the stent and the aortobifemoral graft, bowel repair, and extra-anatomic lower-limb revascularization by axillofemoral and cross-femoral bypass grafting. The patient was discharged 12 days later with no early complications. Although local thrombolysis and stenting may be a technically feasible technique instead of reoperation in early aortofemoral graft thrombosis, long-term results of this procedure may be affected by perigraft hematoma due to perioperative thrombolysis, increased risk of infection due to the prolonged intragraft cannulation, and risk of stent-related aortic injury, especially if an endarterectomy has been performed. All these issues may increase the risk of late aortoenteric fistula. More experience with hybrid, open/endovascular procedures, and more contemporary stent-based devices is needed to assess the efficacy and safety of this alternative treatment.
我们之前描述过一名47岁男性的病例，该患者在肾下腹主动脉内膜切除术及因闭塞性疾病行主动脉双股人工血管转流术（使用膨体聚四氟乙烯人工血管）后发生围手术期移植血管闭塞。患者接受了局部移植血管溶栓治疗，并对主动脉吻合口旁行内膜剥脱术的主动脉处的内膜瓣进行了支架置入。6年后进行的急诊剖腹手术显示，支架导致主动脉壁穿孔并形成巨大的主动脉肠瘘。手术治疗包括取出支架和主动脉双股移植血管、修复肠道以及通过腋股和股股旁路移植术进行解剖外下肢血管重建。患者12天后出院，无早期并发症。尽管局部溶栓和支架置入术在早期主股动脉移植血管血栓形成时可能是一种技术上可行的替代再次手术的方法，但该手术的长期效果可能会受到围手术期溶栓导致的移植血管周围血肿、因移植血管内长时间插管导致的感染风险增加以及支架相关主动脉损伤风险的影响，尤其是在已经进行内膜剥脱术的情况下。所有这些问题都可能增加晚期主动脉肠瘘的风险。需要更多关于杂交手术（开放/血管腔内联合手术）以及更多当代基于支架的器械的经验，以评估这种替代治疗的有效性和安全性。
