Kanaoka Y, Kubo H
Vascular Surgery, Department of Surgery, Jikei University, School of Medicine, Tokyo, Japan.
Minerva Chir. 2008 Jun;63(3):229-35.
The authors report a case of a combined endovascular and open repair (hybrid procedure) for a mycotic thoracoabdominal aneurysm (TAAA) including its 6-year result. A 72-year-old man with diabetes mellitus, old brain infarction and moderate aortic stenosis was transferred to the hospital because of obstinate fever and back pain, The initial computed tomography (CT) scan revealed giant (TAAA), and from the laboratory findings, the white blood cell and C-reactive protein (CRP) were significantly elevated 12,400/mm3 and 23.9 mg/dL respectively. Based on the CT and laboratory findings, a mycotic TAAA was highly suspected. After the remission of inflammation, graft replacement with reconstruction of celiac trunk (CA) and superior mesenteric artery (SMA) was performed via spiral incision under extracorporeal circulation. two months after the first operation, the patient complained about his back pain again. CT showed a pseudoaneurysm which formed at the distal anastomotic site. A hybrid procedure was deemed to be the most appropriate for such patient who needs a second operation. First bilateral renal artery bypass (ilio-renal artery bypass) were done using the saphenous vein grafts (SVGs). Following bypass grafting to renal arteries, endovascular aneurysm repair was performed with handmade stent-graft which was fabricated using a self-expanding "Z" stent and woven Dacron graft. The postoperative course was uneventful, and follow-up CT showed the aneurysm to have shrunk with no endoleaks. At six months after hybrid procedure, the shrinkage of the aneurysm sac and the patency of the graft to renal arteries were confirmed by a CT scan. A hybrid procedure is considered to be useful and feasible for the poor surgical candidate with severe comorbidities, hostile abdomen and a complex anatomy. The long-term results of this hybrid procedure is considered to be promising.
作者报告了一例采用血管内和开放修复相结合的方法（杂交手术）治疗感染性胸腹主动脉瘤（TAAA）的病例及其6年随访结果。一名72岁男性，患有糖尿病、陈旧性脑梗死和中度主动脉瓣狭窄，因顽固性发热和背痛被转诊至我院。初次计算机断层扫描（CT）显示巨大的TAAA，实验室检查发现白细胞和C反应蛋白（CRP）显著升高，分别为12400/mm³和23.9mg/dL。基于CT和实验室检查结果，高度怀疑为感染性TAAA。炎症缓解后，在体外循环下经螺旋切口行腹腔干（CA）和肠系膜上动脉（SMA）重建的人工血管置换术。首次手术后两个月，患者再次诉背痛。CT显示在远端吻合口处形成假性动脉瘤。对于需要二次手术的此类患者，杂交手术被认为是最合适的。首先使用大隐静脉移植物（SVG）进行双侧肾动脉搭桥（髂-肾动脉搭桥）。在完成肾动脉搭桥移植后，使用自制的支架型人工血管进行血管内动脉瘤修复，该人工血管由自膨式“Z”形支架和编织涤纶移植物制成。术后过程顺利，随访CT显示动脉瘤缩小且无内漏。杂交手术后6个月，CT扫描证实动脉瘤囊缩小且肾动脉移植物通畅。对于合并严重疾病、腹腔情况不佳且解剖结构复杂的手术高危患者，杂交手术被认为是有用且可行的。这种杂交手术的长期效果被认为很有前景。
