Cunningham C G, Reilly L M, Rapp J H, Schneider P A, Stoney R J
Department of Surgery, University of California, San Francisco 94143.
Ann Surg. 1991 Sep;214(3):276-87; discussion 287-8. doi: 10.1097/00000658-199109000-00010.
Symptomatic visceral atherosclerosis is a major surgical challenge because of its life-threatening course and the complexity of its definitive operative treatment. Evolution in the operative approach to the visceral aorta and progress in the intraoperative management of patients undergoing complex vascular reconstructions prompted a review of the authors' cumulative experience in the surgical management of chronic visceral ischemia. Among all patients undergoing visceral revascularization at the University of California, San Francisco during the past three decades, 74 patients were identified whose primary reconstruction used transaortic endarterectomy (TA TEA) (n = 48) or antegrade bypass (AB) (n = 26), the authors' preferred revascularization techniques. The two treatment groups were comparable in gender distribution, age, presenting symptoms, and physical findings, although the amount of preoperative weight loss was greater in the AB group (35.8 +/- 19.5 versus 22.4 +/- 12.0, p = 0.003). The groups were also comparable in the prevalence of atherosclerosis risk factors, symptomatic vascular disease at other sites, and previous vascular operations. However associated renal artery atherosclerosis was slightly greater in the TA TEA group (58.3% versus 23.1%, p = 0.07) when compared to the AB group. Antegrade bypass was usually performed transabdominally (88.5%), while TA TEA was approached thoracoretroperitoneally (75.0%). Celiac revascularization was almost universal in both treatment groups, but the TA TEA group underwent significantly more frequent superior mesenteric artery (SMA) revascularization (93.8% versus 46.2%, p = 0.0001) and slightly more frequent inferior mesenteric repair (18.8% versus 3.8%, p = 0.07) than the AB group. In addition the frequency of combined renal and visceral repair (25.0% versus 0.0%, p = 0.01) as well as combined aortic, renal, and visceral repair (22.9% versus 3.8%, p = 0.03) was significantly greater in the TA TEA group. The obligatory interval of renal and visceral ischemia did not differ between the two approaches. The perioperative mortality rate was 12.2% and was the same for TA TEA (14.6%) and AB (7.7%). Overall the incidence of complications was the same with either operative approach, although patients in the TA TEA group tended to have multiple complications (17.1% versus 0.0, p = 0.03) and all significant pulmonary complications occurred in this group. Two patients were lost to follow-up. The cumulative percentage of patients who remained asymptomatic following AB or TA TEA was (respectively) 95.8% and 97.3% at 1 year and 86.5% and 86.1% at 5 years. Both of these operative approaches provide durable symptom relief with acceptable operative morbidity and mortality rates.(ABSTRACT TRUNCATED AT 400 WORDS)
有症状的内脏动脉粥样硬化是一项重大的外科挑战，因为其病程危及生命，且确定性手术治疗复杂。内脏主动脉手术方法的演变以及复杂血管重建患者术中管理的进展促使作者回顾其在慢性内脏缺血外科治疗方面的累积经验。在过去三十年中于加利福尼亚大学旧金山分校接受内脏血运重建的所有患者中，确定了74例患者，其初次重建采用经主动脉内膜切除术（TA TEA）（n = 48）或顺行旁路术（AB）（n = 26），这是作者首选的血运重建技术。两个治疗组在性别分布、年龄、表现出的症状和体格检查结果方面具有可比性，尽管AB组术前体重减轻量更大（35.8±19.5对22.4±12.0，p = 0.003）。两组在动脉粥样硬化危险因素的患病率、其他部位的有症状血管疾病以及既往血管手术方面也具有可比性。然而，与AB组相比，TA TEA组的相关肾动脉粥样硬化略多（58.3%对23.1%，p = 0.07）。顺行旁路术通常经腹进行（88.5%），而TA TEA采用胸腹联合腹膜后入路（75.0%）。两个治疗组腹腔动脉血运重建几乎都很普遍，但TA TEA组肠系膜上动脉（SMA）血运重建频率明显更高（93.8%对46.2%，p = 0.0001），肠系膜下动脉修复频率略高于AB组（18.8%对3.8%，p = 0.07）。此外，TA TEA组肾和内脏联合修复（25.0%对0.0%，p = 0.01）以及主动脉、肾和内脏联合修复（22.9%对3.8%，p = 0.03）的频率明显更高。两种方法肾和内脏缺血的必要间隔时间无差异。围手术期死亡率为12.2%，TA TEA（14.6%）和AB（7.7%）相同。总体而言，两种手术方法并发症的发生率相同，尽管TA TEA组患者往往有多种并发症（17.1%对0.0，p = 0.03），且所有严重肺部并发症均发生在该组。两名患者失访。AB或TA TEA术后无症状患者的累积百分比在1年时分别为95.8%和97.3%，在5年时分别为86.5%和86.1%。这两种手术方法均能提供持久的症状缓解，手术发病率和死亡率可接受。（摘要截短至400字）
