Pfister Karin, Kasprzak Piotr, Oikonomou Kyriakos, Apfelbeck Hanna, Derwich Wojciech, Uller Wibke, Stehr Alexander, Schierling Wilma
Abteilung für Gefäßchirurgie, Universitätsklinikum Regensburg, Deutschland.
Klinik für Gefäßchirurgie, KGU Frankfurt, Deutschland.
Zentralbl Chir. 2018 Oct;143(5):516-525. doi: 10.1055/a-0750-6016. Epub 2018 Oct 24.
Visceral artery aneurysms (VAA) are rare and often incidental findings. Indications for treatment are symptomatic patients, pseudoaneurysms and a true aneurysm of diameter of ≥ 2.5 cm for mesenteric arteries and ≥ 3 cm for renal artery aneurysms. Pregnancy and liver transplantation play an important role in aneurysm rupture. Technical success after open or endovascular procedure and maintenance of organ perfusion are crucial. The aim of this review is to evaluate our data and experience of more than 20 years and to develop a strategy to deal with visceral artery aneurysm in elective and emergency cases.
Between 1995 and 2018, 179 patients (84 males, 95 females, median age 62 [18 - 87] years) were diagnosed with VAA at the Regensburg University Hospital. The site of aneurysm was the splenic artery in 113 (63%) patients (pts), hepatic and renal arteries in 22 and 21 pts (12% each), and gastropancreaticoduodenal artery in 14 (8%) and superior/inferior mesenteric artery in 9 (5%) cases. Surveillance without intervention occurred in 110 (62%) pts, and 34 (19%) pts underwent open and 35 (19%) endovascular repair. In all patients, preoperative imaging was performed, preferably by computed tomography angiography (CTA).
A total of 69 patients underwent open or endovascular repair. 51 (74%) pts were treated electively, 18 (26%) pts presented urgently with acute bleeding. 16 emergency pts received endovascular treatment, and in 2 pts open surgery was performed. After emergency treatment, two pts exhibited segmental liver malperfusion without consequences. In one case, segmental bowel resection was necessary. 32/51 (63%) patients were treated electively by open surgery, 19/51 (37%) by endovascular procedures. There were no liver or bowel infarctions. Four splenectomies and one unilateral nephrectomy were necessary in patients with splenic or renal artery aneurysms. Moreover, three partial renal infarctions were noticed postoperatively (overall 8/21 [38%]). After endovascular repair of splenic or renal artery aneurysms, two cases of splenic and three cases of renal segmental infarction were observed. Splenectomy had to be performed twice (overall 7/14 [50%]). Organ perfusion was monitored by CTA, and preferentially by contrast enhanced ultrasound.
The endovascular approach is the preferred option in an emergency to control bleeding in pseudoaneurysms. Patients for elective splenic or renal artery aneurysm repair have to be evaluated very carefully to achieve technical success with occlusion of the aneurysm and excellent organ perfusion. Imaging techniques such as ultrasound, especially CEUS, are strongly recommended in postoperative follow-up. Partial or complete splenic infarction leads to vaccination.
内脏动脉瘤（VAA）较为罕见，常为偶然发现。治疗指征包括有症状的患者、假性动脉瘤以及肠系膜动脉直径≥2.5 cm、肾动脉动脉瘤直径≥3 cm的真性动脉瘤。妊娠和肝移植在动脉瘤破裂中起重要作用。开放手术或血管腔内手术的技术成功以及器官灌注的维持至关重要。本综述的目的是评估我们20多年的数据和经验，并制定在择期和急诊病例中处理内脏动脉瘤的策略。
1995年至2018年期间，雷根斯堡大学医院诊断出179例VAA患者（男性84例，女性95例，中位年龄62岁[18 - 87岁]）。动脉瘤部位为脾动脉113例（63%），肝动脉和肾动脉各22例和21例（各12%），胃胰十二指肠动脉14例（8%），肠系膜上/下动脉9例（5%）。110例（62%）患者未进行干预而接受监测，34例（19%）患者接受了开放手术修复，35例（19%）患者接受了血管腔内修复。所有患者均进行了术前影像学检查，最好是计算机断层血管造影（CTA）。
共有69例患者接受了开放手术或血管腔内修复。51例（74%）患者为择期治疗，18例（26%）患者因急性出血而急诊就诊。16例急诊患者接受了血管腔内治疗，2例患者进行了开放手术。急诊治疗后，2例患者出现节段性肝灌注不良，但无不良后果。1例患者需要进行节段性肠切除。51例择期治疗的患者中，32例（63%）接受了开放手术，19例（37%）接受了血管腔内手术。无肝或肠梗死发生。脾动脉或肾动脉动脉瘤患者中，4例需要行脾切除术，1例需要行单侧肾切除术。此外，术后发现3例部分肾梗死（共8/21 [38%]）。脾动脉或肾动脉动脉瘤血管腔内修复后，观察到2例脾节段性梗死和3例肾节段性梗死。脾切除术不得不进行了2次（共7/14 [50%]）。通过CTA监测器官灌注，优先采用对比增强超声监测。
血管腔内治疗是急诊控制假性动脉瘤出血的首选方法。对于择期脾动脉或肾动脉动脉瘤修复的患者，必须非常仔细地评估，以实现动脉瘤闭塞的技术成功和良好的器官灌注。强烈建议在术后随访中采用超声等影像学技术，尤其是对比增强超声。部分或完全脾梗死会导致接种疫苗。
