Mellière D, Berrahal D, Desgranges P, Allaire E, Becquemin J P
Service de Chirurgie Vasculaire, Hôpital Henri Mondor, Créteil.
J Mal Vasc. 1998 Dec;23(5):342-8.
In a previous study, we have found that an operation for a combination of internal iliac aneurysms and an abdominal aortic aneurysm carries a heavier mortality than an operation for an abdominal aortic aneurysm alone. The object of this review was to define the prevalence of this combination of aneurysms and the results of the different treatment modalities in order to define the therapeutic choices.
A retrospective study of operations on 426 patients with asymptomatic infrarenal aortic aneurysms. The size of the iliac aneurysm was evaluated in terms of the calibre of the artery above and below the aneurysm and these size were classified as < 2C, = 2C and > 2C relative to that calibre. Three groups were defined: group 1--with at least 1 aneurysm < 2C: group 2--with at least 1 aneurysm = 2C, group 3--with at least 1 aneurysm > 2C.
32 patients had combined aneurysms (9 group 1, 13 group 2 and 10 group 3)--i.e. 7%. Treatment consisted of 23 exclusions by ligation, nearly all proximal, 6 bypasses of which 2 eventually required a ligation and 2 wrappings. Three patients aged 78, 82 and 86 years died, but no death was related to the treatment of the internal iliac aneurysms. On the other hand, massive haemorrhages occurred during the operation in a group 2 patient during an attempt at exclusion by ligation above and below the aneurysm and also in a group 3 patient during an unsuccessful attempt at bypassing. One further bypass proved impossible. Later, 2 group 3 patients developed postoperative complications: one buttock claudication and one invalidating paraplegia.
It is justifiable not to operate on < 2C and, in some cases, = 2C, internal iliac aneurysms. Embolisation was not used in this series. Exclusion by ligation is a good procedure when the other internal iliac artery is patent. Bypassing is the ideal method in bilateral aneurysms but it is associated with the risk of venous haemorrhage and of thrombosis. When flow must be maintained in an internal iliac artery, our first choice is wrapping when the size is < or = 2C and endoneurysmorrhaphy + wrapping when the size is > 2C and performing a bypass may be risky. Unoperated internal iliac aneurysms should be periodically controlled with Duplex or CT scan.
在之前的一项研究中，我们发现髂内动脉瘤合并腹主动脉瘤的手术死亡率高于单纯腹主动脉瘤手术。本综述的目的是确定这种动脉瘤组合的患病率以及不同治疗方式的结果，以便确定治疗选择。
对426例无症状肾下腹主动脉瘤患者的手术进行回顾性研究。根据动脉瘤上下方动脉的管径评估髂动脉瘤的大小，并将这些大小相对于该管径分为<2C、=2C和>2C。定义了三组：第1组——至少有1个动脉瘤<2C；第2组——至少有1个动脉瘤=2C；第3组——至少有1个动脉瘤>2C。
32例患者有合并动脉瘤（第1组9例，第2组13例，第3组10例）——即7%。治疗包括23例结扎排除术，几乎均为近端结扎，6例旁路手术，其中2例最终需要结扎，2例包裹术。3例年龄分别为78岁、82岁和86岁的患者死亡，但无死亡与髂内动脉瘤治疗相关。另一方面，1例第2组患者在尝试对动脉瘤上下方进行结扎排除术时术中发生大出血，1例第3组患者在旁路手术失败时也发生大出血。另有1例旁路手术无法进行。后来，2例第3组患者出现术后并发症：1例臀部跛行，1例导致残疾的截瘫。
对于<2C以及在某些情况下=2C的髂内动脉瘤不进行手术是合理的。本系列未使用栓塞术。当另一侧髂内动脉通畅时，结扎排除术是一种不错的方法。旁路手术是双侧动脉瘤的理想方法，但有静脉出血和血栓形成的风险。当必须保留髂内动脉血流时，当动脉瘤大小<或=2C时我们的首选是包裹术，当动脉瘤大小>2C时首选瘤内缝合法+包裹术，进行旁路手术可能有风险。未手术的髂内动脉瘤应定期用双功超声或CT扫描进行监测。
