内脏动脉瘤治疗方法选择

Treatment Options:
Surgical and endovascular treatment of VAA share the common goal of preventing aneurysm expansion and rupture.
This goal is best accomplished by excluding the aneurysm from the arterial circulation and pressure.
Background Visceral artery aneurysms and pseudoaneurysms represent a rare disease with high mortality. The aim of this study was to report a single center experience of open repair (OR) and endovascular treatment (ET) of 94 patients, and to analyze short- and midterm results. Methods Between 1988 and 2010, 94 patients, 43 men and 51 women, mean age of 57.6 years (range, 23-87 years), were referred to our Institute with a diagnosis of visceral artery aneurysm or pseudoaneurysm. Arteries involved were splenic artery in 44 cases, hepatic artery in 17, renal artery in 18, superior mesenteric artery in six, celiac trunk in three, gastroduodenal in two, and pancreaticoduodenal in four. An abdominal aortic aneurysm coexisted in three (3%) cases, whereas in six (6%) cases, there were multiple visceral aneurysms. ET was indicated based on the anatomical location of the aneurysm or for patients at high risk for surgery. Results A total of 74 patients underwent OR, whereas ET was performed in 20 patients. Technical success was achieved in all cases treated by open surgery. Splenectomy was performed in 11 cases, and in six, splenic autotransplantation was performed. At 6 months of follow-up, a Tc99m-labeled red cell scintigraphy showed that autotransplants were viable in four patients (67%). No cases of pancreatitis or splenic infarction were observed. Among renal artery aneurysms, nephrectomy was necessary in one case of renal infarction for massive thrombosis of the ex-vivo reconstructed renal artery. Four surgical conversions were recorded (one thrombosis of the hepatic artery, one massive hemorrhage after embolization of superior mesenteric artery aneurysm, and two cases of sac enlargement after 24 and 48 months). An endoleak was present in a patient treated for a splenic artery aneurysm, but it resolved spontaneously after 6 months. No complications were observed in patients undergoing surgical conversion after ET. Perioperative mortality in the surgical group was 1.3% (1/74). There was no perioperative mortality in the endovascular group. No statistically significant difference was found between groups in terms of perioperative mortality (p = 1.00). Perioperative morbidity was 9.4% (7/74) in the surgical group, and 10% (2/20) in the endovascular group (p = 1.00). Follow-up was available for 16 patients in the endovascular group (80%) and 63 in the surgical group (85%), with a mean duration of 42 months (1-192 months). In the whole cohort, actuarial survival at 10 years was 68%. The Kaplan–Meier estimates of survival at 1 and 5 years were 100% and 85%, respectively, for OR, and 100% and 40%, respectively, for ET, with no significant difference between the two groups Conclusion ET is safe and feasible in selected patients, but incomplete exclusion may be observed, requiring late surgical conversion in a significant number of patients. Long-term results (high survival, low complication rate) confirm the durability of the surgical approach that in our experience remains the gold standard with satisfactory results, especially for aneurysms involving the visceral hilum.
Hossain A, Reis ED, Dave SP, et al. Am Surg 2001;67:432-7
Trauma
– Blunt – Penetrating – Latrogenic
Inflammation Pancreatitis
Infection
Vasculitis
Neoplasm
Resection with revascularization Ligation End organ resection (Splenectomy)
Mortality 2% in this series of 55 patients
1-,5- and 10- years survival rates of 98%, 98%, and 79.5%
Up to 25% of VAA will rupture Mortality ranges from 20%-100%
Stanley JC, Wakefield Tw, Graham Lmet al. J Vasc Surg 1986;3:836-40
When should VAA be treated?
Fig. Visceral artery aneurysms distribution
Incidence: 0.1~10% Most are asymptomatic 22% present as emergencies
– GIB – Rupture Mortality after rupture – Variable & dependent on location
Mostly degenerative demonstrating Deficiency of the arterial media with loss or fragmentation of elastic fibers and reduced smooth muscle
Atherosclerosis, fibromuscular dysplasia, and collagen disorders are other possible causes
1-,5- and 10- years complication-free survival rates of 95.9%, 93.7%, and 75.2%
Fra Baidu bibliotek
Is Open Repair Still the Gold Standard in Visceral Artery Aneurysm Management?
True aneurysms Rapid documented expansion Size(> 2.0cm or >2x normal diameter) Symptomatic Secondary effects of the aneurysm -Hypertension
Pseudo-Aneurysms All should be treated