孤立性髂动脉瘤治疗方法的选择与分析
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摘要
目的总结孤立性髂动脉瘤治疗方法的选择并分析其优缺点。方法回顾性分析笔者所在医院科室2006年1月至2017年1月期间收治的21例孤立性髂动脉瘤患者的临床资料。结果有4例患者分别接受瘤体切开人造血管移植、腹主动脉及双侧髂动脉瘤切开分叉型人造血管移植、髂内动脉近远端结扎等传统手术。有17例患者分别接受了单纯髂动脉覆膜支架置入、髂内动脉弹簧圈栓塞联合髂动脉覆膜支架置入、弹簧圈封闭髂内动脉瘤近远端等腔内治疗。1例破裂孤立性髂动脉瘤在急诊腔内治疗过程中,因失血性休克虽经积极治疗无效死亡,余下病例均治愈出院。4例开放手术者平均手术时间2.83 h,术中及术后平均输血900 m L,平均住院时间17.5 d。17例采用腔内治疗患者平均手术时间1.58 h,术中及术后平均输血160 m L,平均住院时间7.7 d。仅腔内治疗患者术中造影发现Ⅰ型内漏1例、Ⅱ型内漏1例。采用两种手术方式者均未发生输尿管或肠管损伤、臀肌跛行、乙状结肠缺血等并发症。17例获得随访,随访率为85%,随访时间1~60个月,平均22个月。随访过程中,人工血管及支架移植物均通畅,未发现原有动脉瘤扩张。1例合并系统性红斑狼疮患者出现髂窝脓肿,经对症处理后好转。有2例患者在随访期间因其他疾病死亡,其余无明显的临床症状。结论从本组有限的临床病例资料可以初步看出,对于孤立性髂动脉瘤,采用传统手术及腔内治疗均是比较安全、有效的治疗方式。腔内治疗具有创伤小、恢复快特点,但对于一些特殊的孤立性髂动脉瘤,采用传统手术的可控性要好于腔内介入治疗,在临床上应根据动脉瘤的解剖形态与患者的全身状况选择合适的治疗方法。
Objective To summarize selection of therapeutic method for isolated iliac aneurysms and analyze its advantages and disadvantages. Method The clinical data of 21 patients with isolated iliac aneurysms from January 2006 to January 2017 in this hospital were analyzed retrospectively. Results Four patients were treated with an open surgery such as the unilateral iliac prosthetic graft interposition, aorto-biiliac or aorto-bifemoral arterial bypass graft, ligation of internal iliac artery, etc.. Seventeen patients were treated with an endovascular treatment such as the unilateral iliac stentgrafts, bifurcated aortic stent-grafts, or coil embolization alone, etc.. One patient with ruptured isolated iliac aneurysms died during the endovascular repair, and the rest patients were cured after the operation. The average operative time was2.83 h and 1.58 h, the average hospital stay was 17.5 d and 7.7 d respectively for the patients with the open surgery and the endovascular treatment. Except 1 case of type Ⅰ and 1 case of type Ⅱ endoleaks were found in the patients with the endovascular treatment, no complications such as the ureteral and intestinal injuries, the gluteal muscle claudication,and the sigmoid ischemia were found in all the patients. Seventeen cases were followed-up. The following-up rate was85%. The following-up time was 1–60 months with an average of 22 months. During the following-up period, the grafts and stent grafts were patent and the aneurysm sac diameter was unchanged. The abscess of the iliac fossa occurred in 1patient with systemic lupus erythematosus and improved after the symptomatic treatment. Two patients died of other diseases during the following-up period, and the rest had no obvious clinical symptoms. Conclusions Preliminary results of limited cases in this study show that endovascular repair and open surgery in treatment of appropriately selected patients with isolated iliac artery aneurysms is safe and effective. But in special situation, technical controllability of open surgery might be better than endovascular repair, treatment should be selected according to patient's general condition and anatomy of aneurysm.
Objective To summarize selection of therapeutic method for isolated iliac aneurysms and analyze its advantages and disadvantages. Method The clinical data of 21 patients with isolated iliac aneurysms from January 2006 to January 2017 in this hospital were analyzed retrospectively. Results Four patients were treated with an open surgery such as the unilateral iliac prosthetic graft interposition, aorto-biiliac or aorto-bifemoral arterial bypass graft, ligation of internal iliac artery, etc.. Seventeen patients were treated with an endovascular treatment such as the unilateral iliac stentgrafts, bifurcated aortic stent-grafts, or coil embolization alone, etc.. One patient with ruptured isolated iliac aneurysms died during the endovascular repair, and the rest patients were cured after the operation. The average operative time was2.83 h and 1.58 h, the average hospital stay was 17.5 d and 7.7 d respectively for the patients with the open surgery and the endovascular treatment. Except 1 case of type Ⅰ and 1 case of type Ⅱ endoleaks were found in the patients with the endovascular treatment, no complications such as the ureteral and intestinal injuries, the gluteal muscle claudication,and the sigmoid ischemia were found in all the patients. Seventeen cases were followed-up. The following-up rate was85%. The following-up time was 1–60 months with an average of 22 months. During the following-up period, the grafts and stent grafts were patent and the aneurysm sac diameter was unchanged. The abscess of the iliac fossa occurred in 1patient with systemic lupus erythematosus and improved after the symptomatic treatment. Two patients died of other diseases during the following-up period, and the rest had no obvious clinical symptoms. Conclusions Preliminary results of limited cases in this study show that endovascular repair and open surgery in treatment of appropriately selected patients with isolated iliac artery aneurysms is safe and effective. But in special situation, technical controllability of open surgery might be better than endovascular repair, treatment should be selected according to patient's general condition and anatomy of aneurysm.
引文
1 Fossaceca R,Guzzardi G,Cerini P,et al.Isolated iliac artery aneurysms:a single-centre experience.Radiol Med,2015,120(5):440-448.
2 Roddy SP.Outcomes of open and endovascular repair for ruptured and nonruptured internal iliac artery aneurysms.J Vasc Surg,2014,59(3):869-870.
3 Richardson JW,Greenfield LJ.Natural history and management of iliac aneurysms.J Vasc Surg,1988,8(2):165-171.
4 郭平凡,陈福真,洪志鹏,等.孤立性髂动脉瘤28例的诊断与治疗.中华普通外科杂志,2001,16(9):567.
5 栾景源.腰椎间盘术后髂动脉假性动脉瘤.中国微创外科杂志,2013,13(4):361-362,367.
6 Kretz B,Pagès PB,Loffroy R,et al.Mycotic aneurysm of both internal iliac arteries due to Candida albicans.Ann Vasc Surg,2014,28(3):738.e11-e14.
7 Dueppers P,Jankowiak S,Schelzig H,et al.Spontaneous rupture of an isolated iliac artery dissection in a young man because of cystic medial degeneration Erdheim-Gsell.Ann Vasc Surg,2015,29(3):596.e11-e13.
8 冯勇,胡海地,陈喆,等.孤立性髂动脉瘤19例诊治经验.中华普通外科杂志,2009,24(1):5-7.
9 姚陈,叶彦琛,李勇辉,等.孤立性髂动脉瘤的外科手术治疗.中国血管外科杂志(电子版),2015,7(1):33-36.
10 Shareghi S,Gopal A,Gul K,et al.Diagnostic accuracy of 64multidetector computed tomographic angiography in peripheral vascular disease.Catheter Cardiovasc Interv,2010,75(1):23-31.
11 Santilli SM,Wernsing SE,Lee ES.Expansion rates and outcomes for iliac artery aneurysms.J Vasc Surg,2000,31(1 Pt 1):114-121.
12 Minato N,Itoh T,Natsuaki M,et al.Isolated iliac artery aneurysm and its management.Cardiovasc Surg,1994,2(4):489-494.
13 Matsumoto K,Matsubara K,Watada S,et al.Surgical and endovascular procedures for treating isolated iliac artery aneurysms:ten-year experience.World J Surg,2004,28(8):797-800.
14 Patel NV,Long GW,Cheema ZF,et al.Open vs.endovascular repair of isolated iliac artery aneurysms:A 12-year experience.JVasc Surg,2009,49(5):1147-1153.
15 Buck DB,Bensley RP,Darling J,et al.The effect of endovascular treatment on isolated iliac artery aneurysm treatment and mortality.J Vasc Surg,2015,62(2):331-335.
16 Igari K,Kudo T,Toyofuku T,et al.Comparison between endovascular repair and open surgery for isolated iliac artery aneurysms.Surg Today,2015,45(3):290-296.
17 Uberoi R,Tsetis D,Shrivastava V,et al.Standard of practice for the interventional management of isolated iliac artery aneurysms.Cardiovasc Intervent Radial,2011,34(1):3-13.
18 Melas N,Saratzis A,Dixon H,et al.Isolated common iliac artery aneurysms:a revised classification to assist endovascular repair.JEndovasc Ther,2011,18(5):697-671.
19 Rayt HS,Brown MJ,Lambert KV,et al.Buttock claudication an erectile dysfunction after internal iliac artery embolization in patients prior to endovascular aortic aneurysm repair.Cardiovasc Intervent Radiol,2008,31(4):728-734.
20 Shutze RA,Oglesby W,Lee A,et al.Results of repair of iliac artery aneurysms with the sandwich technique.Proc(Bayl Univ Med Cent),2017,30(1):7-10.
21 栾景源,李选,冯琦琛,等.开窗覆膜支架腔内修复髂动脉瘤.北京大学学报(医学版),2012,44(3):489-491.
22 卿洪琨,张学民,蒋京军,等.自制髂动脉分支装置治疗腹主动脉瘤腔内修复术后髂动脉瘤1例.北京大学学报(医学版),2015,47(5):888-890.
23 Noel-Lamy M,Jaskolka J,Lindsay TF,et al.Internal iliac aneurysm repair outcomes using a modification of the iliac branch graft.Eur JVasc Endovasc Surg,2015,50(4):474-479.
24 吴科敏,王伟,黄建华,等.腹主动脉瘤术中不同髂内动脉处理的疗效观察.中国普通外科杂志,2014,23(12):1620-1624.
25 李海辉,赵亮,谢锐,等.破裂性髂动脉瘤的救治体会.心理医生,2015,21(22):125-127.
26 Igari K,Kudo T,Toyofuku T,et al.Successful endovascular repair of ruptured isolated bilateral internal iliac artery aneurysms.Eur JVasc Endovasc Surg,2013,45(3):218-219.
2 Roddy SP.Outcomes of open and endovascular repair for ruptured and nonruptured internal iliac artery aneurysms.J Vasc Surg,2014,59(3):869-870.
3 Richardson JW,Greenfield LJ.Natural history and management of iliac aneurysms.J Vasc Surg,1988,8(2):165-171.
4 郭平凡,陈福真,洪志鹏,等.孤立性髂动脉瘤28例的诊断与治疗.中华普通外科杂志,2001,16(9):567.
5 栾景源.腰椎间盘术后髂动脉假性动脉瘤.中国微创外科杂志,2013,13(4):361-362,367.
6 Kretz B,Pagès PB,Loffroy R,et al.Mycotic aneurysm of both internal iliac arteries due to Candida albicans.Ann Vasc Surg,2014,28(3):738.e11-e14.
7 Dueppers P,Jankowiak S,Schelzig H,et al.Spontaneous rupture of an isolated iliac artery dissection in a young man because of cystic medial degeneration Erdheim-Gsell.Ann Vasc Surg,2015,29(3):596.e11-e13.
8 冯勇,胡海地,陈喆,等.孤立性髂动脉瘤19例诊治经验.中华普通外科杂志,2009,24(1):5-7.
9 姚陈,叶彦琛,李勇辉,等.孤立性髂动脉瘤的外科手术治疗.中国血管外科杂志(电子版),2015,7(1):33-36.
10 Shareghi S,Gopal A,Gul K,et al.Diagnostic accuracy of 64multidetector computed tomographic angiography in peripheral vascular disease.Catheter Cardiovasc Interv,2010,75(1):23-31.
11 Santilli SM,Wernsing SE,Lee ES.Expansion rates and outcomes for iliac artery aneurysms.J Vasc Surg,2000,31(1 Pt 1):114-121.
12 Minato N,Itoh T,Natsuaki M,et al.Isolated iliac artery aneurysm and its management.Cardiovasc Surg,1994,2(4):489-494.
13 Matsumoto K,Matsubara K,Watada S,et al.Surgical and endovascular procedures for treating isolated iliac artery aneurysms:ten-year experience.World J Surg,2004,28(8):797-800.
14 Patel NV,Long GW,Cheema ZF,et al.Open vs.endovascular repair of isolated iliac artery aneurysms:A 12-year experience.JVasc Surg,2009,49(5):1147-1153.
15 Buck DB,Bensley RP,Darling J,et al.The effect of endovascular treatment on isolated iliac artery aneurysm treatment and mortality.J Vasc Surg,2015,62(2):331-335.
16 Igari K,Kudo T,Toyofuku T,et al.Comparison between endovascular repair and open surgery for isolated iliac artery aneurysms.Surg Today,2015,45(3):290-296.
17 Uberoi R,Tsetis D,Shrivastava V,et al.Standard of practice for the interventional management of isolated iliac artery aneurysms.Cardiovasc Intervent Radial,2011,34(1):3-13.
18 Melas N,Saratzis A,Dixon H,et al.Isolated common iliac artery aneurysms:a revised classification to assist endovascular repair.JEndovasc Ther,2011,18(5):697-671.
19 Rayt HS,Brown MJ,Lambert KV,et al.Buttock claudication an erectile dysfunction after internal iliac artery embolization in patients prior to endovascular aortic aneurysm repair.Cardiovasc Intervent Radiol,2008,31(4):728-734.
20 Shutze RA,Oglesby W,Lee A,et al.Results of repair of iliac artery aneurysms with the sandwich technique.Proc(Bayl Univ Med Cent),2017,30(1):7-10.
21 栾景源,李选,冯琦琛,等.开窗覆膜支架腔内修复髂动脉瘤.北京大学学报(医学版),2012,44(3):489-491.
22 卿洪琨,张学民,蒋京军,等.自制髂动脉分支装置治疗腹主动脉瘤腔内修复术后髂动脉瘤1例.北京大学学报(医学版),2015,47(5):888-890.
23 Noel-Lamy M,Jaskolka J,Lindsay TF,et al.Internal iliac aneurysm repair outcomes using a modification of the iliac branch graft.Eur JVasc Endovasc Surg,2015,50(4):474-479.
24 吴科敏,王伟,黄建华,等.腹主动脉瘤术中不同髂内动脉处理的疗效观察.中国普通外科杂志,2014,23(12):1620-1624.
25 李海辉,赵亮,谢锐,等.破裂性髂动脉瘤的救治体会.心理医生,2015,21(22):125-127.
26 Igari K,Kudo T,Toyofuku T,et al.Successful endovascular repair of ruptured isolated bilateral internal iliac artery aneurysms.Eur JVasc Endovasc Surg,2013,45(3):218-219.