Relationship between acute kidney injury before thoracic endovascular aneurysm repair and in-hospital outcomes in patients with type B acute aortic dissection

ObjectiveAcute 肾损害(AKI ) 经常发生在基于导管的 interventional 过程和增加死亡以后。然而，类型 B 尖锐大动脉的解剖(AAD ) 的 AKI 以前胸的 endovascular 动脉瘤修理(TEVAR ) 的含意仍然保持不清楚。这研究与类型 B AAD.MethodsBetween 2009 在病人在 TEVAR 前评估了 AKI 的发生，预言者，和在里面医院结果并且 2013， 76 个病人回顾地被评估从症状发作在 36 h 以内为类型 B AAD 收到了 TEVAR。病人被分类进 no-AKI 对 AKI 组，并且 AKI 的严厉进一步根据肾疾病被上演：在外科手术前的 AKI 的 TEVAR.ResultsThe 发生前改进全球结果标准是 36.8% 。在里面医院复杂并发症与 no-AKI 相比在有外科手术前的 AKI 的病人是显著地更高的(50.0% 对 4.2% 分别地；P &#x0003c；0.001 ) ，包括尖锐肾的失败(21.4% 对 0 分别地；P &#x0003c；0.001 ) ，并且他们与 AKI 的严厉增加了(P &#x0003c；0.001 ) 。身体温度和白血房间计数的最大的层次是以前显著地与最大的浆液 creatinine 有关铺平 TEVAR。Multivariate 分析在承认上显示出那收缩血压(或：1.023；95% CI：1.003-1.044；P = 0.0238 ) 并且双边的肾的动脉参与(或：19.076；95% CI：1.914-190.164；P = 0.0120 ) 外科手术前的 AKI.ConclusionsPreoperative AKI 的强壮的预言者经常与类型 B AAD 在病人被发生，并且与更高的在里面医院复杂并发症相关并且提高了煽动性的反应。承认和双边的肾的动脉参与上的收缩血压是为在 TEVAR 前的 AKI 的主要风险因素。

Review of Thoracic Endovascular Aneurysm Repair (TEVAR), Spinal Cord Ischemia (SCI), Cerebrospinal Fluid (CSF) Drainage and Blood Pressure (BP) Augmentation

The object of this review is to examine the role of TEVAR in causing SCI. The anatomy and physiology of blood flow to the spinal cord is examined. The role of auto regulation of blood flow within the spinal cord is also examined. This review examines the reported results from the scientific literature of the effect of thoracic aortic aneurysm repair on spinal cord blood flow. In the light of the-se findings several conclusions can reasonably be reached. These conclusions are that the development of SCI can reasonably be predicted based on complexity and extent of the TEVAR procedure performed and BP augmentation and CSF drainage can significantly reduce the impact of SCI.

Successful use of emergent endovascular aneurysm repair for a ruptured hypotensive abdominal aortic aneurysm

Ruptured aortic aneurysm has a surgical mortality ranging from 50%-70%, one of the highest rates of all vascular emergencies [1-5]. Less invasive approaches to repair have been developed that could potentially improve these statistics [1,5-7]. Endovascular aneurysm repair (EVAR) is a minimally invasive approach that may be an alternative to open surgical repair for select cases of ruptured aortic aneurysms [1,5]. Unfortunately, the role of EVAR in patients with acute rupture of an abdominal aneurysm is not clear, especially for patients that are hemodynamically unstable [1,8-10]. The literature is limited regarding use of EVAR in this population of patients. We present a case of the successful use of EVAR for an emergent repair in a hypotensive hemodynamically unstable patient with an acutely ruptured abdominal aortic aneurysm (AAA).

Transarterial Embolization versus Translumber Embolization for Type Ⅱ Endoleak after Endovascular Abdomi nal Aortic Aneurysm Repair:A Meta-Analysis

Objective Type II endoleak is the most common subtype of endoleak as a complication after endovascular aneurysm repair(EVAR).The efficacy of transarterial(TA)embolization and translumber(TL)embolization in the management of type II endoleak remains equipoise.The aim of this study is to compare the technical and clinical success between TA embolization andTL embolization for type II endoleak after EVAR.Methods The protocol was registered(CRD 42018114453)and the electronic databases(Pubmed,Embase,Web of Science,and Cochrane)were systematically searched till March 2019.The search terms included EVAR,type II endoleak,and embolization.The articles were read and extracted by two authors independently to include randomized control trails and retrospective studies that compared TA embolization and TL embolization in patients who developed type II endoleak after EVAR.The technical and clinical success rates were metaanalyzed with random effect model.Results A total of 6 articles with 268 patients and 290 type II endoleaks were included.The pooled odds ratio(OR)of technical success rate for TA vs.TL was 0.56(95%C7,0.10-3.18;P=0.51)and the pooled OR of clinical success rate for TA vs.TL was 0.31(95%CI,0.07-1.29;P=0.11).As a limitation,6 articles were all retrospective studies which may lead to bias.Conclusion Both TA.andTL could be eflective procedure of embolizations to resolve the type II endoleak.The metaanalysis result indicated that TA embolization was not inferior toTL embolization in technical success and clinical success.

Influence of severe neck angulation on hemodynamic and clinical outcomes following endovascular aneurysm repair:a hemodynamic analysis and a retrospective cohort study

Background: For patients with severe neck angulation (SNA), hemodynamic and clinical outcomes following endovascular aneurysm repair (EVAR) are still unclear. This study aimed to explore the influence of SNA on hemodynamic and clinical outcomes following EVAR.Methods: This study included a hemodynamic analysis and a retrospective cohort study from West China Hospital of Sichuan University between January 2011 and December 2020. The Cox regression model, inverse probability of treatment weighting (IPTW) analysis, sensitivity analysis, and subgroup analysis were applied. Primary outcome was type IA endoleak (T1AEL).Results: In this hemodynamic analysis, nine non-severe neck angulation (nSNA) and 16 SNA idealized models were constructed. We found a significant difference in drag force between SNA and nSNA models (7.016 ± 2.579 Nvs. 4.283 ± 1.460 N,P = 0.008), and proximal neck angles were significantly associated with the magnitude of drag force (F = 0.082 ×α-0.006 ×β + 2.818, α: 95% confidence interval [CI] 0.070-0.094;P = 0.001;β: 95% CI -0.019 to 0.007;P = 0.319). In our cohort study, 514 nSNA patients (71.5 ± 8.5 years;459 males) and 208 SNA patients (72.5 ± 7.8 years;135 males) were included, with a median follow-up duration of 34 months (16-63 months). All baseline characteristics were well balanced after IPTW matching. We found that SNA was associated with a significant risk of adverse limb event (hazard ratio [HR] 2.18, 95% CI 1.09-3.12), yet was not associated with T1AEL, overall survival, or reintervention. In patients without proximal or distal additional procedures (DAP), subgroup analyses suggested a significant risk of T1AEL (Proximal: HR 5.25, 95% CI 1.51-18.23;Distal: HR 5.07, 95% CI 1.60-16.07) and adverse limb event (Proximal: HR 2.27, 95% CI 1.01-5.07;Distal: HR 2.91, 95% CI 1.30-6.54) in SNA patients. However, no noticeable difference was observed in patients with proximal or DAP.Conclusions: SNA has a critical influence on hemodynamic and clinical outcomes following EVAR. Appropriate additional procedures may be of great benefit to SNA patients.

Incidental extravascular findings in computed tomographic angiography for planning or monitoring endovascular aortic aneurysm repair: Smoker patients, increased lung cancer prevalence?

AIM To validate the feasibility of high resolution computed tomography(HRCT) of the lung prior to computed tomography angiography(CTA) in assessing incidental thoracic findings during endovascular aortic aneurysm repair(EVAR) planning or follow-up.METHODS We conducted a retrospective study among 181 patients(143 men, mean age 71 years, range 50-94) referred to our centre for CTA EVAR planning or followup. HRCT and CTA were performed before or after 1 or 12 mo respectively to EVAR in all patients. All HRCT examinations were reviewed by two radiologists with 15 and 8 years experience in thoracic imaging. The results were compared with histology, bronchoscopy or follow-up HRCT in 12, 8 and 82 nodules respectively. RESULTS There were a total of 102 suspected nodules in 92 HRCT examinations, with a mean of 1.79 nodules per patient and an average diameter of 9.2 mm(range 4-56 mm). Eightynine out of 181 HRCTs resulted negative for the presence of suspected nodules with a mean smoking history of 10 pack-years(p-y, range 5-18 p-y). Eighty-two out of 102(76.4%) of the nodules met criteria for computed tomography follow-up, to exclude the malignant evolution. Of the remaining 20 nodules, 10 out of 20(50%) nodules, suspected for malignancy, underwent biopsy and then surgical intervention that confirmed the neoplastic nature: 4(20%) adenocarcinomas, 4(20%) squamous cell carcinomas, 1(5%) small cell lung cancer and 1(5%) breast cancer metastasis); 8 out of 20(40%) underwent bronchoscopy(8 pneumonia) and 2 out of 20(10%) underwent biopsy with the diagnosis of sarcoidosis.CONCLUSION HRCT in EVAR planning and follow-up allows to correctly identify patients requiring additional treatments, especially in case of lung cancer.

Follow-up of endovascular aortic aneurysm repair:Preliminary validation of digital tomosynthesis and contrast enhanced ultrasound in detection of medium- to long-term complications

AIM: To validate the feasibility of digital tomosynthesis of the abdomen(DTA) combined with contrast enhanced ultrasound(CEUS) in assessing complications after endovascular aortic aneurysm repair(EVAR) by using computed tomography angiography(CTA) as the gold standard.METHODS: For this prospective study we enrolled 163 patients(123 men; mean age, 65.7 years) referred for CTA for EVAR follow-up. CTA, DTA and CEUS were performed at 1 and 12 mo in all patients, with a maximum time interval of 2 d.RESULTS: Among 163 patients 33 presented complications at CTA. DTA and CTA correlated for the presence of complications in 32/33(96.96%) patients and for the absence of complications in 127/130(97.69%) patients; the sensitivity, specificity, positive predictive value(PPV), negative predictive value(NPV) and accuracy of DTA were 97%, 98%, 91%, 99%, and 98%, respectively. CEUS and CTA correlated for the presence of complications in 19/33(57.57%) patients and for the absence of complications in 129/130(99.23%) patients; the sensitivity, specificity, PPV, NPV and accuracy of CEUS were 58%, 99%, 95%, 90%, and 91%, respectively. Sensitivity, specificity and accuracy of combining DTA and CEUS together in detecting EVAR complications were 77%, 98% and 95%, respectively.CONCLUSION: Combining DTA and CEUS in EVAR follow-up has the potential to limit the use of CTA only in doubtful cases.

Using a Surgeon-modified Iliac Branch Device to Preserve the Internal Iliac Artery during Endovascular Aneurysm Repair： Single-center Experiences and Early Results

Background：To evaluate the feasibility of a new surgeon-modified iliac branch device （IBD） technique to maintain pelvic perfusion in the management of common iliac artery （CIA） aneurysm during endovascular aneurysm repair （EVAR）.Methods：From January 2011 to December 2013,a new surgeon-modified IBD technique was performed in department of vascular surgery of Peking Union Medical College Hospital in five patients treated for CIA aneurysm with or without abdominal aortic aneurysm.A stent-graft limb was initially deployed in vitro,anastomosed with vascular graft,creating a modified IBD reloaded into a larger sheath,with or without a guidewire preloaded into the side branch.The reloaded IBD was then placed in the iliac artery,with a covered stent bridging internal iliac artery and the branch.Finally,a bifurcated stent-graft was deployed,and a limb device was used to connect the main body and IBD.Results：Technical successes were obtained in all patients.The mean follow-up length was 24 months （range：6-38 months）.All grafts remained patent without any sign of endoleaks.There were no aneurysm ruptures,deaths,or other complications related to pelvic flow.Conclusions：Using the surgeon-modified IBD to preserve pelvic flow is a feasible endovascular technique and an appealing solution for personalized treatment of CIA aneurysm during EVAR.

Endovascular Repair for Abdominal Aortic Aneurysm with an Ectopic Pelvic Kidney: Case Report and Procedural Consideration of the Aberrant Renal Artery

A 91-year-old female presented with a pulsatile abdominal mass. Her past medical history included hypertension and hyperlipidemia. A 6.9 cm infrarenal abdominal aortic aneurysm, with a left ectopic pelvic kidney and two aberrant renal arteries, one each from the left and right common iliac arteries was found on computed tomography. Because of the high risk of rupture, surgery was recommended and an endovascular aneurysm repair was performed. The antegrade flow of the aberrant renal artery from the left common iliac artery was preserved. The right aberrant renal artery was covered with stent graft. The patient’s serum creatinine level remained unchanged throughout the postoperative course, with an uneventful postoperative recovery.

Endovascular treatment of aortoiliac aneurysms: From intentional occlusion of the internal iliac artery to branch iliac stent graft

Approximately 20%-40% of patients with abdominal aortic aneurysms can have unilateral or bilateral iliac artery aneurysms and/or ectasia. This influences and compromises the distal sealing zone during endovascular aneurysm repair. There are a few endovascular techniques that are used to treat these types of aneurysms, including intentional occlusion/over-stenting of the internal iliac artery on one or both sides, the "bell-bottom" technique, and the more recent method of using an iliac branch stent graft. In some cases, other options include the "snorkel and sandwich" technique and hybrid interventions. Pelvic ischemia, represented as buttock claudication, has been reported in 16%-55% of cases; this is followed by impotence, which has been described in 10%-17% of cases following internal iliac artery occlusion. The bellbottom technique can be used for a common iliac artery up to 24 mm in diameter given that the largest diameter of the stent graft is 28 mm. There is a paucity of data and evidence regarding the "snorkel and sandwich" technique, which can be used in a few clinical scenarios. The hybrid intervention is comprised of a surgical operation, and is not purely endovascular. The newest branch stent graft technology enables preservation of the anterograde flow of important side branches. Technical success with the newest technique ranges from 85%-96.3%, and in some small series, technical success is 100%. Buttock claudication was reported in up to 4% of patients treated with a branch stent graft at 5-year follow-up. Mid- and short-term follow-up results showed branch patency of up to 88% during the 5-6-year period. Furthermore, branch graft occlusion is a potential complication, and it has been described to occur in 1.2%-11% of cases. Iliac branch stent graft placement represents a further development in endovascular medicine, and it has a high technical success rate without serious complications.

以3D影像融合技术引导腔内治疗主动脉疾病研究进展

3D影像融合技术是以锥形束CT为介导将介入治疗前和治疗中的影像数据融合并以之引导介入操作,可显著提高腔内介入治疗主动脉疾病成功率,减少辐射暴露和碘对比剂用量并缩短治疗时间等。本文就3D影像融合技术用于引导腔内治疗主动脉疾病研究进展进行综述。

西藏地区腹主动脉瘤腔内隔绝修复术的中期随访结果分析

目的分析西藏地区腹主动脉瘤(AAA)患者腔内隔绝修复手术的转归情况。方法收集2015年5月至2023年4月西藏自治区人民医院收治的31例AAA患者的临床资料,所有患者均进行了AAA腔内隔绝修复术。收集所有患者的基本特征、合并疾病、AAA最大直径、术前检查结果等信息,观察所有患者的治疗情况、围手术期并发症发生情况及随访结果。结果31例AAA患者中,美国麻醉医师协会(ASA)3级患者18例,4级患者7例。27例患者经双侧股动脉入路,4例患者经双侧股动脉和左侧肱动脉入路,手术成功率为100%。围手术期间1例患者出现臀肌跛行症状。随访时间为1~93个月。随访期间,失访2例,死亡2例,Ⅰ型内漏1例,Ⅱ型内漏1例。经随访,所有患者未发生支架移位、内漏等并发症。结论在西藏地区采用腔内隔绝修复术治疗AAA是安全、有效的。

胸腹主动脉瘤精准外科诊疗体系构建及应用

胸腹主动脉瘤(TAAA)累及主动脉及胸腹段多支内脏动脉和脊髓供血动脉,但因动脉病变受累范围广、异质性高,手术重建主动脉及多支内脏动脉难度较大,围手术期病死率及截瘫、脏器缺血等严重并发症发生率较高,因此,TAAA患者需要制定个体化的临床诊治策略。本述评归纳总结中国医学科学院北京协和医学院北京协和医院TAAA精准外科诊疗体系的构建与应用,通过改良传统术式建立TAAA全腔内治疗体系,应用血流仿真模型制定手术策略,优化特殊病因TAAA的诊疗策略,从而提升TAAA的诊治水平,改善患者的预后情况,以期为TAAA的诊治提供参考。

Stanford A型主动脉夹层治疗的发展及现状

主动脉夹层(aortic dissection,AD)是一种极其凶险的心血管外科急危重症,发病急,进展迅速,病情复杂凶险,病死率极高。该疾病术后易出现并发症,手术死亡率高。AD有多种分型,Stanford分型是临床最常用的分型之一,以Stanford A型AD最常见且最凶险。随着医疗技术的快速发展,目前AD的诊治水平已经显著提升,本文就Stanford A型AD治疗的发展及现状作一综述。

腹主动脉瘤腔内治疗术径路血管解剖学特征及并发症的研究进展

腹主动脉瘤(AAA)是腹主动脉节段的病理性扩张,腔内治疗(EVAR)是解剖结构合适的AAA患者的首选治疗方式。径路血管作为EVAR术中穿刺以及器械输送的途径,其解剖学特征对血管并发症的发生有着显著影响。本文对EVAR径路血管解剖学特征及其并发症的研究情况进行综述。

1例EVAR术后支架感染合并全身感染病人行自体深静脉原位重建术的护理

总结1例腹主动脉瘤腔内修复术后(EVAR)支架感染合并全身感染病人行自体深静脉原位重建术的护理:术前预防瘤体破裂、积极控制感染预防休克的发生;术后做好生命体征的监测及专科观察,严格消毒隔离预防再感染发生,做好血压的控制、疼痛的管理,给予营养支持、手术伤口的护理及引流的观察,并实施心理护理;严防移植物破裂、吻合口瘘及下肢静脉高压的发生。经过积极的治疗和护理,病人术后感染控制,伤口恢复良好,未出现严重的并发症,康复出院。认为EVAR术后支架感染合并全身感染的病人病情危急,基础情况差,感染面积广,死亡率高;自体深静脉原位重建术式复杂,该手术方式对治疗和护理要求高,通过全程的管理能有效提高病人术后生存率,减少感染及并发症的发生。

An Unusual Case of Deep Vein Thrombosis and Mycotic Aneurysms Secondary to Salmonella Bacteraemia

Salmonella, a food-borne pathogen, can cause mild self-limiting gastroenteritis. However, immunocompromised hosts and older adults with complex medical conditions may develop a complicated form of bacteraemia, with a high mortality rate involving extra-intestinal foci of infection and mycotic aneurysms. We report the case of a 61-year-old man with poorly controlled diabetes mellitus, hypertension, dyslipidaemia, and congestive heart failure, who presented with unilateral left lower limb swelling, extensive deep vein thrombosis, and concomitant Salmonella bacteraemia. An oral anticoagulant and intravenous antibiotic therapy were initiated. Although the patient remained haemodynamically stable, he complained of constant left lower limb weakness and lower back pain. A computed tomography angiography scan of the thorax and abdomen revealed saccular aneurysms with contained hematoma of the left common iliac artery. The oral anticoagulant was discontinued, and an inferior vena cava filter was inserted as part of the venous thrombosis management. The patient was offered aorto-uni-iliac endovascular aneurysm repair and received intravenous antibiotic therapy, postoperatively, for six weeks. The postoperative blood cultures remained negative, and he was discharged with a course of ciprofloxacin administered orally. However, three months after the surgery, the patient died of recurrent septicaemia. This case illustrates the importance of remaining vigilant for potential endovascular complications of Salmonella bacteraemia, such as mycotic aneurysms and deep vein thrombosis, among high-risk patients. Further, this case highlights the challenges of eliminating Salmonella bacteraemia and its related complications, albeit treating it with both a prolonged course of medical therapy and surgical intervention.

Surgical Treatment of Aortic Aneurysm and Aortic Dissection:A Retrospective Analysis of 122 Cases

The study summarizes the clinical experience of surgical treatments of various types of thoracic aneurysm and aortic dissection. Clinical data of 122 patients with thoracic aneurysm and aortic dissection during July 2005 to July 2008 were retrospectively analyzed. The elective operations were performed in 107 patients while emergency surgery was done in 15 cases. Different surgical strategies were employed on the basis of diseased region, including simple ascending aortic replacement （n=3）, aortic root replacement （n=43）, hemi-arch replacement/total arch replacement ＋ elephant trunk technique （n=32）, thoracic/thoracoabdominal aortic replacement （n=8） and endovascular repair （n=36）. In this series, there is 4 cases of perioperative death due to massive cerebral hemorrhage （n=1）, respiratory failure （n=1） and multiple organ dysfunction syndrome （MODS） （n=2）. Three cases developed post-operative massive cerebral infarction and the relatives of the patients abandoned treatment. Instant success rate of endovascular repair was 100%. The intimal rupture was sealed. Blood flow was unobstructed in true lumen and no false lumen was visualized. It was concluded that aggressive surgery should be considered in the patients with thoracic aneurysm and aortic dissection. Surgical procedures should vary with the location and the nature of the lesions.

Ischemic <i>Cauda equina</i>Syndrome Due to Spinal Embolization as a First Manifestation of an Infrarenal Abdominal Aortic Aneurysm

Spinal cord ischemia is an uncommon complication of an abdominal aortic aneurysm (AAA). We report the case of a 59-year-old man admitted for an acute ischemic Cauda equina syndrome secondary to a spinal cord embolization from an unknown partially thrombosed aortic aneurysm. The patient being at risk of further embolization, we achieved an emergency EVAR. The vascular post-operative course was uneventful. Neurologically, a post operative lumbar medullar MRI confirmed an ischemic Cauda equina syndrome and six months after the surgery, the patient still had a motor and sensory deficit in both lower limbs.

三维CTA和DSA图像融合技术对腹主动脉瘤腔内修复治疗术的效果评价

目的探讨三维CT血管造影(3D-CTA)和数字减影血管造影(DSA)图像融合技术在腹主动脉瘤腔内修复治疗术(EVAR)中的应用效果。方法选取102例行EVAR手术的患者,均行3D-CTA及DSA检查,并将3D-CTA检查图像与DSA数据进行图像融合,比较不同检查方法对各个征象以及术后并发症的检出率。结果3D-CTA与DSA图像融合技术对FL直径缩小、TL直径占比增加、支架近端FL血栓化、支架远端FL血栓化的检出率均高于3D-CTA及DSA检查(P<0.05)。三种检查方法对夹层破裂、内漏、支架近端逆行撕裂、新发夹层的检出率比较,差异无统计学意义(P>0.05)。结论3D-CTA和DSA图像融合技术在EVAR术后效果评估中具有重要意义,能够及时发现并发症,为临床干预提供可靠依据。