破裂型腹主動(dòng)脈瘤治療策略

1、破裂型腹主動(dòng)脈瘤治療策略,哈爾濱醫(yī)科大學(xué)附屬第二醫(yī)院血管外科 姜維良,Vascular Surgery 2nd Teaching Hosp. Harbin Medical University,Harbin, Heilongjiang, China,,Abdominal aortic aneurysm: A comprehensive REVIEWSourabh Aggarwal … Alka Sharma MD .

2、 (India) Exp Clin Cardiol Vol 16 No 1 2011.,AAA發(fā)生的危險(xiǎn)因素包括: 年齡超過60歲吸煙，高血壓和白色人種。破裂危險(xiǎn)因素為：動(dòng)脈瘤尺寸，增長速度，持續(xù)吸煙和持續(xù)性高血壓。,破裂型腹主動(dòng)脈瘤治療策略,破裂型腹主動(dòng)脈瘤治療策略,動(dòng)脈瘤的年破裂率與直徑的關(guān)系:Lessthan4.0cm–0%4.0cmto4.9cm–0.5%to5%5.0cmto5.9c

3、m–3%to15%6.0cmto6.9cm–10%to20%7.0cmto7.9cm–20%to40%8.0cmorgreater–30%to50%Brewster DC,et al.Guidelines for the treatment of abdominal aortic aneurysms. Report of a subcommittee of th

4、e Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery. J Vasc Surg 2003;37:1106-17,破裂型腹主動(dòng)脈瘤治療策略,AAA破裂嚴(yán)重威脅患者的生命rAAA治療每個(gè)環(huán)節(jié)都很重要，關(guān)系到搶救成功率。,破裂型腹主動(dòng)脈瘤治療策略,通過單因素和多因素回顧性分析137例rAAA的死亡危

5、險(xiǎn)因素：30天死亡率為37%。Open surgery in endovascular aneurysm repair era: simpli?edclassi?cation in two risk groups owing to factors affectingmortality in 137 ruptured abdominal aortic aneurysms (RAAAs)Stefano Bonardell

6、i et al. （ Unit and Chair of Vascular Surgery, Universita ` degli Studi,A.O. Spedali Civili Brescia, Brescia, Italy ）Updates Surg (2011) 63:39–44,破裂型腹主動(dòng)脈瘤治療策略,破裂性腹主動(dòng)脈瘤分類限制性非限制性,破裂型腹主動(dòng)脈瘤治療策略,治療階段1.術(shù)前準(zhǔn)備和急救2.治療方案制定和手術(shù)

7、實(shí)施3.術(shù)后治療,破裂型腹主動(dòng)脈瘤治療策略,1.術(shù)前急救和手術(shù)準(zhǔn)備 rAAA診斷： 典型+腹部搏動(dòng)性包塊 +腰背腹部疼痛 +低血容量性休克,破裂型腹主動(dòng)脈瘤治療策略,急救措施抗休克 深靜脈輸液通道 補(bǔ)充有效循環(huán)血量 保護(hù)重要臟器功能,破裂型腹主動(dòng)脈瘤治療策略,循環(huán)狀態(tài)控制1.控制最低有效灌注壓在60-70（平均動(dòng)脈壓

8、）2.中心靜脈壓控制在5-8cmH2O3.頸、橈動(dòng)脈 可觸及搏動(dòng),破裂型腹主動(dòng)脈瘤治療策略,心臟、腦、腎臟功能的保護(hù)依賴于良好的灌注壓。血壓的維持重視有效循環(huán)血量的補(bǔ)充而非血管活性藥物。,破裂型腹主動(dòng)脈瘤治療策略,影像學(xué)檢查1.如果有可能，CTA檢查是很有價(jià)值的。2.如活動(dòng)性出血存在，可進(jìn)行DSA檢查，同時(shí)可以球囊阻斷主動(dòng)脈控制出血。3.彩超多用于急診入院時(shí)的診斷性檢查。4.其他的影像學(xué)檢查必要性不大。,,,,破裂型腹主動(dòng)

9、脈瘤治療策略,手術(shù)時(shí)機(jī)的掌握限制性破裂病例—完成影像學(xué)檢查后盡快確定 治療方案后手術(shù)?；顒?dòng)性出血病例---快速補(bǔ)充有效循環(huán)血量，循 環(huán)稍穩(wěn)定后立即實(shí)施手術(shù)。,破裂型腹主動(dòng)脈瘤治療策略,治療方式選擇1.外科修復(fù)2.EVAR a.患者狀態(tài)和醫(yī)生的能力

10、 b.動(dòng)脈瘤解剖結(jié)構(gòu) c.患者意愿 d.器材狀態(tài),破裂型腹主動(dòng)脈瘤治療策略,外科開放手術(shù)中的處理1.盡快控制出血2.快速暴露瘤頸，完成瘤頸阻斷。3.術(shù)中注意心、肺、腦、腎臟功能保護(hù)4.腹膜后減壓,破裂型腹主動(dòng)脈瘤治療策略,臨時(shí)主動(dòng)脈阻斷方式：1.隔肌角-腹腔動(dòng)脈2.腎動(dòng)脈下3.腎動(dòng)脈上4.球囊阻斷 盡快暴露瘤頸，轉(zhuǎn)換成腎下

11、瘤頸阻斷。,破裂型腹主動(dòng)脈瘤治療策略,完成瘤頸阻斷后 ----判定循環(huán)狀態(tài) 快速補(bǔ)充有效循環(huán)血量 必要時(shí)IVC或動(dòng)脈輸血,破裂型腹主動(dòng)脈瘤治療策略,動(dòng)脈置換與常規(guī)方法相同,破裂型腹主動(dòng)脈瘤治療策略,EVAR修復(fù)原則1.具有AAA EVAR 能力和手術(shù)條件2.合適的器材3.解剖結(jié)構(gòu)適宜4.患者的狀態(tài)和意愿,破裂型腹主

12、動(dòng)脈瘤治療策略,EVAR方式1.雙臂型2.AUI,,,腹主動(dòng)脈瘤,術(shù)中測量,,,腹主動(dòng)脈瘤,EVAR－－AUI,,,AAA EVAR--AUI,腹主動(dòng)脈瘤,假性動(dòng)脈瘤,25,,破裂型腹主動(dòng)脈瘤治療策略,EVAR優(yōu)點(diǎn)： 創(chuàng)傷小 球囊阻斷控制出血速度快缺點(diǎn)： 器材限制 技術(shù)限制 腹膜后高壓綜合征,破裂型腹主動(dòng)脈瘤治療策略,手術(shù)后治療要點(diǎn)1.維持循環(huán)穩(wěn)定2.盡快恢復(fù)腎臟功能3.呼吸功能支持4.營養(yǎng)支持5.

13、適當(dāng)抗感染治療6.注意凝血功能調(diào)整7.促進(jìn)消化道功能恢復(fù),影響rAAA預(yù)后的因素,破裂型腹主動(dòng)脈瘤治療策略,單因素分析確定入院時(shí)血色素Hb B ≤ 8 g/dl 以及休克為死亡危險(xiǎn)因素，而多因素分析顯示，只有休克具有顯著性意義?；謴?fù)血容量比提高血色素指標(biāo)相比，更能夠增加成功的可能性。Open surgery in endovascular aneurysm repair era: simpli?ed classi?catio

14、n in two risk groups owing to factors affecting mortality in 137 ruptured abdominal aortic aneurysms (RAAAs)Stefano Bonardelli et al. （ Unit and Chair of Vascular Surgery, Universita ` degli Studi,A.O. Spedali Civili

15、Brescia, Brescia, Italy ）Updates Surg (2011) 63:39–44,破裂型腹主動(dòng)脈瘤治療策略,回顧性分析109 patients with RAAA during a 5 year period (2001-2005)的 30-day 死亡率, CPR比率以及Hardman 危險(xiǎn)因素。Outcome of patients with ruptured abdominal aortic an

16、eurysm after cardiopulmonary resuscitation. Greeven AP, …, Hamming JF. Department of Surgery, Leiden University Medical Center, 2300 RC Leiden, The Netherlands. Acta Chir Belg. 2011 Mar-Apr;111(2):78-82.,破裂型腹主動(dòng)脈瘤治療策略,3

17、0-day 總死亡率40%. 接受CPR（心臟復(fù)蘇）的病人死亡率明顯升高 (89% vs. 30%, p <0.0001). 外科手術(shù)前接受CPR的病人死亡率100% (n = 12). CONCLUSION: CPR 對rAAA病人有不利影響。此類病人于術(shù)前接受CPR存活機(jī)會(huì)渺茫。 Outcome of patients with ruptured abdominal aortic aneurysm after car

18、diopulmonary resuscitation. Greeven AP, …, Hamming JF. Department of Surgery, Leiden University Medical Center, 2300 RC Leiden, The Netherlands. Acta Chir Belg. 2011 Mar-Apr;111(2):78-82.,破裂型腹主動(dòng)脈瘤治療策略,56例RAAA, between Ja

19、nuary 2006 and April 2008 , 急診EVAR 與open repair對比.J Cardiovasc Surg (Torino). 2011 Jun;52(3):363-9.Ruptured abdominal aortic aneurysm: endovascular or open approach in a Dutch general hospital. Van Schaik DE, Dolman

20、s DE, Ho G, Geenen GP, Vos L, Van Der Waal JC, De Groot HG, Van Der Laan Department of Surgery, Amphia Hospital, Breda, The Netherlands -,破裂型腹主動(dòng)脈瘤治療策略,RESULTS: 15例急診EVAR (26.8%). Vs 41例open（72.2%）30天死亡率：eEVAR-group 2

21、6%, open repair-group 46%. 平均ICU時(shí)間分別為：3.9 days and 4.8 days 平均住院時(shí)間分別為13 days and 10.5 days. 平均失血量分別為210cc and 2760cc.（P＜0.05）. 總并發(fā)癥發(fā)生率兩組無明顯差別。,破裂型腹主動(dòng)脈瘤治療策略,CONCLUSION: RAAA with an eEVAR procedure 死亡率明顯低于開放式手術(shù)。對于rAA

22、A可行的情況下推薦進(jìn)行急診腔內(nèi)治療. J Cardiovasc Surg (Torino). 2011 Jun;52(3):363-9.Ruptured abdominal aortic aneurysm: endovascular or open approach in a Dutch general hospital. Van Schaik DE, Dolmans DE, Ho G, Geenen GP, Vos L, Van

23、 Der Waal JC, De Groot HG, Van Der Laan Department of Surgery, Amphia Hospital, Breda, The Netherlands -,破裂型腹主動(dòng)脈瘤治療策略,1990 -2008年 160例 rAAA patients. 32 (20%) EVAR for rAAA; 112 例非限制性破裂free rupture (70%) ;48 例為限制性破裂 (30

24、%). 生存率：30 days, 1 year, and 5 years 分別為69% (62,77), 57% (50,65), 50% (43,59), and 25% (19,34),, EVAR group 和open surgery無明顯差別 (p = 0.24).Ann Vasc Surg. 2011 May;25(4):461-8.Comparative predictors of mortality for end

25、ovascular and open repair of ruptured infrarenal abdominal aortic aneurysms.Sarac TP, Bannazadeh M, Rowan AF, Bena J, Srivastava S, Eagleton M, Lyden S, Clair DG, Kashyap V.Department of Vascular Surgery, Cleveland Clin

26、ic Lerner School of Medicine, Cleveland Clinic,,破裂型腹主動(dòng)脈瘤治療策略,術(shù)中死亡率5.6%, EVAR 組無術(shù)中死亡病例(p = 0.03). 30-day 死亡率EVAR 31.9% vs open surgery (31.2% vs. 32%; p = 0.93) 無明顯差別. Ann Vasc Surg. 2011 May;25(4):461-8.Comparative

27、 predictors of mortality for endovascular and open repair of ruptured infrarenal abdominal aortic aneurysms.Sarac TP, Bannazadeh M, Rowan AF, Bena J, Srivastava S, Eagleton M, Lyden S, Clair DG, Kashyap V.Department of

28、 Vascular Surgery, Cleveland Clinic Lerner School of Medicine, Cleveland Clinic,,破裂型腹主動(dòng)脈瘤治療策略,多因素分析30-day 死亡率與腎功能衰竭 (RI) odds ratio (OR): 2.4 (1.1, 5.3), p = 0.04; 低血壓有關(guān)OR: 2.4 (1.1, 5.3), p = 0.02; 心跳驟停and cardiac ar

29、rest OR: 3.8 (1.1, 11.6, p = 0.03), 其中對長期生存率有影響的僅有RI OR: 2.32 (1.55, 3.47), p < 0.001Ann Vasc Surg. 2011 May;25(4):461-8.Comparative predictors of mortality for endovascular and open repair of ruptured infrarenal a

30、bdominal aortic aneurysms.Sarac TP, Bannazadeh M, Rowan AF, Bena J, Srivastava S, Eagleton M, Lyden S, Clair DG, Kashyap V.Department of Vascular Surgery, Cleveland Clinic Lerner School of Medicine, Cleveland Clinic,,破

31、裂型腹主動(dòng)脈瘤治療策略,CONCLUSIONS: rAAA 死亡率較高. EVAR 在30-day 和遠(yuǎn)期死亡率方面等同于開放式手術(shù)。對兩種方法而言，術(shù)前心跳驟停和腎功能衰竭均影響療效。Ann Vasc Surg. 2011 May;25(4):461-8.Comparative predictors of mortality for endovascular and open repair of ruptured infra

32、renal abdominal aortic aneurysms.Sarac TP, Bannazadeh M, Rowan AF, Bena J, Srivastava S, Eagleton M, Lyden S, Clair DG, Kashyap V.Department of Vascular Surgery, Cleveland Clinic Lerner School of Medicine, Cleveland Cl

33、inic,,破裂型腹主動(dòng)脈瘤治療策略,破裂性胸腹主動(dòng)脈瘤--雜交手術(shù)是可行的治療選擇,雜交腔內(nèi)修復(fù)術(shù)Hybrid procedure case 1,TAAARUPTUREAge79Maleshock,胸腹動(dòng)脈口徑Diameter of Thoracic and Abdominal Aorta,,Case 5,人造血管吻合方式Manner of Artificial Bypass,,Case 5,右腎動(dòng)脈-腸系膜上動(dòng)脈吻合

34、Right Renal A.-SMA Anastomosis,,Case 5,左腎動(dòng)脈吻合Left Renal A. Anastomosis,,Case 5,腹腔動(dòng)脈干吻合Bypassing the Celiac A.,,Case 5,,術(shù)后CTA復(fù)查,破裂型腹主動(dòng)脈瘤治療策略,總結(jié)1.術(shù)前急救有效補(bǔ)充循環(huán)血量最重要2.手術(shù)方案盡快確定與實(shí)施3.open surgery與EVAR個(gè)體化選擇4.術(shù)后治療非常重要,Thanks