破裂型腹主动脉瘤治疗策略.ppt

破裂型腹主动脉瘤治疗策略,哈尔滨医科大学附属第二医院血管外科 姜维良,Vascular Surgery 2nd Teaching Hosp.Harbin Medical University,Harbin,Heilongjiang,China,Abdominal aortic aneurysm:A comprehensive REVIEWSourabh Aggarwal Alka Sharma MD.(India)Exp Clin Cardiol Vol 16 No 1 2011.,AAA发生的危险因素包括:年龄超过60岁吸烟，高血压和白色人种。破裂危险因素为：动脉瘤尺寸，增长速度，持续吸烟和持续性高血压。,破裂型腹主动脉瘤治疗策略,破裂型腹主动脉瘤治疗策略,动脉瘤的年破裂率与直径的关系:Lessthan4.0cm0%4.0cmto4.9cm0.5%to5%5.0cmto5.9cm3%to15%6.0cmto6.9cm10%to20%7.0cmto7.9cm20%to40%8.0cmorgreater30%to50%Brewster DC,et al.Guidelines for the treatment of abdominal aortic aneurysms.Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery.J Vasc Surg 2003;37:1106-17,破裂型腹主动脉瘤治疗策略,AAA破裂严重威胁患者的生命rAAA治疗每个环节都很重要，关系到抢救成功率。,破裂型腹主动脉瘤治疗策略,通过单因素和多因素回顾性分析137例rAAA的死亡危险因素：30天死亡率为37%。Open surgery in endovascular aneurysm repair era:simpliedclassication in two risk groups owing to factors affectingmortality in 137 ruptured abdominal aortic aneurysms(RAAAs)Stefano Bonardelli et al.（Unit and Chair of Vascular Surgery,Universita degli Studi,A.O.Spedali Civili Brescia,Brescia,Italy）Updates Surg(2011)63:3944,破裂型腹主动脉瘤治疗策略,破裂性腹主动脉瘤分类限制性非限制性,破裂型腹主动脉瘤治疗策略,治疗阶段1.术前准备和急救2.治疗方案制定和手术实施3.术后治疗,破裂型腹主动脉瘤治疗策略,1.术前急救和手术准备 rAAA诊断：典型+腹部搏动性包块+腰背腹部疼痛+低血容量性休克,破裂型腹主动脉瘤治疗策略,急救措施抗休克 深静脉输液通道 补充有效循环血量 保护重要脏器功能,破裂型腹主动脉瘤治疗策略,循环状态控制1.控制最低有效灌注压在60-70（平均动脉压）2.中心静脉压控制在5-8cmH2O3.颈、桡动脉 可触及搏动,破裂型腹主动脉瘤治疗策略,心脏、脑、肾脏功能的保护依赖于良好的灌注压。血压的维持重视有效循环血量的补充而非血管活性药物。,破裂型腹主动脉瘤治疗策略,影像学检查1.如果有可能，CTA检查是很有价值的。2.如活动性出血存在，可进行DSA检查，同时可以球囊阻断主动脉控制出血。3.彩超多用于急诊入院时的诊断性检查。4.其他的影像学检查必要性不大。,破裂型腹主动脉瘤治疗策略,手术时机的掌握限制性破裂病例完成影像学检查后尽快确定 治疗方案后手术。活动性出血病例-快速补充有效循环血量，循 环稍稳定后立即实施手术。,破裂型腹主动脉瘤治疗策略,治疗方式选择1.外科修复2.EVAR a.患者状态和医生的能力 b.动脉瘤解剖结构 c.患者意愿 d.器材状态,破裂型腹主动脉瘤治疗策略,外科开放手术中的处理1.尽快控制出血2.快速暴露瘤颈，完成瘤颈阻断。3.术中注意心、肺、脑、肾脏功能保护4.腹膜后减压,破裂型腹主动脉瘤治疗策略,临时主动脉阻断方式：1.隔肌角-腹腔动脉2.肾动脉下3.肾动脉上4.球囊阻断 尽快暴露瘤颈，转换成肾下瘤颈阻断。,破裂型腹主动脉瘤治疗策略,完成瘤颈阻断后-判定循环状态 快速补充有效循环血量 必要时IVC或动脉输血,破裂型腹主动脉瘤治疗策略,动脉置换与常规方法相同,破裂型腹主动脉瘤治疗策略,EVAR修复原则1.具有AAA EVAR 能力和手术条件2.合适的器材3.解剖结构适宜4.患者的状态和意愿,破裂型腹主动脉瘤治疗策略,EVAR方式1.双臂型2.AUI,腹主动脉瘤,术中测量,腹主动脉瘤,EVARAUI,AAA EVAR-AUI,腹主动脉瘤,假性动脉瘤,25,破裂型腹主动脉瘤治疗策略,EVAR优点：创伤小 球囊阻断控制出血速度快缺点：器材限制 技术限制 腹膜后高压综合征,破裂型腹主动脉瘤治疗策略,手术后治疗要点1.维持循环稳定2.尽快恢复肾脏功能3.呼吸功能支持4.营养支持5.适当抗感染治疗6.注意凝血功能调整7.促进消化道功能恢复,影响rAAA预后的因素,破裂型腹主动脉瘤治疗策略,单因素分析确定入院时血色素Hb B 8 g/dl 以及休克为死亡危险因素，而多因素分析显示，只有休克具有显著性意义。恢复血容量比提高血色素指标相比，更能够增加成功的可能性。Open surgery in endovascular aneurysm repair era:simplied classication 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 Brescia,Brescia,Italy）Updates Surg(2011)63:3944,破裂型腹主动脉瘤治疗策略,回顾性分析109 patients with RAAA during a 5 year period(2001-2005)的 30-day 死亡率,CPR比率以及Hardman 危险因素。Outcome of patients with ruptured abdominal aortic aneurysm 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.,破裂型腹主动脉瘤治疗策略,30-day 总死亡率40%.接受CPR（心脏复苏）的病人死亡率明显升高(89%vs.30%,p 0.0001).外科手术前接受CPR的病人死亡率100%(n=12).CONCLUSION:CPR 对rAAA病人有不利影响。此类病人于术前接受CPR存活机会渺茫。Outcome of patients with ruptured abdominal aortic aneurysm 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.,破裂型腹主动脉瘤治疗策略,56例RAAA,between January 2006 and April 2008,急诊EVAR 与open repair对比.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,Dolmans 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-,破裂型腹主动脉瘤治疗策略,RESULTS:15例急诊EVAR(26.8%).Vs 41例open（72.2%）30天死亡率：eEVAR-group 26%,open repair-group 46%.平均ICU时间分别为：3.9 days and 4.8 days 平均住院时间分别为13 days and 10.5 days.平均失血量分别为210cc and 2760cc.（P0.05）.总并发症发生率两组无明显差别。,破裂型腹主动脉瘤治疗策略,CONCLUSION:RAAA with an eEVAR procedure 死亡率明显低于开放式手术。对于rAAA可行的情况下推荐进行急诊腔内治疗.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 Der Waal JC,De Groot HG,Van Der Laan Department of Surgery,Amphia Hospital,Breda,The Netherlands-,破裂型腹主动脉瘤治疗策略,1990-2008年 160例 rAAA patients.32(20%)EVAR for rAAA;112 例非限制性破裂free rupture(70%);48 例为限制性破裂(30%).生存率：30 days,1 year,and 5 years 分别为69%(62,77),57%(50,65),50%(43,59),and 25%(19,34),EVAR group 和open surgery无明显差别(p=0.24).Ann Vasc Surg.2011 May;25(4):461-8.Comparative 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 Vascular Surgery,Cleveland Clinic Lerner School of Medicine,Cleveland Clinic,破裂型腹主动脉瘤治疗策略,术中死亡率5.6%,EVAR 组无术中死亡病例(p=0.03).30-day 死亡率EVAR 31.9%vs open surgery(31.2%vs.32%;p=0.93)无明显差别.Ann Vasc Surg.2011 May;25(4):461-8.Comparative 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 Vascular Surgery,Cleveland Clinic Lerner School of Medicine,Cleveland Clinic,破裂型腹主动脉瘤治疗策略,多因素分析30-day 死亡率与肾功能衰竭(RI)odds ratio(OR):2.4(1.1,5.3),p=0.04;低血压有关OR:2.4(1.1,5.3),p=0.02;心跳骤停and cardiac arrest OR:3.8(1.1,11.6,p=0.03),其中对长期生存率有影响的仅有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 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 Clinic,破裂型腹主动脉瘤治疗策略,CONCLUSIONS:rAAA 死亡率较高.EVAR 在30-day 和远期死亡率方面等同于开放式手术。对两种方法而言，术前心跳骤停和肾功能衰竭均影响疗效。Ann Vasc Surg.2011 May;25(4):461-8.Comparative 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 Vascular Surgery,Cleveland Clinic Lerner School of Medicine,Cleveland Clinic,破裂型腹主动脉瘤治疗策略,破裂性胸腹主动脉瘤-杂交手术是可行的治疗选择,杂交腔内修复术Hybrid procedure case 1,TAAARUPTUREAge79Maleshock,胸腹动脉口径Diameter of Thoracic and Abdominal Aorta,Case 5,人造血管吻合方式Manner of Artificial Bypass,Case 5,右肾动脉-肠系膜上动脉吻合Right Renal A.-SMA Anastomosis,Case 5,左肾动脉吻合Left Renal A.Anastomosis,Case 5,腹腔动脉干吻合Bypassing the Celiac A.,Case 5,术后CTA复查,破裂型腹主动脉瘤治疗策略,总结1.术前急救有效补充循环血量最重要2.手术方案尽快确定与实施3.open surgery与EVAR个体化选择4.术后治疗非常重要,Thanks for your attention！,Vascular Surgery 2nd Teaching Hosp.of Harbin Medical University,Harbin,Heilongjiang,China哈尔滨医科大学附属第二医院 血管外科,