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腹主动脉瘤是一种常见的病因不明的主动脉疾病，发病隐匿，具有较高的致残率和死亡率，近年来发病率呈明显上升趋势。年龄增高是腹主动脉瘤最主要的危险因素，65岁以上男性中发病率高达8%。 2021年10月28日，《新英格兰医学杂志》（NEJM）在临床实践栏目发表《腹主动脉瘤的治疗》（Schanzer A, Oderich GS. N Engl J Med 2021;385:1690-8），全面探讨了腹主动脉瘤手术治疗的时机、治疗与监测以及指导治疗策略选择的证据。我们在此简介其主要内容。 腹主动脉瘤的定义为主动脉直径＞3 cm。腹主动脉瘤的易感因素包括高龄、家族史、既往或当前吸烟、高胆固醇血症和高血压；糖尿病与患病风险降低相关。腹主动脉瘤造成的主要危险是动脉瘤破裂和患者出血死亡风险。因此，治疗目标是在动脉瘤破裂前将其修复。虽然有几方面因素会影响修复术的时机和类型，但动脉瘤破裂的最重要预测因素是动脉瘤直径，动脉瘤越大，破裂风险越大。在对不适合手术治疗的腹主动脉瘤患者进行的前瞻性观察性研究中，动脉瘤直径5.0～5.9 cm的男性患者的破裂风险为每年1%，动脉瘤直径≥6 cm的男性患者的破裂风险为每年14.1%；女性患者的相应分析分别为3.9%和22.3%。  策略和证据  修复术时机 随机试验表明，对于直径＜5.5cm的腹主动脉瘤，手术与密切监测相比并无生存优势，这支持以下观点：这一直径是修复术的适当阈值，对直径＜5.5 cm的动脉瘤进行监测是安全的并且符合成本效益。虽然在这些试验中，监测组的干预阈值也包括动脉瘤快速生长（定义为生长速度＞每年1 cm），但目前并无严格数据支持根据快速生长行修复术。考虑到女性的主动脉本身较小，并且女性的小腹主动脉瘤破裂率较高，因此大多数专家和指南建议对女性患者采用较小的修复术阈值（直径5.0 cm）。 监测和治疗 对于直径3.0～3.9 cm的小腹主动脉瘤患者，应通过每3年一次的双功能超声检查进行影像学监测随访；对于直径4.0～4.9 cm的动脉瘤患者，应每年进行一次随访；对于直径≥5.0 cm的动脉瘤患者，应每6个月进行一次随访。建议患者戒烟，以降低动脉瘤生长和破裂风险。他汀类药物、β受体阻滞剂和其他降压药可能降低心血管风险，但这些药物并未被证明可减缓动脉瘤生长，因此不应为了这一目的开出上述药物。 对于动脉瘤达到一定直径，需要行修复术的患者，治疗方式包括开放式修复术或主动脉瘤腔内修复术（EVAR）。开放式修复术需要做经腹中线切口或腹膜后切口，暴露出主动脉和髂动脉，并将这些动脉钳闭。采用开放式修复术时，动脉瘤节段被直管型或分叉型假体取代。采用EVAR时，动脉瘤保持原样，通过导管置入支架，使血流改变路径，避开瘤腔，因此无需暂时钳闭主动脉（图1）。
图1. 肾动脉下腹主动脉瘤的腔内修复术 多数情况下，将一个分叉型模块化支架锚定在肾动脉下方一段正常主动脉中，并延伸入两侧一段正常髂总动脉内。行EVAR要求患者的解剖结构适合，包括足够的密封区，以便支架与动脉壁对接密封。其他要求包括股动脉和髂动脉直径足够，以及无血管转角过度或动脉粥样硬化碎片严重等情况。 1991年发明EVAR以来，许多医疗机构已广泛采用EVAR，将其作为解剖结构适合的患者的首选治疗方案，而开放式修复术仅用于解剖结构不适合EVAR的患者。 指导治疗策略选择的证据 迄今比较择期开放式修复术结局与EVAR结局的三项最大规模随机、对照试验获得了一致结果。三项试验均表明，EVAR的30日发病率和死亡率均显著低于开放式修复术（0.5%～1.7% vs. 3.0%～4.7%）。接受EVAR治疗的患者恢复速度较快。然而，EVAR的短期生存优势在随访期间减小；在生存超过2～3年的患者中，两种手术方式的生存率相似，并且8～10年随访期间的生存率仍相似。EVAR后的再次干预率高于开放式修复术后，但随访期间的再次干预大多通过导管技术实施。总体而言，EVAR费用高于开放式手术费用。 美国的临床经验数据支持这些试验的结果。一项倾向评分匹配分析纳入了在2001~2004年接受腹主动脉瘤修复术的超过44,000名Medicare受益人，结果表明EVAR和开放式修复术后的30日死亡率分别为1.2%和4.8%（P＜0.001）。5年随访时，两组的全因死亡率相似，生存曲线在3年时交汇。在接受EVAR治疗的患者中，与修复术相关的再次干预率较高（9.0% vs. 1.7%；P＜0.001）。然而，在接受开放式修复术的患者中，因伤口相关或开腹术相关并发症（如切口疝或肠梗阻）接受手术的可能性较大（9.7% vs. 4.1%；P＜0.001）。 选择修复策略时应遵循共同决策原则，且应考虑以下因素：患者的解剖结构是否适合，手术风险，以及患者是否愿意终身每年接受影像学随访。多项指南建议患者在EVAR后终身接受影像学随访，目的是发现和纠正与主动脉装置或其他装置相关的并发症，如瘤腔内持续血流（如内漏）或残留的主动脉瘤腔扩大。 术后影像学监测的目的是发现严重并发症，避免患者因动脉瘤破裂而死亡。影像学检查通常包括EVAR后最初几个月的计算机断层扫描（CT）血管造影，以及之后每年的双功能超声检查。对于某些患者，超声检查在技术上可能不可行（如体型较大患者），这种情况可能需要CT血管造影或磁共振血管造影。 根据记录，有5.4%的患者在EVAR后发生腹主动脉瘤破裂。据报道，患者在早期、中期和长期随访时均对再次干预有需求，目的是使动脉瘤始终保持在血液循环之外，以及防止迟发性动脉瘤破裂，对再次干预的需求并未随着时间推移趋于平稳。因此，患者需要终身接受随访。开放式修复术的情况则不同，由于修复效果更为持久，并且对再次干预的需求较少，因此终身随访并不是很重要。患者接受开放式修复术后，大多数血管外科医师会随访至患者完全恢复术前基线状态。此后，患者通常只在出现新问题时才就诊，因为开放式修复术后破裂的情况极为罕见。 不确定领域 目前尚不明确为何各项试验均表明，EVAR相对于开放式修复术的早期生存优势在2～3年之后未能维持。可能的原因包括基础心血管风险，对后续治疗建议的依从性差；与保持原样的动脉瘤相关的高炎症状态持续存在，进而导致心血管事件；影像学检查显示在无内漏的情况下，持续存在瘤腔压力增加；以及装置失功。 虽然支架疲劳是一部分装置失功的原因，但另有许多装置失功的原因是支架置入不当，即支架被置入了不符合支架放置要求，解剖结构不适合置入支架的患者体内。据报道，在接受EVAR的患者中，有18%～63%的解剖结构不理想，且与较差结局明确相关。如果该技术广泛应用于解剖结构不理想患者的情况继续增多，短期益处将被以下几方面抵消：治疗失败率提高，费用高昂的再次干预和随访期间动脉瘤随时破裂的可能性。 新的腔内修复技术正不断发展，以扩大EVAR的适用范围，使其也可以应用于解剖结构不适合当前市售装置（置于肾动脉以下）的患者。这些技术需要通过特殊设计的，带有纤维开口（强化开窗）或侧臂（定向分支）的支架与主动脉侧支（如肾动脉和肠系膜动脉）相连。置入主动脉支架后，在开窗或分支与每条目标血管之间放置桥接支架。开窗型和分支型支架主动脉腔内修复术（从主动脉弓到内脏节段，再到髂动脉）已被世界各地的复杂动脉瘤大型专科治疗中心采用。一般而言，对于主动脉瘤（如近肾腹主动脉瘤）主要位于腹部的患者，首选强化开窗型支架（图2A），而对于动脉瘤延伸至胸腔的患者，首选分支型支架（图2B）。
图2. 复杂胸腹主动脉瘤的腔内修复术 图中显示了复杂胸腹主动脉瘤的开窗（图A）和分支（图B）腔内修复术 这些复杂主动脉瘤的开放式修复术在技术上难度更大，需要在术中暴露更大范围，而且主动脉钳闭造成的终末器官缺血时间也更长。因此，相关发病率和死亡率显著高于肾下腹主动脉瘤修复术。据我们所知，目前尚无在复杂主动脉瘤患者中比较开放式修复术和FB-EVAR的随机试验。单中心和多中心前瞻性观察性研究表明，在接受FB-EVAR治疗的患者中，并发症发生率和死亡率均低于开放式修复术历史队列的数据。例如，根据美国主动脉研究联盟（U.S. Aortic Research Consortium）的一项研究，在因近肾腹主动脉瘤或胸腹主动脉瘤接受FB-EVAR治疗的893例患者中，30日死亡率为1.1%，而在手术量大的医疗中心开展，评估胸腹动脉瘤开放式修复术的多项大规模、单中心研究中，30日死亡率为7%～16%。 指南 美国血管外科学会（Societyfor Vascular Surgery，SVS）和欧洲血管外科学会（EuropeanSociety for Vascular Surgery，ESVS）已发布腹主动脉瘤治疗指南。两份指南均为直径≥5.5 cm梭状动脉瘤的择期修复术提出了2级（弱）建议，证据质量为B级（中，SVS）或C级（低，ESVS）。鉴于女性的主动脉本身较小，上述学会为女性直径≥5.0 cm梭状动脉瘤的择期修复术提出了2级（弱）建议，证据质量为B级（中，SVS）或C级（低，ESVS）。虽然指南未就EVAR相对于开放式修复术的优势提出建议，但ESVS指南建议，对于大多数解剖结构适合并且达到一定预期寿命（如＞2年）的患者，在EVAR和开放式修复术之间首选EVAR。两项指南均指出，目前并无经证实可减缓动脉瘤扩大速度的药物疗法。 由于目前并无随机试验数据说明对患者一级亲属进行腹主动脉瘤筛查的结局和成本效益，因此SVS和ESVS指南均建议考虑对一级亲属进行一次超声筛查（证据质量，C级[低]；建议，2级[弱]），但两个学会建议的筛查年龄不同（分别为65岁和50岁）。与SVS指南一致。美国预防服务工作组（U.S.Preventive Services Task Force）为男性提出的最新筛查建议与上述指南一致，但由于缺乏充分数据，该工作组不建议对一级亲属患腹主动脉瘤的女性进行筛查。 附：ESVS2019腹部主髂动脉瘤指南自译版Centres performing aortic surgery are recommended to enter cases in a validated prospective registry to allow for monitoring of changes in practice and outcomes. 建议进行主动脉手术的中心在已批准的前瞻性注册研究中纳入病例，可以监测治疗实践和转归的变化。 It is recommended that centres or networks of collaborating centres treating patients with abdominal aortic aneurysms can offer both endovascular and open aortic surgery at all times. 建议治疗腹主动脉瘤患者的单中心或多中心合作网可以随时进行腔内和开放主动脉手术。 Abdominal aortic aneurysm repair should only be considered in centres with a minimum yearly caseload of 30 repairs. 腹主动脉瘤修复术应该考虑在每年不少于30例的中心中进行。 Abdominal aortic aneurysm repair should not be performed in centres with a yearly caseload <20. 腹主动脉修复术不应该考虑在每年少于20例的中心进行。 Once the intervention threshold has been reached, the waiting time for vascular surgical care is recommended to be kept to a minimum, with an eight week pathway as a reasonable upper limit from referral to elective treatment of abdominal aortic aneurysms. 一旦达到干预指证，等待手术时间推荐控制在最短，从转诊到腹主动脉瘤择期手术的合理时间上限是8周。 An established protocol for the management of aortic aneurysm emergencies is recommended. 推荐制定主动脉瘤急诊管理流程。 Ultrasonography is recommended for the first line diagnosis and surveillance of small abdominal aortic aneurysms. 超声推荐作为小腹主动脉瘤的一线诊断随访工具。 The anteroposterior measuring plane with a consistent calliper placement should be considered the preferred method for ultrasound abdominal aortic diameter measurement. 有参考标尺的前后位测量平面应该被作为超声下腹主动脉直径测量的最优方法。 In patients with abdominal aortic aneurysms computed tomography angiography is recommended for therapeutic decision making and treatment planning, and for the diagnosis of rupture. 腹主动脉瘤患者推荐用CTA制定治疗决策、治疗方案和判断破裂。 Aortic diameter measurement with computed tomography angiography should be considered using dedicated post- processing software analysis in three perpendicular planes with a consistent calliper placement. CTA主动脉直径测量应该考虑使用带参考标尺的3个相互垂直的层面进行后处理软件分析。 It is recommended that patients with incidentally detected abdominal aortic aneurysm are referred to a vascular surgeon for evaluation, except for cases with very limited life expectancy. 除了预期寿命非常有限的病例外，推荐将偶然发现的腹主动脉瘤患者转给血管外科医生进行评估。 Population screening for abdominal aortic aneurysm with a single ultrasound scan for all men at age 65 years is recommended. 所有大于65岁的男性推荐单独以超声筛查腹主动脉瘤。 Men with an aorta 2.5-2.9 cm in diameter at initial screening may be considered for rescreening after 5-10 years. 主动脉直径在2.5-2.9cm的患者可以考虑在5-10年后再次复查。 Population screening for abdominal aortic aneurysm in women is not recommended. 女性不推荐进行腹主动脉瘤筛查。 All men and women aged 50 years and older with a first degree relative with an abdominal aortic aneurysm may be considered for abdominal aortic aneurysm screening at 10 year intervals. 所有年龄在50岁及以上，与腹主动脉瘤患者有一级亲属关系的男性和女性，可以考虑每10年进行一次腹主动脉瘤筛查。 Screening for abdominal aortic aneurysm at 5-10 year intervals may be considered for all men and women with a true peripheral arterial aneurysm. 所有真性外周动脉瘤患者可以考虑每5-10年进行一次腹主动脉瘤筛查。 Ultrasonography is recommended for aneurysm surveillance; every three years for aneurysms 3-3.9 cm in diameter, annually for aneurysms 4.0-4.9 cm, and every 3-6 month for aneurysms≥5.0 cm. 推荐用超声检查进行动脉瘤监测：动脉瘤直径3-3.9厘米的每3年检查1次；直径4.0-4.9厘米的每1年检查1次；直径≥5.0厘米的每3-6个月检查1次。 Patients with a small abdominal aortic aneurysm are recommended to stop smoking (to reduce the abdominal aortic aneurysm growth rate and risk of rupture) and to receive help to do this. 对于小直径的腹主动脉瘤患者，推荐戒烟（以减缓腹主动脉瘤的增大速度和破裂风险），并接受相应帮助。 No specific medical therapy has been proven to slow the expansion rate of an abdominal aortic aneurysm, and therefore is not recommended. 没有特定的药物治疗被证明可以减缓腹主动脉瘤的增大速度，因此无用药推荐。 Strategies targeted at a healthy lifestyle, including exercise and a healthy diet, should be considered in all patients with abdominal aortic aneurysm. 所有腹主动脉瘤患者都应该考虑制定健康生活方式的计划，包括运动和健康饮食。 Blood pressure control, statins and antiplatelet therapy should be considered in all patients with abdominal aortic aneurysm. 所有腹主动脉瘤患者都应该考虑控制血压，使用他汀类药物和抗血小板药物。 In men, the threshold for considering elective abdominal aortic aneurysm repair is recommended to be ≥5.5 cm diameter. 男性择期腹主动脉瘤修复的干预指证，推荐为直径≥5.5cm。 In women with acceptable surgical risk the threshold for considering elective abdominal aortic aneurysm repair may be considered to be ≥5.0 cm diameter. 手术风险可接受的女性择期腹主动脉瘤修复的干预指证，推荐为直径≥5.0cm。 When rapid abdominal aortic aneurysm growth is observed (≥1 cm/year), fast track referral to a vascular surgeon with additional imaging should be considered. 如果发现腹主动脉瘤迅速增长（≥1cm/年），应该考虑快速转诊给血管外科医生并进行后续的影像检查。 Emergency referral to a vascular surgeon of patients with symptomatic abdominal aortic aneurysm is recommended. 有症状的腹主动脉瘤患者，推荐紧急转诊给血管外科医生。 Patients who initially are not candidates for abdominal aortic aneurysm repair should be considered for continued surveillance, referral to other specialists for optimisation of their fitness status and then reassessed. 对于不适合腹主动脉瘤修复的初诊患者，应该考虑继续随访，转诊给其他专科医生以改善其健康状况，然后重新评估。 Routine referral for cardiac work up, coronary angiography and cardiopulmonary exercise testing is not recommended prior to abdominal aortic aneurysm repair. 不推荐在腹主动脉修复术之前进行心脏检查、冠脉造影、心肺运动试验。 In patients with poor functional capacity (defined as ≤4 metabolic equivalents) or with significant clinical risk factors (such as unstable angina, decompensated heart failure, severe valvular disease, and significant arrhythmia), referral for cardiac work up and optimisation is recommended prior to elective abdominal aortic aneurysm repair. 对于心功能差（代谢当量，MET≤4）或有明显临床风险因素（如不稳定性心绞痛、失代偿期心衰、严重瓣膜病变、明显心律不齐）的患者，在腹主动脉修复术之前，推荐转诊做心功能检查和改善治疗。 In patients with stable coronary artery disease, routine coronary revascularisation before elective abdominal aortic aneurysm repair is not recommended. 对于稳定的冠脉疾病患者，不推荐在择期腹主动脉修复术之前进行常规的冠脉复流。 In patients with unstable coronary artery disease or considered to be at high risk of cardiac events following abdominal aortic aneurysm repair, prophylactic preoperative coronary revascularisation should be considered. 对于不稳定的冠脉疾病患者或者术后有高危冠脉事件风险的患者，应该考虑在腹主动脉修复术前进行预防性的冠脉复流手术。 In patients with moderate to severe heart failure, pharmacological optimisation of heart failure under expert guidance should be considered before elective abdominal aortic aneurysm repair. 对于中重度心功能衰竭的患者，在择期腹主动脉瘤修复术之前，应该考虑在专科医生指导下调整心衰药物。 In patients with severe aortic valve stenosis, evaluation for aortic valve replacement prior to elective abdominal aortic aneurysm repair is recommended. 对于严重心脏瓣膜狭窄的患者，推荐在择期腹主动脉修复术之前优先进行主动脉瓣膜置换的评估。 In patients on dual antiplatelet therapy after interventional coronary revascularisation, delaying abdominal aortic aneurysm repair until reduction to monotherapy, may be considered. Alternatively, if AAA repair becomes necessary, EVAR may be considered under dual antiplatelet therapy. 对于冠脉复流后双联抗血小板治疗的患者，可以考虑延期进行主动脉修复，直至药物降级至单抗血小板治疗。如果亟需主动脉瘤修复，可以考虑在双抗的同时进行EVAR。 In all patients, pulmonary function testing with spirometry prior to elective abdominal aortic aneurysm repair should be considered. 对于所有的患者，应该在择期腹主动脉修复术之前优先考虑肺功能测定。 In patients with risk factors for pulmonary complications or a recent decline in respiratory function, specialist referral for respiratory work up and optimisation is recommended prior to elective abdominal aortic aneurysm repair. 对于有肺因性并发症风险因素或者近期肺功能下降的患者，在择期腹主动脉修复术之前，应该考虑转诊给呼吸专科医生进行肺功能检查和改善治疗。 Routine chest X ray prior to abdominal aortic aneurysm repair is not recommended. 在腹主动脉修复术之前，不推荐常规做胸部平片检查。 In patients undergoing abdominal aortic aneurysm repair, assessment of pre-operative kidney function by measuring serum creatinine and estimating GFR is recommended, and those with severe renal impairment (estimated Glomerular Filtration Rate <30 mL/min/1.73 m2) should be referred to a renal physician. 对于进行腹主动脉修复术的患者，推荐术前用肌酐和GFR评估肾功能，严重的肾功能不全患者（预估GFR˂30 mL/min/1.73 m2）应该转诊给肾内专科医生。 Patients with renal impairment should be adequately hydrated before elective abdominal aortic aneurysm repair, and estimated glomerular filtration rate, fluid input, and urine output should be monitored after abdominal aortic aneurysm repair to recognise and manage reduced kidney function. 对于择期腹主动脉瘤合并肾功能不全的患者，术前应该充分水化，术后应该评估GFR、液体量、尿量，以观察和管理肾功能变化。 In patients undergoing elective abdominal aortic aneurysm repair, assessment of pre-operative nutritional status by measuring serum albumin is recommended, with an albumin level of <2.8 g/dL as a threshold for pre-operative correction. 对于择期腹主动脉修复术的患者，推荐检测白蛋白作为术前营养评估，白蛋白低于2.8g/dL则需术前纠正。 Routine screening for asymptomatic carotid stenosis prior to abdominal aortic aneurysm repair is not recommended. 在腹主动脉修复术前，不推荐常规进行无症状颈动脉狭窄的检查。 Patients with abdominal aortic aneurysms and concomitant symptomatic carotid stenosis within the last 6 months should be considered for carotid intervention before aneurysm repair. 腹主动脉瘤患者，伴有近6个月内有症状的颈动脉狭窄，应该先行干预颈动脉。 Routine prophylactic carotid intervention for asymptomatic carotid stenosis prior to abdominal aortic aneurysm repair is not recommended. 腹主动脉瘤患者，不推荐常规对于无症状颈动脉狭窄进行预防性颈动脉干预。 Commencement of beta blockers is not recommended prior to abdominal aortic aneurysm repair. β受体阻滞剂药物治疗不优于腹主动脉修复术。 Statins are recommended before (if possible, at least 4 weeks) elective abdominal aortic aneurysm surgery to reduce cardiovascular morbidity. 择期腹主动脉修复术之前，推荐使用他汀类药物（如果可能，至少4周）以降低心血管发病率。 An established monotherapy with aspirin or thienopyridines (e.g. clopidogrel) is recommended to be continued during the peri-operative period after open and endovascular abdominal aortic aneurysm repair. 开放或腔内腹主动脉修复术后围手术期间，推荐继续使用单抗血小板药物（阿司匹林或吡啶类，如氯吡格雷）。 In all patients undergoing open or endovascular abdominal aortic aneurysm repair, peri-operative systemic antibiotic prophylaxis is recommended. 对于所有进行开放或腔内腹主动脉修复术的患者，推荐围手术期预防性使用抗生素。 In patients undergoing open abdominal aortic aneurysm repair, peri-operative epidural analgesia should be considered, to maximise pain relief and minimise early post- operative complications. 对于进行腹主动脉修复术的患者，应该考虑围手术期硬膜外麻醉，以尽量减轻疼痛和减少术后并发症。 During endovascular abdominal aortic aneurysm repair radiation dose reduction strategies are recommended, such as Keeping as much distance as possible from the radiation source for both personnel and patient. Minimising the time of exposure, use of digital subtraction acquisitions and lateral angulations. Positioning the image intensifier close to the patient, with a well collimated beam. Using necessary magnification levels only. Diligent use and appropriate positioning of lead shields, including personal shields (apron, thyroid, shins and goggles) and mobile shields. 在腔内腹主动脉修复术中，推荐使用减少辐射剂量的策略，如： 患者和术者尽量远离放射源；减少曝光时间，使用减影技术和侧位；平行光束（球管）位置合适，影像增强器（平板）贴近患者；只使用足以成像的射线强度；灵活使用铅屏，包括个人保护（围裙、围脖、腿套、眼镜）和移动铅屏。 Intra-operative cell salvage and re-transfusion should be considered during open abdominal aortic aneurysm repair. 开放腹主动脉修复术中应该考虑自体血留存和回输。 Intravenous heparin (50e100 IU/kg) is recommended before aortic cross clamping. 主动脉阻断钳夹前，推荐静脉内使用肝素（50-100IU/kg）。 It is recommended to perform the proximal anastomosis as close as possible to the renal arteries to prevent later aneurysm development in the remaining infrarenal aortic segment. 为了预防肾下主动脉残留部分远期再发动脉瘤，推荐在开放手术中近心端解剖分离尽量靠近肾动脉。 In selected cases of suspected insufficient perfusion of pelvic organs with risk of colonic ischaemia, reimplantation of the inferior mesenteric artery may be considered during open abdominal aortic aneurysm repair. 怀疑术后盆腔器官灌注不足导致结肠缺血风险可能的选择性病例，在开放腹主动脉修复术中可以考虑重建肠系膜下动脉。 In open abdominal aortic aneurysm repair, it is recommended to preserve the blood flow to at least one internal iliac artery to reduce the risk of buttock claudication and colonic ischaemia. 在开放腹主动脉修复术中，推荐保留至少一侧髂内动脉以降低臀肌间跛和结肠缺血的风险。 In patients treated for abdominal aortic aneurysm by open repair, prophylactic use of mesh reinforcement of midline laparotomies may be considered for patients at high risk of incisional hernia. 在开放腹主动脉修复术中，对于高危切口疝风险的患者，可以考虑关闭正中切口时预防使用补片。 An ultrasound guided percutaneous approach should be considered in endovascular aortic aneurysm repair. 在腔内腹主动脉修复术中，应该考虑在超声引导下经皮穿刺建立入路。 Preservation of large accessory renal arteries (>3 mm) or those that supply a significant portion of the kidney (>1/3) may be considered in endovascular aneurysm repair. 在腔内腹主动脉修复术中，大于3mm的或者供血范围超过1/3肾脏的副肾动脉可以考虑保留。 For newer generations of stent grafts based on existing platforms, such as low profile devices, long-term follow up and evaluation of the durability in prospective registries is recommended. 在原有平台上换代的覆膜支架（如小外径），推荐在临床前瞻性研究中评估和随访支架的耐久性。 New techniques/concepts (such as endovascular aneurysm sealing with endobags) are not recommended in clinical practice and should only be used with caution, preferably within the framework of studies approved by research ethics committees, until adequately evaluated. 新技术、概念（如囊袋腔内瘤体固定）不推荐在临床尝试使用，只适合在研究伦理委员会允许的研究框架内进行合理评估后，谨慎使用。 Laparoscopic abdominal aortic aneurysm repair is not recommended in routine clinical practice, outside highly specialised centres, registries or trials. 腔镜下腹主动脉修复术不推荐在临床常规开展，除非是在高度专业的中心、注册研究和临床研究中开展。 In most patients with suitable anatomy and reasonable life expectancy, endovascular abdominal aortic aneurysm repair should be considered as the preferred treatment modality. 对于解剖条件合适、预期寿命合适的大部分患者，腔内腹主动脉瘤修复术应该考虑作为首选治疗。 In patients with long life expectancy, open abdominal aortic aneurysm repair should be considered as the preferred treatment modality. 对于预期寿命长的患者，开放腹主动脉瘤修复术应该考虑作为首选治疗。 In patients with limited life expectancy, elective abdominal aortic aneurysm repair is not recommended. 对于预期寿命有限的患者，不推荐择期腹主动脉瘤修复术。 In haemodynamically stable patients with suspected ruptured abdominal aortic aneurysm, prompt thoraco- abdominal computed tomography angiography is recommended as the imaging modality of choice. 对于血流动力学稳定的可疑破裂腹主动脉瘤患者，推荐的影像检查选择是迅速进行胸腹CTA检查。 In haemodynamically unstable patients with suspected ruptured abdominal aortic aneurysm, prompt thoraco- abdominal computed tomography angiography, allowing assessment for endovascular repair, should be considered before transferring the patient to the operating room. 对于血流动力学不稳定的可疑破裂腹主动脉瘤患者，应该考虑在转运患者到手术室之前迅速进行胸腹CTA检查，建立腔内修复术的入路。 Symptomatic non-ruptured abdominal aortic aneurysms should be considered for deferred urgent repair ideally under elective repair conditions. 有症状未破裂的腹主动脉瘤理论上应该考虑在择期修复的手术条件下进行延期急诊修复。 In patients with ruptured abdominal aortic aneurysm, a policy of permissive hypotension, by restricting fluid resuscitation, is recommended in the conscious patient. 对于清醒的已破裂腹主动脉瘤患者，推荐采用限制复苏液体以维持低血压的策略。 Local anaesthesia should be considered as the anaesthetic modality of choice for endovascular repair of ruptured abdominal aortic aneurysm whenever tolerated by the patient. 对于进行腔内修复时已破裂腹主动脉瘤患者，无论患者能否耐受，局麻都应该作为麻醉方式的首选。 Aortic balloon occlusion for proximal control should be considered in haemodynamically unstable ruptured abdominal aortic aneurysm patients undergoing open or endovascular repair. 对于血流动力学不稳定的已破裂腹主动脉瘤患者，进行腔内或开放手术时，应该考虑使用主动脉球囊阻断近心端（主动脉）。 In patients undergoing endovascular repair for ruptured abdominal aortic aneurysms, a bifurcated device, in preference to an aorto-uni-iliac device, should be considered whenever anatomically suitable. 对于进行腔内修复的已破裂腹主动脉瘤患者，无论解剖是否合适，相较AUI支架，应该优先考虑分叉型支架。 Selection of patients with ruptured abdominal aortic aneurysm for palliation based entirely on scoring systems or solely on advanced age is not recommended. 已破裂腹主动脉瘤患者，不推荐完全按照评分系统进行镇痛或者只是根据年龄进行镇痛。 In all patients undergoing open or endovascular treatment for ruptured abdominal aortic aneurysm, monitoring of intra-abdominal pressure for early diagnosis and management of intra-abdominal hypertension/abdominal compartment syndrome is recommended. 对于所有进行腔内或开放手术的已破裂腹主动脉瘤患者，推荐监测早期腹腔内压力和管理腹腔内高压/腹筋膜室综合征。 In the presence of abdominal compartment syndrome after open or endovascular treatment of ruptured abdominal aortic aneurysm, decompressive laparotomy is recommended. 对于进行腔内或开放手术的已破裂腹主动脉瘤患者，有腹筋膜室高压的表现，推荐剖腹减压。 In the management of open abdomen following decompression for abdominal compartment syndrome after open or endovascular treatment of ruptured abdominal aortic aneurysm, vacuum assisted closure system should be considered. 对于腔内或开放手术后的已破裂腹主动脉瘤患者，剖腹减压后的管理，推荐使用负压闭合装置。 In patients with ruptured abdominal aortic aneurysm and suitable anatomy, endovascular repair is recommended as a first option. 解剖条件合适的已破裂腹主动脉瘤患者，推荐腔内修复作为第一选择。 In all patients after abdominal aortic aneurysm repair, cardiovascular risk management, with blood pressure and lipid control as well as antiplatelet therapy, is recommended. 所有腹主动脉瘤修复术后患者，推荐心血管危险因素的管理、血压、血脂的控制以及抗血小板的治疗。 In patients treated for abdominal aortic aneurysm with new onset or worsening of lower limb ischaemia, immediate evaluation of graft related problems, such as limb kinking or occlusion, is recommended. 腹主动脉瘤术后患者出现新发或加重的下肢缺血，推荐马上进行支架相关问题的评估，如髂支成角、闭塞等。 For radical treatment of aortic graft or stent graft infection complete graft/stent graft explantation is recommended. 主动脉人工血管或支架感染的根治性治疗，推荐完全取出人工血管/支架。 In selected high risk patients with graft/stent graft infection, conservative and/or palliative options should be considered. 对于人工血管/支架感染高危的选择性的患者，保守或者姑息性的治疗选择都应该被考虑。 In situ reconstruction with prosthetic material is not recommended in heavily contaminated or infected areas. 不推荐在重度污染或感染的区域用假体原位重建。 In patients with previous abdominal aortic aneurysm repair routine use of antibiotic prophylaxis in conjunction with dental or other surgical procedures for prevention of graft infection is not recommended. 对于已行腹主动脉瘤修复术的患者，随后进行牙科或其他外科手术时，不推荐常规使用抗生素预防支架感染。 In patients with previous abdominal aortic aneurysm repair antibiotic prophylaxis should be considered in conjunction with high risk infectious procedures, including abscess drainage, dental procedures requiring manipulation of the gingival or peri-apical region of the teeth or breaching the oral mucosa, as well as in immuno-compromised patients undergoing surgical or interventional procedures. 对于已行腹主动脉瘤修复术的患者，随后进行高危感染风险手术（如脓肿引流、涉及牙槽/根周操作的或打开口腔粘膜的牙科手术、免疫功能低下患者进行的外科或腔内手术），推荐预防性使用抗生素。 In any patient with an aortic prosthesis presenting with gastrointestinal bleeding, prompt assessment to identify a possible secondary aortoenteric fistula is recommended. 任何主动脉假体植入患者出现胃肠道出血，推荐立即评估是否有可能是继发性主动脉肠瘘。 In patients with a suspected or confirmed secondary aorto- enteric fistula, emergency referral to a high volume vascular surgical centre for treatment decision is recommended. 对于任何怀疑或确诊继发性主动脉肠瘘的患者，推荐急诊转运到高级别的血管外科中心进行诊治。 In patients with secondary aorto-enteric fistula and bleeding, staged endovascular stent grafting as a bridge to open surgery may be considered. 对于继发性主动脉肠瘘合并出血的患者，临时性腔内支架修复可以考虑作为开放手术的桥接手段。 In all patients after open repair for abdominal aortic aneurysm, imaging follow up of the aorta and peripheral arteries may be considered every five years. 对于所有开放腹主动脉瘤修复术后患者，可以考虑每五年进行主动脉和外周动脉的影像学随访。 In patients with Type I endoleak after endovascular abdominal aortic aneurysm repair, re-intervention to achieve a seal, primarily by endovascular means, is recommended. 对于腔内腹主动脉瘤修复术后I型内漏的患者，推荐优先采用腔内技术再次干预，封闭内漏。 Expansion of sac diameter ≥1 cm detected during follow up after endovascular abdominal aortic aneurysm repair using the same imaging modality and measurement method may be considered as a reasonable threshold for significant growth. 腔内腹主动脉瘤修复术后随访，同样的影像学手段和测量方法下，瘤腔直径增大1cm，应该考虑为显著增大的确诊指证。 Re-intervention for Type II endoleak after endovascular abdominal aortic aneurysm repair should be considered in the presence of significant aneurysm growth (see Recommendation 87), primarily by endovascular means. 腔内腹主动脉瘤修复术后II型内漏，如发现瘤体有显著增大（见87条），应该考虑优先采用腔内技术再干预。 In patients with Type III endoleak after endovascular abdominal aortic aneurysm repair, re-intervention is recommended, primarily by endovascular means. 腔内腹主动脉瘤修复术后III型内漏，推荐优先采用腔内技术再干预。 Significant aneurysm sac growth after endovascular abdominal aortic aneurysm repair, without visible endoleak on standard imaging, should be considered for further diagnostic evaluation with alternative imaging modalities to exclude the presence of an unidentified endoleak, and should be considered for treatment. 腔内腹主动脉瘤修复术后瘤腔显著增大，没有可见的内漏或影像学表现，应该考虑更换影像学检查手段进行后续诊断评估以排除无法确认的内漏，并且应该考虑治疗。 Early (within 30 days) post-operative follow up after endovascular aortic repair including imaging of the stent graft to assess presence of endoleak, component overlap and sealing zone length is recommended. 腔内腹主动脉修复术后早期随访（30天内），推荐影像学检查评估内漏、支架组件重叠和锚定区。 Patients considered at low risk of endovascular aortic repair failure after their first post-operative CTA, may be considered for stratification to less frequent imaging follow ups. 首次复查CTA后考虑腔内主动脉修复失败风险低危的患者，可以考虑归入低频次影像学随访的群组。 In patients with juxtarenal abdominal aortic aneurysm and acceptable surgical risk, the minimum threshold for elective repair may be considered to be 5.5 cm diameter. 对于近肾腹主动脉瘤而且手术风险可接受的患者，择期修复的最小直径可以考虑为5.5cm。 Centralisation to specialised high volume centres that can offer both complex open and complex endovascular repair for treatment of juxtarenal abdominal aortic aneurysm is recommended. 推荐在可以同时进行复杂开放和腔内手术的高级别专科中心集中治疗近肾腹主动脉瘤。 In patients with juxtarenal abdominal aortic aneurysm, open repair or complex endovascular repair should be considered based on patient status, anatomy, local routines, team experience, and patient preference. 对于近肾腹主动脉瘤的患者，开放或复杂腔内修复术应该在患者状况、解剖、所在医院常规流程、团队经验和患者偏好的基础上进行选择。 In complex endovascular repair of juxtarenal abdominal aortic aneurysm, endovascular repair with fenestrated stent grafts should be considered the preferred treatment option when feasible. 对于近肾腹主动脉瘤患者进行复杂腔内修复，如果合适，首选治疗选择应该考虑开窗支架。 In complex endovascular repair for juxtarenal abdominal aortic aneurysm, using parallel graft techniques may be considered as an alternative in the emergency setting or when fenestrated stent grafts are not indicated or available, or as a bailout, ideally restricted to ≤2 chimneys. 对于近肾腹主动脉瘤患者进行复杂腔内修复，平行支架技术应该考虑作为替代选择，如急诊手术、开窗支架不合适或无法获得、紧急情况下理论上不多于2支的烟囱重建。 In patients with juxtarenal abdominal aortic aneurysm, new techniques/concepts, including endovascular aneurysm seal, endostaples, and in situ laser fenestration, are not recommended as first line treatment, but should be limited to studies approved by research ethics committees, until adequately evaluated. 对于近肾腹主动脉瘤的患者，新的技术或理念（腔内动脉瘤锚定、腔内铆钉、原位激光开窗）不推荐作为一线治疗，但在充分评估后可以在临床研究伦理委员会的批准下进行研究。 In patients with ruptured juxta/pararenal abdominal aortic aneurysm open repair or complex endovascular repair (with a physician modified fenestrated stent graft, off the shelf branched stent graft, or parallel graft) may be considered based on patient status, anatomy, local routines, team experience, and patient preference. 对于已破裂的近肾/平肾腹主动脉瘤患者，开放或复杂腔内修复术（自制开窗支架、标准分支支架或者平行支架）可以在患者状况、解剖、所在医院常规流程、团队经验和患者偏好的基础上进行选择。 In patients undergoing open repair of juxtarenal abdominal aortic aneurysm a strategy to preserve renal function by means of cold crystalloid renal perfusion may be considered. 对于进行开放手术修复近肾腹主动脉瘤的患者，可以考虑用冷晶体液肾脏灌注的办法保护肾功能。 In patients treated for juxtarenal abdominal aortic aneurysm by endovascular repair, a thorough long-term follow up programme including annual computed tomography angiography is recommended. 对于以腔内手术修复近肾腹主动脉瘤的患者，推荐终生进行随访，包括每年一次CTA。 The threshold for elective repair of isolated iliac artery aneurysm (common iliac artery, internal iliac artery and external iliac artery, or combination thereof) may be considered at a minimum of 3.5 cm diameter. 孤立性髂动脉瘤（髂总动脉、髂内动脉、髂外动脉或多发髂动脉瘤）的择期修复指证的最小直径可以设为3.5cm。 In patients with iliac artery aneurysm endovascular repair may be considered as first line therapy. 对于髂动脉瘤患者，腔内修复可以考虑作为一线治疗。 Preserving blood flow to at least one internal iliac artery during open surgical and endovascular repair of iliac artery aneurysms is recommended. 在开放或腔内修复髂动脉瘤术中，推荐保留至少一侧髂内动脉血流。 In patients where internal iliac artery embolisation or ligation is necessary, occlusion of the proximal main stem of the vessel is recommended if technically feasible, to preserve distal collateral circulation to the pelvis. 对于需要栓塞或结扎髂内动脉的患者，如果技术可行，推荐闭塞近端主干，以保留盆底的远端侧枝血流。 It is recommended that the diagnosis of a mycotic aortic aneurysm is based on a combination of clinical, laboratory, and imaging parameters. 感染性主动脉瘤，推荐基于临床表现、实验室检查和影像学指标综合进行诊断。 Treatment of patients with a suspected mycotic aortic aneurysm with intravenous antibiotics is recommended; empirical antibiotic treatment against Staphylococcus aureus and Gram negative rods should be initiated as soon as cultures have been secured, and continued in those with negative cultures. 可疑感染性主动脉瘤的患者，推荐经静脉使用抗生素。经验性使用抗生素的同时，葡萄球菌和革兰阴性杆菌应尽早培养分离确认，阴性结果应继续培养。 Mycotic aneurysm repair is recommended irrespective of aneurysm size. 感染性动脉瘤修复不考虑动脉瘤大小。 Surgical techniques used in mycotic aneurysm repair should be considered based on patient status, local routines, and team experience, with endovascular repair being an acceptable alternative to open repair. 感染性动脉瘤修复中，开放技术应该在患者状况、所在地区常规流程、团队经验的基础上选择使用，腔内修复作为可接受的替代手段。 Long-term post-operative antibiotic treatment (6-12 months or lifelong) and surveillance should be considered after mycotic aneurysm repair. 感染性动脉瘤修复术后，应该考虑长期使用抗生素（6-12个月或终身）并随访。 All patients with symptomatic inflammatory abdominal aortic aneurysms should be considered for medical anti- inflammatory treatment. 对于所有有症状的炎性腹主动脉瘤患者，应该考虑抗炎症药物治疗。 In patients with inflammatory abdominal aortic aneurysm with a threshold diameter of 5.5 cm and suitable anatomy, endovascular repair should be considered as a first option. 对于直径5.5cm以上、解剖合适的、有症状的炎性腹主动脉瘤患者，腔内修复应该作为第一选择。 In all patients with penetrating aortic ulcer, isolated abdominal aortic dissection, aortic pseudoaneurysm, or intramural haematoma, medical treatment, including blood pressure control, is recommended. 对于所有穿透性溃疡、孤立性腹主动脉夹层、主动脉假性动脉瘤或壁间血肿的患者，推荐包括血压控制在内的药物治疗。 In uncomplicated penetrating aortic ulcer, dissection, or intramural haematoma of the abdominal aorta, serial imaging surveillance is recommended. 对于非复杂的穿透性溃疡、夹层或壁间血肿的患者，推荐进行影像学随访。 In patients with complicated penetrating aortic ulcer, dissection, or intramural haematoma, and in pseudoaneurysm in the abdominal aorta, repair is recommended. 对于复杂的穿透性溃疡、夹层、壁间血肿或主动脉假性动脉瘤的患者，推荐进行修复。 Early treatment may be considered for saccular abdominal aortic aneurysms, with a lower threshold for elective repair than for standard fusiform abdominal aortic aneurysms. 相较标准的纺锤状腹主动脉瘤，囊状（偏心性的）腹主动脉瘤可以考虑降低择期手术的指征，早期治疗。 In patients with complicated penetrating aortic ulcer, dissection, intramural haematoma, or pseudoaneurysm of the abdominal aorta, endovascular repair should be considered as a first option. 对于复杂的穿透性溃疡、夹层、壁间血肿或主动脉假性动脉瘤的患者，腔内修复应该考虑作为首选治疗。 Patients with abdominal aneurysm and concomitant cancer are not recommended prophylactic aneurysm repair on a different indication (diameter threshold) from patients without cancer, including cases of chemotherapy. 对于伴发癌症的腹主动脉瘤患者（包括化疗），直径指征与无癌症患者相同，不推荐做预防性的动脉瘤修复。 In patients with concomitant malignancy, a staged surgical approach, with endovascular repair of a large or symptomatic abdominal aortic aneurysm first, to allow for treatment of malignancy with minimal delay, is recommended. 对于伴发肿瘤的患者，推荐进行分期外科处理：大直径或有症状的腹主动脉瘤先行腔内修复，最短时间桥接肿瘤治疗。 In patients with concomitant cancer, prolonged low molecular weight heparin prophylaxis up to four weeks after abdominal aortic aneurysm repair should be considered. 对于同时有癌症的患者，应在腹主动脉瘤修复术后，考虑预防性延长使用低分子肝素达4周。 In patients with abdominal aortic aneurysm in whom the disease cannot be solely explained by a non-genetic cause, such as patients <60 years or in patients with a positive family history, genetic counselling is recommended prior to genetic testing. 对于无法单纯用非遗传因素（如大于60岁或者有家族史）解释的腹主动脉瘤患者，推荐先行询问遗传史，优于基因检测。 Referral to a multidisciplinary aortic team at a highly specialised centre is recommended to manage patients with an aortic disorder suspected of having an underlying genetic cause. 推荐将患者转运给高级别专业性中心的多学科协作主动脉团队，来管理具有潜在遗传性因素的主动脉疾病患者。 In young patients with suspected connective tissue disorders and abdominal aortic aneurysms, open surgical repair is recommended as first option. 对于可疑结缔组织疾病合并腹主动脉瘤的患者，开放手术推荐作为第一选择。 A retroperitoneal approach for patients requiring open surgical repair or endovascular repair if anatomically feasible may be considered as preferred options for the surgical treatment of abdominal aortic aneurysm with a co-existing horseshoe kidney. 对于腹主动脉瘤合并马蹄肾，解剖合适需要开放或腔内修复的患者，开放手术时可以考虑将腹膜后入路作为最优选择。 Preservation of the renal isthmus and anomalous renal arteries >3 mm in diameter should be considered during both open and endovascular repair of abdominal aortic aneurysm with a co-existing horseshoe kidney. 对于腹主动脉瘤合并马蹄肾，进行开放或腔内修复的患者，应该考虑保留峡部和大于3mm的异常肾动脉。 SVS腹主动脉瘤指南(一)：术前监测血管新青年 2021-07-05 08:00 近期，美国血管外科协会陆续在《Journal of Vascular Surgery》杂志上就腹主动脉瘤治疗中的几个令人关注的问题给出了他们的建议，并且提出了一些争议点以及未来的方向，小编将为大家一一呈现。 Society for Vascular Surgery implementationof guidelines in abdominal aortic aneurysms: preoperative surveillance and threshold for repair Rae S. Rokosh, Winona W. Wu, Mark K.Eskandari, and Elliot L. Chaikof 1. 无症状的真性腹主动脉瘤的干预仍依据超声，CTA或MRI上测量到的主动脉最大外径：
2. 直径＜4.0cm的无症状真性AAA每年破裂的风险几乎可以忽略不计； 3. Cochrane上一项对UKSAT (UK small aneurysm trial)，ADAM (aneurysm detection and management study)，CAESAR (comparison of surveillance vs aortic endografting for small aneurysm repair)和PIVOTAL (positive impact of endovascular options for treating aneurysm early)研究的分析显示无症状小AAA（4.0-5.4cm）立即进行干预的获益不明显[2] 4. 普遍认为，对于女性最大径达到5cm，对于男性最大径达到5.5cm时，AAA年破裂的风险超过择期手术相关的围手术期风险； 5. 根据AAA直径估计的年破裂风险如下表[3,4]（女性患者适用性较差）：
6. 对于无症状患者推荐采用超声（更倾向于超声）或CT进行监测，术前监测的频率如下表：
7. AAA修复的指证[5]：
8. 争议和未来的方向： 传统最大径标准的陷阱：
最近的证据提示：在女性中，动脉瘤直径除以体表面积相比单纯动脉瘤直径，在破裂风险方面更有预测价值[7]
SVS腹主动脉瘤指南(二)：治疗原则血管新青年 2021-07-11 08:30 Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Repair of an abdominal aortic aneurysm Rae S. Rokosh, Benjamin W. Starnes, andElliot L. Chaikof 1. 腹主动脉瘤（AAA）的最佳干预时间点依据临床表现和动脉瘤状态：
2. AAA择期手术究竟腔内治疗还是开放手术应充分考虑以下几点后个体化选择：
3. 如果解剖学适合，破裂AAA的治疗首选EVAR（1C级证据），建议从急诊入院至干预（door-to-intervention）的时间不超过90分钟[1]。 4. 当主动脉的解剖超出现有的商品化EVAR器械IFU时，或者预期寿命高于10-15年时，应当考虑开放手术[2]。 5. 观察性研究显示相比开放手术，破裂AAA患者接受EVAR手术的早中期生存获益更明显，但是需要当心这是相关性而非因果关系[3]。 6. 破裂AAA患者腔内治疗的围手术期生存获益尚未被RCT证实。 7. 相比开放手术，AAA择期EVAR手术能够降低死亡率和并发症发生率，更快地康复。但是，远期再干预的发生率更高，且远期生存获益无明显差异[4]。 8. 破裂AAA急救处理流程的有效实施能够降低30天死亡率，具体策略见下图[5]：
9. 医疗卫生系统应当考虑建立一个破裂AAA急诊治疗的结构化、多学科、分级诊疗制度，如果没有转运禁忌症，应当快速转运至一个可行EVAR手术的医疗机构。 10. 目前，已有几个评分系统声称能够准确地预测破裂AAA的30天死亡率[6]。VSGNNE（VascularStudy Group of Northern New England）风险评估表在预测AAA择期EVAR术后院内死亡方面已经得到了外部验证。未来，VSGNNE风险评估表应作为术前常规，以促进病人为中心的沟通和共同决策，尤其是那些计算下来高死亡风险并且预期寿命较短的患者[7]。 SVS腹主动脉瘤指南(三)：内漏管理血管新青年 2021-07-18 10:30 Society for Vascular Surgery implementationof clinical practice guidelines for patients with an abdominal aortic aneurysm:endoleak management Rae S. Rokosh, Winona W. Wu, Ronald L. Dalman, andElliot L. Chaiko 1. 内漏是指EVAR术后瘤腔内存在持续血流灌入。虽然有些内漏能够自发缓解或是不导致瘤腔扩张，但仍有部分内漏需二次干预以预防瘤腔扩张、破裂。而干预的指证主要依据内漏的类型以及相关的动脉瘤破裂风险。具体的内漏分型见下图：
2. SVS临床指南推荐[1]：
3. I型和III型内漏导致瘤腔直接暴露在系统血压下，破裂的风险较高[2]。 4. EVAR术后即刻造影，II型内漏发生的比例≤25%
5. 一部分瘤腔扩张的患者，看似是II型内漏，但实际上是隐蔽的I型或III型内漏动脉血流入分支血管中误以为是II型。
6. 目前，II型内漏究竟是一个良性病程还是会导致远期的动脉瘤相关并发症尚存在争议，其最佳随访方案和治疗策略仍不清楚。 7. 虽然目前的指南推荐：II型内漏如果出现症状或存在明显瘤腔扩张，则需要及时干预，但是，最近的证据显示接受治疗的II型内漏患者生存或动脉瘤相关的结局都没有明显改善[7,8]。 8. 持续的II型内漏很常见，治疗策略建议如下[4,9]：
9. 即使是这样一个渐进性的治疗策略，术后II型内漏的复发率仍高达60%[9]。 10. 目前，比较内漏不同治疗方式的证据较少，虽然腔内治疗的失败率较高，但不代表它不是最佳的治疗方式。 11. II型内漏以及相关瘤腔扩张的最佳单一或联合序贯腔内治疗方式需要前瞻性RCT证实。两个系统评价已经发现相比经动脉栓塞术，经腰栓塞有着更高的临床成功率[4,10]。 12. 在II型内漏高风险患者中，需要前瞻性RCT证实有选择地进行预防性主动脉分支栓塞和瘤腔栓塞的获益。近期有两个小样本RCT在EVAR术后II型内漏高危患者中，评估一期瘤腔栓塞[11]和肠系膜下动脉栓塞[12]，早期结果已经显现出一期栓塞能够降低II型内漏，提高瘤腔体积缩小的比例。 备注：本指南是SVS制定，适用于美国临床实践的操作指南，仅供参考，在具体临床工作中，仍需根据国内各家医院自身的情况，患者病情制定个体化的治疗方案。 参考文献见公众号：血管新青年中国心胸医学影像论坛-带您轻松掌握腹主动脉瘤 CTA 评估要点腹主动脉瘤是腹主动脉的异常扩张，它的扩张会带来主动脉破裂的风险，一旦破裂十分凶险，死亡率很高。传统的开放式手术创伤较大，需要全麻，恢复时间较长，而动脉瘤腔内修复术（Aneurysm Endovascular Aneurysm Repair, EVAR）具有创伤小、局麻、恢复快的特点。 影像医生阅读腹主动脉 CTA（Computed tomography angiography）在术前评估、术后随访有着至关重要的作用。本文介绍腹主动脉瘤 CTA 术前评估要点。 背景知识 1. 腹主动脉瘤的定义 异常扩张的主动脉直径超过近端正常主动脉 50%，或者扩张超过 3 cm。 2. 腹主动脉瘤的直径与破裂风险的关系
3. 腹主动脉瘤腔内治疗的适应证
腹主动脉瘤分类 1. 按受累部位，分为 3 类： （1）肾动脉上型（Suprarenal aortic aneurysm）：动脉瘤累及肾动脉上方。
（2）肾动脉旁型（Juxtarenal aortic aneurysm）：动脉瘤上缘至肾动脉距离＜1 cm。
（3）肾动脉下型（Infrarenal aortic aneurysm）: 动脉瘤上缘至肾动脉距离 ≥ 1 cm。
肾动脉下方至瘤体上方的区域为支架的「着陆区」（landing zone），此区至关重要。 2. 按照髂动脉是否受累，分为 2 类： （1）髂动脉受累型。
（2）髂动脉未受累型。
读片要点 影像科医生阅读腹主动脉 CTA 诊断腹主动脉瘤时，需要注意三大方面：
1. 主动脉颈的评估 （1）长度：这是最重要的径线，当动脉瘤体上缘距离肾动脉水平下缘 ≥ 1.5 cm 时，较易进行腔内修复。
（2）角度：是指肾动脉水平上方的主动脉与下方的主动脉的夹角，＞150°时表示较平直，腔内修复术易进行。
（3）动脉颈的粥样硬化情况，当钙化斑块及粥样斑块＞50% 时，为重度粥样硬化；25%～50% 为中度，＜25% 为轻度。
（4）主动脉颈的形态：平直型较易进行腔内修复，锥形和倒锥型较难。
2. 动脉瘤体的评估 （1）动脉瘤弯曲指数（Aortic Aneurysm Tortuosity Index）：是指从肾动脉下方沿管腔表面至动脉分叉处的曲线 L1 与直线 L2 的长度比，比值＜1.2 时代表较平直，易进行腔内修复术。
（2）动脉瘤角度（Aortic Aneurysm Angle）：此角度越小，腔内修复术越困难。
（3）动脉瘤分支血管（Aneurysm Branch Vessels）：包括副肾动脉、腰动脉、肠系膜下动脉，仔细评估是否有侧枝血管，如：有重要的副肾动脉，可行副肾动脉开窗术，如累及肠系膜下动脉，覆膜支架盖住肠系膜下动脉前，应预先评估及处理肠系膜上动脉，防止肠缺血坏死。
3. 髂动脉的评估 （1）髂总动脉受累情况
（2）髂总动脉长度：髂总动脉总长度＞3 cm 时，支架可以不延伸至髂外动脉。
（3）髂总动脉的直径和钙化情况：钙化较重或管腔较细时，腔内修复术困难。
（4）髂总动脉的弯曲指数，角度。 弯曲指数<1.25 时，手术较易；＞1.6 时，手术较难。 角度越大，表示越平直，手术较容易。
总结 经过学习，我们知道了影像科医生阅读腹主动脉 CTA 时，除了测量动脉瘤的直径，还需要注意的三大方面：主动脉颈（指动脉瘤上方的主动脉）（Aortic neck）、动脉瘤体（Aortic aneurysm）、动脉瘤下方的髂动脉（Iliac artery）。只有综合考虑各个径线，才能对腹主动脉瘤有良好的综合评估，顺利指导腔内修复术的进行。 版权信息 内容来源：《NEJM医学前沿》、厦门大学附属心血管病医院血管外、 心胸医学影像联盟、血管新青年公众号。仅供个人学习使用。若有侵权，请联系删除。 |
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