首都医科大学附属北京天坛医院 血管外科，北京 100070
Department of Vascular Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
背景与目的 近肾腹主动脉闭塞属于主髂动脉闭塞的极端情况，治疗相对棘手。尽管腔内治疗适用于此类患者，开放手术治疗仍有其适应证所在。本研究分析近肾腹主动脉闭塞患者行开放手术治疗的效果，并总结经验及其治疗策略。方法 收集首都医科大学附属北京天坛医院血管外科2018年7月—2022年5月期间行开放手术治疗的10例近肾腹主动脉闭塞患者的临床资料。回顾性分析患者的一般资料、手术方式、手术时间、术中出血量、腹主动脉阻断方式、肾上腹主动脉阻断时间、手术并发症、症状缓解程度及随访结果。结果 10例患者手术均顺利完成。手术时间210~420 min，中位手术时间为265 min；术中出血200~1 200 mL，中位出血量375 mL。3例行膈下腹主动脉-双股动脉人工血管搭桥术，其中1例同时行右膝上截肢术；1例行膈下腹主动脉-双髂总动脉人工血管搭桥术，同时重建肠系膜下动脉；5例行肾下腹主动脉-双股动脉人工血管搭桥术；1例行腋动脉-双股动脉人工血管搭桥术并左颈动脉内膜剥脱术。膈下腹主动脉阻断4例，肾上肾下序贯腹主动脉阻断1例，肾下腹主动脉阻断4例。肾上腹主动脉阻断时间14~20 min，中位阻断时间20 min。围手术期无心脑血管意外、死亡、肾功能障碍及人工血管感染发生。10例患者术后双下肢间歇性跛行或静息痛症状均消失，双侧足背或胫后动脉搏动均可扪及。10例患者获随访4~40个月，中位随访时间27个月，随访期间桥血管均通畅、吻合口无狭窄、无下肢及肠道缺血表现。结论 近肾腹主动脉闭塞患者行开放手术治疗效果确切，桥血管远期通畅率高，需根据患者不同情况采取个体化的治疗方式。
Background and Aims Juxtarenal abdominal aortic occlusion is an extreme condition of aortoiliac occlusive disease, and its treatment is often challenging. Although endovascular therapy is suitable for such patients, there are still some indications for open surgery. This study was performed to evaluate the efficacy of open surgery for juxtarenal abdominal aortic occlusion and summarize the experience and its treatment strategies.Methods The clinical data of 10 patients with juxtarenal abdominal aortic occlusion undergoing open surgery from July 2018 to May 2022 were collected. The general information, surgical procedures, operative time, intraoperative blood loss, methods for blockage of the blood flow through the abdominal aorta, duration of cross-clamping of the suprarenal abdominal aorta, surgical complications and degree of symptom relief as well as the follow-up results were retrospectively analyzed.Results Operation was successfully completed in all the 10 patients. The operative time was 210 to 420 min with a median operative time of 265 min; the intraoperative blood loss was 200 to 1 200 mL with a median blood loss of 375 mL. The prosthetic bypass from the subphrenic abdominal aorta to bilateral femoral arteries was established in 3 patients, of whom, one case underwent simultaneous amputation; the prosthetic bypass from the subphrenic abdominal aorta to bilateral common iliac arteries with inferior mesenteric artery reconstruction was used in one patient; the prosthetic bypass from the subrenal abdominal aorta to bilateral femoral arteries was created in 5 patients; the prosthetic bypass from the axillary artery to bilateral femoral arteries with carotid endarterectomy was performed in one patient. Subphrenic aortic cross-clamping was performed in 4 cases, sequential cross-clamping of the suprarenal and subrenal aorta was performed in 1 case, and subrenal aortic cross-clamping was performed in 4 cases. The time for subphrenic aortic cross-clamping was 14 to 20 min with a median time of 20 min. No cardiac-cerebrovascular accidents, operative death, renal dysfunction and prosthesis infection occurred during perioperative period. After operation, symptom of intermittent claudication or resting pain was relieved in all the 10 patients, and the pulses of bilateral dorsalis pedis and posterior tibial arteries were palpable. In the 10 patients, follow-up was conducted for 4 to 40 months with a median follow-up time of 27 months, during which time, all prosthetic grafts remained patent, and no anastomotic stenosis, lower limb ischemia and intestinal ischemia were noted.Conclusion Open surgery has demonstrable efficacy in the treatment of juxtarenal abdominal aortic occlusion, with a high long-term patency of the bridging vessels. Individualized treatment should be adopted according to different situations.