Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3742_Библиотеки_им_академика_М_И_Перельмана
.pdf
220 Section 10: Renal and Mesenteric Disease
estimated to be close to 3%. This risk is higher in the setting of pregnancy, portal hypertension,
liver transplant, and vasculitis. Intervention is currently recommended for all symptomatic
patients as well as those with an aneurysm diameter larger than 2.5 cm. Small calcified splenic
artery aneurysms incidentally identified on CT scans of the abdomen do not require repair in
most instances.
CTA abdomen showing splenic artery aneurysm.
Complete thrombosis of aneurysm sac using coils with
preser ved flow to the spleen.
Correct Answer C 2.5 cm or larger
Reference
Barrionuevo, P., Malas, M. B., Nejim, B., et al. (2019). A systematic review and meta-analysis of the
management of visceral artery aneurysms. J Vasc Surg, 70(5), 1694–1699. PMID: 31126761
3. RATIONALE
Post-embolization syndrome is characterized by fever, abdominal pain, and leukocytosis and is more common after embolization of hepatic tumors and is likely caused by an
inflammatory response to the necrotic tissue. Splenic infarct following coil embolization does not require any treatment unless splenic abscess develops. Distal splenic artery
embolization is associated with greater incidences of splenic infarct and abscess then
proximal embolization. Splenic abscess is encountered less frequently but often requires
percutaneous drainage or splenectomy following confirmation with non-contrast CT scan
of the abdomen.
Correct Answer C Splenic abscess
Reference
Ahuja, C., Farsad, K., & Chadha, M. (2015). An overview of splenic embolization. AJR Am J Roentgenol,
205(4), 720–725. PMID: 26397320
4. RATIONALE
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Section 10: Renal and Mesenteric Disease 221
Hepatic artery aneurysms are the second most common visceral aneurysms, and the majority
are extrahepatic and occur in the common hepatic artery. The most common cause is atherosclerotic degeneration with less common causes such as fibromuscular dysplasia, polyarteritis
nodosa, mycotic degeneration, and inflammatory pseudoaneurysms due to acute pancreatitis
and cholecystitis. Traumatic pseudoaneurysms account for almost half of the intrahepatic
aneurysms encountered. Rupture rate can be as high as 20%, with intrahepatic aneurysms
reporting even higher rupture rates. Hepatic artery aneurysms have one of the highest rates of
rupture of all visceral artery aneurysms and a high mortality rate of 40% when presenting with
rupture. Rupture can also occur into the gastrointestinal or biliary tract. Current management
recommendations include treatment for all symptomatic hepatic aneurysms and all true aneurysms >2 cm. Pseudoaneurysms of the hepatic artery should be treated regardless of their size.
Because of a high rate of anatomic variations (replaced right or left hepatic arteries originating from the superior mesenteric artery in 18% or from the left gastroduodenal artery in 12%),
careful attention to exposure of the hepatic artery must be performed. Surgical exposure can be
obtained by right subcostal incision. If the aneurysm is proximal to the gastroduodenal artery,
the aneurysm can be ligated with collateral f low precluding the need for in-line reconstruction.
If the aneurysm extends into the proper hepatic artery, reconstruction will be required, avoiding branch ligation, which can result in hepatic necrosis if the distal portion of the right hepatic
artery is ligated. Cholecystectomy should be considered in this instance. Hepatic artery ligation
should be avoided in patients with baseline liver dysfunction or liver cirrhosis. Catheter-based
approaches are preferable for intraparenchymal lesions. Embolization does carry the risk of
liver necrosis, abscess, and sepsis.
Correct Answer C 20%
222 Section 10: Renal and Mesenteric Disease
Reference
Berceli, S. A. (2005). Hepatic and splenic artery aneurysms. Semin Vasc Surg, 18(4), 196–201. PMID:
16360576
5. RATIONALE
The lifetime risk of rupture of celiac artery aneurysm is between 6% and 20% with a mortality of
50%. Because of the low incidence of celiac arter y aneurysm, it is difficult to reliably identify risk
factors for rupture. As with splenic artery aneur ysms, a “double-rupture” phenomenon can occur
with initial contained lesser sac bleeding followed in variable time intervals by extension into the
peritoneal cavity. Several contemporary studies do not report rupture of celiac artery aneurysm
smaller than 2.5 cm diameter. Therefore, for asymptomatic patients, a celiac artery aneurysm less
than 2.5 cm can be monitored by visceral duplex imaging or CTA of the abdomen. Endovascular
technique usually includes embolization and/or exclusion of the celiac artery because of the short
length of the celiac trunk. The short length of the celiac trunk limits complete stent graft exclusion
of most aneurysms. Successful endovascular repair, therefore, relies on adequate collateral blood
supply to the liver. The preferred open surgical treatment of celiac artery aneur ysms is aneurysm
resection with revascularization. Autologous vein or a prosthetic bypass is used as a conduit for the
celiac artery with distal anastomosis to the common hepatic artery or the divided end of the celiac
trunk. An aortic punch is useful to create a circular opening in the aorta, and occasionally aortic
reimplantation of celiac artery is possible. Aneurysmorrhaphy has been employed in less than 10%
of cases for saccular aneurysms involving a small portion of the arterial circumference. However,
most patients will require an aortoceliac or aorto-hepatic bypass after resection of the aneur ysm.
Correct Answer B 6%–20%
Section 10: Renal and Mesenteric Disease 223
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Reference
Stone, W. M., Abbas, M. A., Gloviczki, P., et al. (2002). Celiac arterial aneurysms: a critical reappraisal
of a rare entity. Arch Surg, 137(6), 670–674. PMID: 12049537
6. RATIONALE
Gastric artery aneurysms and gastroepiploic artery aneurysms are rare; in combination they
account for 4% of all visceral aneurysms. The etiology includes atherosclerosis (30%), trauma (25%),
and inflammation (15%), including pancreatitis, peptic ulcer disease, and vasculitis. More than
90% of gastroepiploic artery aneurysms are ruptured at presentation because they are intraperitoneal. The mortality rate from rupture is 70%. Management generally consists of operative ligation
with or without arterial reconstruction. Aneurysm in the distribution of the jejunal, ileal, and colic
branches is rare and comprises 2% of all visceral aneurysms. Rupture of jejunal and ileal aneurysms is less common than colic aneurysms. Gastroduodenal aneurysms and pancreaticoduodenal aneurysms are uncommon (1.5%–2% of visceral aneurysms). They are commonly associated
with acute pancreatitis resulting in pseudoaneurysm formation from pancreatic inflammation or
pseudocyst. When true pancreaticoduodenal aneurysms are associated with celiac arter y occlusive disease, both aneur ysm and celiac stenosis or occlusion should be treated to minimize the risk
of abolishing the collateral supply. Endovascular techniques have changed the approach to gastroduodenal artery aneurysms and pancreaticoduodenal artery aneurysms. Coil embolization has
been the most popular option but requires close surveillance, as recanalization causing recurrent
bleeding is common. True pancreaticoduodenal artery aneurysms associated with celiac artery
224 Section 10: Renal and Mesenteric Disease
stenosis or occlusion are difficult to treat with endovascular means alone, and combined open and
endovascular approaches are a better option. Hybrid repair is often required.
Correct Answer D 90% present with rupture, with 70% mortality
Reference
Shanley, C. J., Shah, N. L., & Messina, L. M. (1996). Uncommon splanchnic artery aneurysms: pancre-
aticoduodenal, gastroduodenal, superior mesenteric, inferior mesenteric, and colic. Ann Vasc
Surg, 10(5), 506–515. PMID: 8905073
7. RATIONALE
Most renal artery aneurysms are asymptomatic and are usually found incidentally on imaging for unrelated conditions. Of those that develop symptoms, hypertension is the most
common. Hypertension may be the result of renin-mediated vasoconstriction in the setting of renal artery stenosis, which can result in formation of post-stenotic fusiform aneurysms. Other symptoms include flank pain and hematuria. The most serious complication is
rupture, presenting as flank or abdominal pain with hypotension, with a mortality of about
10%. Among survivors of aneurysm ruptures, 90% have a loss of the kidney. The mortality
is significantly greater in the pregnant population, where it is associated with a 50% maternal mortality and a 75% fetal mortality. Traditionally a 2-cm diameter was considered the
threshold for repair, but many authorities now advise waiting until the aneurysm reaches
3 cm or larger in light of a benign natural history of renal artery aneurysms. Preoperative
imaging with thin-cut high-quality computed tomography angiogram of the abdomen is performed. Three-dimensional reconstruction is imperative to define the aneurysm and branch
anatomy preoperatively. Most of these aneurysms are saccular and arise at the bifurcation/
branch points, and 75% are bilateral.
Correct Answer B 10%
Reference
Klausner, J. Q., Lawrence, P. F., Harlander-Locke, M. P., et al. (2015). The contemporary management of
renal artery aneurysms. J Vasc Surg, 61(4), 978–984. PMID: 25537277
8. RATIONALE
The saphenous vein is the most commonly used bypass conduit in about 75% of patients requiring repair of a renal artery aneurysm. However, its risks include aneurysmal dilatation over time.
Therefore, the hypogastric artery is favored for children and young adults in order to avoid late
degeneration. Autologous tissue is often favored due to its resistance to infection, ease of handling
for branched renal artery aneurysm repair, and long-term durability. Primary patency rates with
the use of saphenous vein graft and PTFE are comparable. Early graft failures are due to thrombosis or stenosis requiring urgent intervention to avoid renal compromise. An end-to-end anastomosis with generous spatulation of the graft and artery can lessen the risk of stricture. Interposition
graft or endovascular techniques (transluminal angioplasty with and without stenting) in a
high-risk situation are useful techniques. Over time, saphenous vein grafts may demonstrate dilation, which has been reported to occur in 20%–40% of vein grafts when used for aortorenal bypass.
However, progression to a true aneurysm in these vein grafts is less common. Aneurysm at branch
points, most commonly the main renal artery bifurcation, is more frequent than main renal artery
lesions and requires complex repair. For saccular aneurysms, aneur ysmorrhaphy with or without
Section 10: Renal and Mesenteric Disease 225
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
patching can be performed, but salvage of all branches frequently require resection, grafting, and
consideration of branch reimplantation. In complex distal branch aneurysms, ex vivo repair and
auto-transplantation should be considered.
Correct Answer C Hypogastric artery
Reference
Coleman, D. M., & Stanley, J. C. (2015). Renal artery aneurysms. J Vasc Surg, 62(3), 779–785. PMID:
26213273
9. RATIONALE
Postoperative mortality following open aneurysmectomy in most high-volume centers is
unusual following renal artery aneurysm repair. However, early complications, including
acute thrombosis of the reconstructed renal artery or one of its branches, occurs in 1%–2% of
cases. Segmental arterial occlusion usually causes a limited infarction of a small segment of
the kidney, resulting in renovascular hypertension. Late stenosis of the reconstructed arteries
may affect 2% of cases. Improvement in blood pressures has been observed in more than 50% of
patients undergoing surgical treatment of a renal artery aneurysm without coexisting stenotic
disease. Most large series document excellent postoperative renal artery patency rates well
above 90% at 10 years.
Correct Answer A 90% or greater
Reference
Henke, P. K., Cardneau, J. D., Welling, T. H., et al. (2001). Renal artery aneurysms: a 35-year clinical
experience with 252 aneurysms in 168 patients. Ann Surg, 234(4), 454–462; discussion 462–453.
PMID: 11573039
10. RATIONALE
The most frequent presenting feature of spontaneous renal artery dissection is uncontrolled
hypertension and sudden onset of severe flank pain. Definitive diagnosis is made by catheterbased angiography, multidetector CTA, and MRA, which are quite reliable in the diagnosis of
spontaneous renal artery dissection. Unilateral spontaneous renal dissection may be a risk factor
for the subsequent dissection of the contralateral renal artery. Medical management with pain
control and management of hypertension should be immediately started. The role of anticoagulation is controversial. Endovascular options are preferred, and in patients with luminal thrombosis, thrombolytics followed by covered stent are recommended. In this patient, a 6 Fr Ansel sheath
was used for support and a 0.018″ wire was maneuvered successfully into the true lumen. Two 6
mm × 2.5 cm overlapping Viabahn (W.L. Gore, Newark, DE) stents were deployed up to the first
bifurcation point, favoring the true lumen and restoring flow to the kidney. Surgical repair as a
definitive treatment has also been described in the literature but carries a higher morbidity.
Correct Answer D Covered stent
Reference
Afshinnia, F., Sundaram, B., Rao, P., et al. (2013). Evaluation of characteristics, associations and
clinical course of isolated spontaneous renal artery dissection. Nephrol Dial Transplant, 28(8),
2089–2098. PMID: 23563282
226 Section 10: Renal and Mesenteric Disease
11. RATIONALE
The patient’s history, lack of physical findings with elevated WBC count, and serum lactate
level are suggestive of superior mesenteric artery embolus. Fluid resuscitation and an emergency CTA of the abdomen and pelvis with contrast enhancement should be performed.
The findings showed a filling defect near the origin of the superior mesenteric artery
with some contrast seen in the superior mesenteric artery distal to the filling defect. The
patient underwent superior mesenteric artery via midline laparotomy using inframesocolic
Section 10: Renal and Mesenteric Disease 227
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
approach. Acute mesenteric ischemia is the result of superior mesenteric artery embolus
in 40% of cases and is usually associated with atrial fibrillation, valvular disease, recent
myocardial infarction, and arterial thrombosis in 30% of cases; arterial dissection in <5%;
and venous mesenteric infarction in 5%–15% with nonocclusive mesenteric hypoperfusion
in 10%–15% of cases. In contrast to thrombotic occlusion, the proximal 10–16 inches of jejunum is usually spared as the embolus lodges beyond the origin of the pancreaticoduodenal
arteries near the origin of the middle colic artery. In thrombotic occlusion, the entire small
bowel from the ligament of Treitz to the distal transverse colon is involved with ischemia.
Emergent treatment is necessary in acute mesenteric ischemia, which has a mortality
approaching 50%.
Correct Answer B CT scan of the abdomen and pelvis with IV contrast
Reference
Acosta, S., & Björck, M. (2003). Acute thrombo-embolic occlusion of the superior mesenteric artery: a
prospective study in a well defined population. Eur J Vasc Endovasc Surg, 26(2), 179–183. PMID:
12917835
12. RATIONALE
Preoperative arteriography showing occlusion of proximal
superior mesenteric artery and enlarged gastroduodenal
artery and arc of Rolen.
Intraoperative picture showing opened supramesenteric artery beyond occlusion and prosthetic graft to be
sutured to the arter y for distal anastomosis.
228 Section 10: Renal and Mesenteric Disease
Postoperative CTA showing patent antegrade supraceliac aorta to superior mesenteric artery by pass.
The diagnosis of chronic mesenteric artery ischemia remains a challenge and results in considerable morbidity and high mortality in patients affected with this condition. One of the most
devastating complications of chronic mesenteric ischemia is mesenteric arterial thrombosis
resulting in infarction of the bowel. Acute arterial thrombosis superimposed on preexisting
atherosclerotic disease represents the second most common cause of acute mesenteric ischemia, as up to 20% of patients with acute mesenteric ischemia have a demonstrated history of
chronic mesenteric ischemia. The diagnosis can be confirmed by readily available celiac and
mesenteric duplex imaging. The optimal method of treatment and type of revascularization
(open versus endovascular) and type of open reconstruction (transaortic endarterectomy versus
antegrade aortomesenteric versus retrograde aortomesenteric bypass) remains controversial.
In most reported series long-term patency using objective means is lacking. Endovascular
therapy is less invasive, but its success depends on the type of occlusion (stenosis versus total
long segment occlusion). Jimenez et al. reported on 47 patients with antegrade aortomesenteric
bypass using a prosthetic graft with satisfactory functional outcome, with in-hospital mortality
of 11%, primary patency of 69%, primary assisted patency 94%, and secondary patency of 100%
at 5 years.
Correct Answer B Antegrade supraceliac aorta to superior mesenteric artery bypass
Reference
Jimenez, J. G., Huber, T. S., Ozaki, C. K., et al. (2002). Durabilit y of antegrade synthetic aortomesenteric
bypass for chronic mesenteric ischemia. J Vasc Surg, 35(6), 1078–1084. PMID: 12042717
13. RATIONALE
Diagnosis of chronic mesenteric ischemia can be challenging. Classic symptoms include “food
fear” (sitophobia), abdominal pain, and weight loss. Abdominal pain is postprandial. In some
Section 10: Renal and Mesenteric Disease 229
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
patients, the clinical presentation of chronic mesenteric ischemia can be less specific with
vague abdominal pain, nausea, and vomiting with or without change in bowel habits. In the
past, high-grade stenosis or occlusion of at least two arteries (celiac, SMA, or IMA) had to be
demonstrated before diagnosing mesenteric ischemia. Since the superior mesenteric artery
supplies the major portion of the GI tract, severe stenosis or occlusion of the superior mesenteric
artery in isolation can present with symptoms of chronic mesenteric ischemia. The old concept
that mesenteric ischemia is due to limited blood supply to the small intestine during digestion
has been challenged. The latest concept is that ischemia of the small bowel is due to preferential
blood supply to the stomach upon food ingestion. Absence of collaterals (gastroduodenal, arc of
Riolan or marginal artery) indicates that celiac/mesenteric arterial occlusive disease is unlikely
to be hemodynamically significant.
Correct Answer D Medical management with surveillance duplex imaging of celiac and
superior mesenteric artery
Reference
Chang, R. W., Chang, J. B., & Longo, W. E. (2006). Update in management of mesenteric ischemia.
World J Gastroenterol, 12(20), 3243–3247. PMID: 16718846
14. RATIONALE
A retrograde bypass originating from the distal abdominal aorta or from the right common
iliac artery to the superior mesenteric artery in selected high-risk patients for whom an endovascular option does not exist can be used. This operation is performed using a transperitoneal
approach. An 8-mm externally supported PTFE graft is selected. The superior mesenteric artery
is exposed in the root of the mesentery to the right of the superior mesenteric vein and is dissected up to the level of the left renal vein. The distal aorta and right common iliac artery are
mobilized. The inflow anastomosis is performed first in an end-to-side fashion. The superior
mesenteric artery anastomosis is performed in an end-to-side antegrade manner. It is imperative to allow a gentle curve (C shape) for the graft to avoid kinking as the bowel returns to its
normal anatomic position in the abdomen. The graft is covered with the retroperitoneum and
greater omentum depending on the anatomical situation. An autologous conduit (femoral-popliteal vein) is preferred in patients with bowel infarction requiring resection.
Correct Answer C Retrograde bypass using a ringed prosthetic graft from infrarenal aorta or
right common iliac artery to superior mesenteric artery
Reference
Cho, J. S., Carr, J. A., Jacobsen, G., et al. (2002). Long-term outcome after mesenteric artery reconstruc-
tion: a 37-year experience. J Vasc Surg, 35(3), 453–460. PMID: 11877692
15. RATIONALE
Trapdoor aortic endarterectomy is best indicated in the setting of chronic mesenteric ischemia
with significant perivisceral aortic disease. It is most useful when the occlusion of the celiac
and superior mesenteric artery is confined to the proximal 2–3 cm. This operation should not
be used for acute mesenteric ischemia. The aorta is exposed using a left flank retroperitoneal
approach with the incision extending to the ninth intercostal space. The left kidney is mobilized
anteriorly, and the lumbar vein of the left renal vein is identified, ligated, and divided. The diaphragmatic left crus is divided, and the supraceliac aorta with the origin of celiac and superior
Соседние файлы в папке Библиотека им академика М.И. Перельмана