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
230 Section 10: Renal and Mesenteric Disease
mesenteric artery is exposed. The supraceliac aorta is dissected circumferentially. Following
heparinization, the aorta is clamped 2–3 cm above the celiac axis and 2–3 cm below the superior
mesenteric artery. The distal clamp may have to be placed below the left renal artery. The celiac
axis and superior mesenteric artery are controlled with double silastic vessel loops. Intravenous
mannitol (25–50 gm) is administered by the anesthesia team. The aortotomy is performed
around the orifices of the celiac and superior mesenteric artery. The plane of endarterectomy
is developed, and the visceral vessel orifices and extraction of the plaque is carried out with a
smooth feathered end. The aortotomy is closed with 4-0 cardiovascular polypropylene suture.
Correct Answer D Trapdoor aortic endarterectomy
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
16. RATIONALE
In the presence of bowel ischemia, one should strongly consider using autologous vein reconstruction. Although more time consuming and with the potential risks of kinking, redundancy, and
twisting, autologous grafts are more resistant to infection. One should be cognizant of the anatomic
position of the anastomosed bypass to the superior mesenteric artery, as the bypass may assume a
slightly different course when the bowel is returned to its proper anatomical position.
Dur ing ABF graft distal 16 inches of sma ll intest ine became ischemic. A retrograde by pass from t he right limb of the g raft
to SMA using reversed GSV–postoperative DSA.
Section 10: Renal and Mesenteric Disease 231
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Correct Answer D Retrograde bypass from the right limb of the aortobifemoral graft to the
superior mesenteric artery using greater saphenous vein harvested from the groin and upper
thigh
Reference
Hans, S. S. (2020). Mesenteric revascularization in a patient with acute on chronic bowel ischemia.
In S. S. Hans (Ed.), Challenging arterial reconstructions: 100 clinical cases (pp. 229–233). Cham,
Switzerland: Springer Nature Switzerland AG.
17. RATIONALE
Retrograde open superior mesenteric artery stenting is an attractive alternative to open
bypass or percutaneous stenting in patients with acute mesenteric ischemia who require
abdominal exploration and in those with flush mesenteric occlusion who have failed to
respond to conservative treatment and are unsuitable for stenting using percutaneous
access. During abdominal exploration, the transverse mesocolon is retracted cranially.
The rest of the mesentery is retracted to the right and opened longitudinally anterior to the
superior mesenteric artery. The superior mesenteric artery and its branches are dissected
free and controlled with silastic vessel loops. Following systemic heparinization the superior
mesenteric artery is accessed in a retrograde manner using a 0.018-inch micropuncture kit,
which is subsequently exchanged for a 0.035-inch guide wire, and a 6 Fr sheath is inserted.
Limited angiography is performed. A 5 Fr catheter angled 0.035″, 180 cm glide wire (Terumo
Interventional System, Sommerset, NJ) is used to cross the superior mesenteric artery lesion
into the abdominal aorta. The wire is then exchanged for a stiff Amplatz guide wire (Cook
Medical, Bloomington, IN). Primary stenting with a balloon-expandable stent is performed.
If retrograde access could not be obtained, antegrade access via a left brachial access
approach may be used.
Correct Answer C Retrograde superior mesenteric artery stenting and bowel resection with
bowel in discontinuity
Reference
Oderich, G. S., Macedo, R., Stone, D. H., et al. (2018). Multicenter study of retrograde open mesenteric
artery stenting through laparotomy for treatment of acute and chronic mesenteric ischemia.
J Vasc Surg, 68(2), 470–480.e471. PMID: 29548812
18. RATIONALE
Superior mesenteric artery stenting is less durable than open bypass, with a lower primary
patency and significant incidence of in-stent restenosis (20%–66%). Treatment with stent angioplasty is recommended in patients who develop recurrent symptoms of chronic mesenteric
ischemia or those with preocclusive in-stent restenosis. Tallarita et al. reported on 30 patients
with reintervention for mesenteric artery in-stent restenosis, with 24 patients presenting
with recurrent symptoms (21 chronic, 3 acute), and 6 had asymptomatic preocclusive lesions.
Twenty-six patients underwent repeat endovascular treatment with stent placement in 17 and
stent angioplasty in 9. The remaining four patients had open bypass, and one was performed
for acute ischemia. Mesenteric reinterventions were associated with low mortality (3%), high
complication rate (27%), and excellent symptom improvement (92%).
Correct Answer C Stent angioplasty
232 Section 10: Renal and Mesenteric Disease
Reference
Tallarita, T., Oderich, G. S., Macedo, T. A., et al. (2011). Reinterventions for stent restenosis in patients
treated for atherosclerotic mesenteric artery disease. J Vasc Surg, 54(5), 1422–1429.e1421. PMID:
21963821
19. RATIONALE
Embolization is a dreaded complication that can be identified following a technically successful
angioplasty and stenting. Some inherent risks arise from the “shaggy aorta.” These irregularities
can include soft plaque, calcific lesions, and ectatic segment that are crossed with the balloon
or stent delivery system. To reduce the risk of distal embolization in these high-risk patients,
it is paramount to have adequate preprocedure planning so that the approach allows for the
least catheter manipulation within the diseased aorta. In patients with severe acute angle of a
superior mesenteric artery in a diseased aortic segment, the femoral approach has an increased
risk of distal embolization. On the contrary, if the descending thoracic aorta has severe disease,
a retrograde femoral approach may be safer. Filter options should be considered in patients with
a high risk of embolization. Predilatation of the target lesion should not be overly aggressive
and should be performed to allow a safe passage of the stent. Inadequate anticoagulation can
result in thrombus formation in the sheath or catheter. If embolization does occur, aspiration
embolectomy catheters can be used to clear the debris by advancing the large-bore sheath close
to the embolic debris and performing strong aspiration. If the sheath cannot be advanced to the
area of embolization, a 5 Fr diagnostic catheter or an aspiration embolectomy catheter such as
Export catheter (Medtronic Corp., Santa Ana, CA) can be used to aspirate the debris. If aspiration is not successful, inflating the balloon may break the emboli into smaller pieces, resulting
in occlusion of very small branches of the mesenteric arteries and resulting in minimal ischemic damage.
Correct Answer D Preprocedure planning with selection of arterial access and availability of
filter options
Reference
Molnar, R. G., & Gandillion, C. (2021). Complications of endovascular therapy for occlusive dis-
ease of splanchnic arteries including renal arteries. In S. S. Hans & M. J. Conrad (Eds.),
Vascular and endovascular complications: a practical approach (pp. 35–40). Boca Raton, FL:
CRC Press.
20. RATIONALE
A meticulous technique ensuring true luminal positioning of the crossing wire is fundamental in treating occlusive lesions of the visceral vessels. Once the crossing catheter is
confirmed to be in the true lumen, a 0.014″ support wire and the use of balloon-expandable
stents should be used in small-diameter vessels with eccentric high-grade stenotic plaques.
Balloon-expandable stents are necessary for these ostial lesions to provide strong radial
force. For severely diseased segments, predilation with a standard balloon to approximately
greater than 5% of the reference vessel diameter will allow for safe placement of the stent
at the target lesion. If this is not performed, the balloon-mounted stent may not be able to
cross the lesion without resistance and with the possibility of stent becoming dislodged from
the balloon. The stent size should be one-to-one with the reference vessel diameter to avoid
Section 10: Renal and Mesenteric Disease 233
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
vessel perforation; distal dissection and undersizing can lead to malposition of the stent.
Should the crossing wire not be within the true lumen, the stent will be deployed in a subintimal plane and will likely lead to vessel occlusion.
Correct Answer D Ensuring true lumen position of the crossing wire by contrast injection
through a low-profile crossing catheter
Reference
Molnar, R. G., & Gandillion, C. (2021). Complications of endovascular therapy for occlusive dis-
ease of splanchnic arteries including renal arteries. In S. S. Hans & M. J. Conrad (Eds.),
Vascular and endovascular complications: a practical approach (pp. 35–40). Boca Raton, FL:
CRC Press.
21. RATIONALE
Aortorenal bypass with an internal iliac artery graft. (Reproduced with permission from Stanley JC, Zelenock GB,
Messina LM, et al. (1995). Pediatric renovascular hypertension: a thirty-year experience of operative treatment.
J Vasc Surg, 21,219.)
234 Section 10: Renal and Mesenteric Disease
Renal arter y-aortic (white arrow) and superior mesenteric artery-aortic (black arrow) implantation in conjunction with a
thoracoabdominal by pass for a suprarenal abdominal aortic coarctation and severe ostial stenoses of the implanted arteries.
(Reproduced with permission from Stanley JC, Criado E, Upchurch GR Jr., et al. (2006). Pediatric renovascu lar hypertension:
132 primary and 30 secondar y operations in 97 children. J Vasc Surg, 44:1219–1228. p. 1225.)
lntrarenal abdominal aortic coarctation (bracket), (a) associated with renal artery ostial stenoses. (b) Proximal abdominal patch aortoplasty (arrow) and bilateral renal artery aortic implantations. (Reproduced with permission from Stanley
JC, Criado E, Eliason JL, et al. (2008). Abdominal aortic coarctation: surgical treatment of 53 patients with a thoracoabdominal bypass, patch aortoplasty, or interposition aortoaortic graf t. J Vasc Surg, 44:1073–1082. p. 1077.)
Section 10: Renal and Mesenteric Disease 235
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Patients with TA should undergo vascular reconstruction when the disease is in remission.
Renal artery-aortic reimplantation with abdominal aortic patch angioplasty using a PTFE patch
is preferred, as the Dacron patch may undergo late aneurysmal deterioration. Patches are made
large enough so as not to be constrictive as the child grows into adulthood. In certain instances,
a primary thoracoabdominal bypass is favored over aortoplasty because of the patient’s age
and the risk of anastomotic disease affecting the renal or splanchnic arteries. PTFE prostheses
are preferable over a Dacron graft. Extraperitoneal reflection of the abdominal viscera provides
excellent access to the upper abdominal aorta, which is the site of bypass origin. Grafts
originating in the chest are easily tunneled through the posterior diaphragm, behind the left
kidney though the distal aorta. Critical ostial stenosis of the celiac and superior mesenteric
artery should be reconstructed at the time of treatment of developmental aortic and renal artery
narrowing. However, many children are often critically ill, which will add to the complexity of
the procedure. Recurrent stenosis or technical failures affect nearly 15% of these.
Correct Answer
B Primary angioplasty with PTFE patch and bilateral renal artery
reimplantation
Reference
Stanley, J. C., Criado, E., Eliason, J. L., et al. (2008). Abdominal aortic coarctation: surgical treatment
of 53 patients with a thoracoabdominal bypass, patch aortoplasty, or interposition aortoaortic
graft. J Vasc Surg, 48(5), 1073–1082. PMID: 18692352
22. RATIONALE
Exposure of aortorenal bypass procedures in children is like that undertaken in adults undergoing
similar bypass procedures. The internal iliac artery is the preferred conduit when treating midstenosis or distal main renal artery stenosis in children. In children, stenosis involving the origin
of the main renal artery, small-diameter renal artery branches, or accessory renal arteries beyond
a stenotic segment can be implanted into aorta. In the case of branches, an accessory renal artery
can be implanted into the non-diseased adjacent main or segmental renal artery. Anastomoses
are spatulated and completed with interrupted sutures in very young children with small arteries.
Stenosis of multiple small renal arteries may require approximation of these vessels to form a large
common orifice to which an aortorenal graft can be anastomosed. Synthetic prosthetic grafts
are rarely used for pediatric renal artery reconstruction because of the risk of infection, technical
difficulties, and unpredictable long-term durability. Vein grafts are not favored because of their
propensity to undergo late aneurysmal dilation. When other, more acceptable reconstructive
procedures prove impossible and a vein is the only conduit available, it should be covered with a
synthetic mesh to decrease the chance of aneurysmal dilation.
Correct Answer
D Internal iliac artery graft
Reference
Stanley, J. C., Criado, E., Eliason, J. L., et al. (2008). Abdominal aortic coarctation: surgical treatment
of 53 patients with a thoracoabdominal bypass, patch aortoplasty, or interposition aortoaortic
graft. J Vasc Surg, 48(5), 1073–1082. PMID: 18692352
23. RATIONALE
Direct renal artery implantation and single-staged concomitant aortic reconstruction offer
excellent results with a cure of hypertension in 70%, improved in 25%, and unchanged in 5%,
236 Section 10: Renal and Mesenteric Disease
with a negligible operative mortality. Impaired renal function before and after the operative
procedure occurs in <1% of these patients. Recurrent stenosis or technical failure affects nearly
15% of these young children and will require later secondary intervention. These children
have very complex disease, and optimal care demands careful planning of open arterial
reconstruction.
Correct Answer C 70% of patients
Reference
Stanley, J. C., Criado, E., Eliason, J. L., et al. (2008). Abdominal aortic coarctation: surgical treatment
of 53 patients with a thoracoabdominal bypass, patch aortoplasty, or interposition aortoaortic
graft. J Vasc Surg, 48(5), 1073–1082. PMID: 18692352
SECTION 11: UPPER EXTREMITY
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
ARTERIAL DISEASE
MCQs 1–10
Q1. The most common reason for repair of a
subclavian artery aneurysm is:
A. To prevent thromboembolic
complications
B. Brachial plexopathy
C. Subclavian vein compression
D. To prevent rupture
Q2. The most common nerve injured during
open repair of a subclavian artery aneurysm in its second portion is:
A. Vagus
B. Recurrent laryngeal
C. Phrenic
D. Lower cord of brachial plexus
Q3. The incidence of axillary and brachial
artery aneurysms among peripheral
artery aneurysms is:
A. <1%
B. 1%–3%
C. 3.1%–4%
D. 4.1%–5%
Q4. Repair of axillary and brachial artery
aneurysm is recommended for an aneurysm size of:
A. 0.5–1 cm
B. 1.1–1.5 cm
C. 1.6–1.9 cm
D. >2 cm
Q5. For distal ulnar arterial bypass, the con-
duit of choice is:
A. Greater saphenous vein
B. Basilic vein/cephalic vein from ipsilateral
arm
C. Basilic vein/cephalic vein from contralat-
eral arm
D. Contralateral radial artery
Q6. Patients with critical hand ischemia
resulting from arterial occlusive disease
secondary to diabetes mellitus and associated end-stage renal disease have a 2-year
survival of:
A. 60%
B. 50%
C. 45%
D. 30%
Q7. Hypothenar hammer syndrome is caused
by:
A. Occlusion of the radial artery
B. Trauma to the distal ulnar artery as it
passes through Guyon canal
C. Post-stenotic dilatation/aneurysm from
arterial thoracic outlet syndrome
D. Scleroderma
Q8. Upper extremity compartment syndrome
most often involves:
A. Extensor compartment
B. Superficial flexor compartment
C. Deep flexor compartment
D. Superficial and deep flexor
compartments
Q9. The risks of upper extremity ischemia in
patients with occlusion of an axillofemoral graft is:
A. <1%
B. 1%–2%
C. 2.5%
D. 3%
DOI: 10.1201/9781003389897-11
238 Section 11: Upper Extremity Arterial Disease
Q10. Anastomotic disruption and pseudoaneu-
rysm following axillofemoral bypass graft
at proximal anastomosis is due to:
A. Technical error
B. Infection
C. Failure to leave redundancy in the graft
D. Infection, technical error, and failure to
leave redundancy in the graft
Section 11: Upper Extremity Arterial Disease 239
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
RATIONALE 1–10
1. RATIONALE
The majority of subclavian artery aneurysms (SAAs) are located in the proximal segment (39%).
The middle segment accounts for 25% and distal segment 24% with associated involvement of
the proximal axillary artery. Indications for subclavian artery aneurysm repair include size
>2 cm, symptoms, or size >1.5 cm and concurrent operation for other aortic pathology. Proximal
aneurysms are mostly caused by atherosclerotic disease, collagen disorders, trauma, and
infection. The middle segment SAAs are mainly caused by collagen disorders and trauma.
Distal SAAs are mostly described in relation to thoracic outlet syndrome or as a consequence
of blunt or penetrating trauma. Most patients present with a pulsating mass and shoulder pain.
Other symptoms include pain from distal embolization and symptoms from local compression,
thrombosis, and rupture. Duplex ultrasound scanning for distal SCCA, CTA, and catheter-based
angiography are often necessary prior to open repair. Despite the increasing interest in endovascular repair of the aneurysm, open repair of the subclavian artery is preferable and requires
thoracotomy. For repair of proximal SAAs, sternotomy without supraclavicular and transclavicular/infraclavicular incision with partial resection of the clavicle may be necessary. The majority of subclavian artery aneurysm and nearly all aberrant subclavian artery aneurysms can now
be repaired using a TEVAR-based approach without the need for sternotomy or thoracotomy.
Correct Answer A To prevent thromboembolic complications
Reference
Andersen, N. D., Barfield, M. E., Hanna, J. M., et al. (2013). Intrathoracic subclavian artery aneurysm
repair in the thoracic endovascular aortic repair era. J Vasc Surg, 57(4), 915–925. PMID: 23375432
2. RATIONALE
The recurrent laryngeal nerve injury is the most common nerve to be injured during open
repair of a subclavian artery aneurysm resulting in hoarseness. Stent graft repair is being
increasingly utilized, but these options are dependent on the anatomical characteristics of the
aneurysm and vascular access. Traumatic subclavian artery aneurysm and iatrogenic subclavian artery aneurysm are best repaired using endovascular techniques. Patency of the reconstruction following endovascular repair may further improve with the development of better
stent grafts, as in-stent stenosis and thrombosis were reported in an earlier series.
Correct Answer B Recurrent laryngeal
Reference
Vierhout, B. P., Zeebregts, C. J., van den Dungen, J. J., & Reijnen, M. M. (2010). Changing profiles of
diagnostic and treatment options in subclavian artery aneurysms. Eur J Vasc Endovasc Surg,
40(1), 27–34. PMID: 20399124
3. RATIONALE
Most aneurysms involving the upper extremity arteries are posttraumatic or secondary to
connective tissue disorders or congenital in origin. These aneurysms are relatively uncommon and account for <1% of all peripheral artery aneurysms. Chronic repetitive trauma from
the use of crutches can cause aneurysmal degeneration in the proximity arteries (axillary and
high brachial) in the upper extremity. All symptomatic true and all pseudoaneurysms in the
Соседние файлы в папке Библиотека им академика М.И. Перельмана