• 四川大學(xué)華西醫(yī)院血管中心（四川成都 610041）;

目的 　了解高風(fēng)險腹主動脈瘤患者行開放和腔內(nèi)治療術(shù)后嚴重并發(fā)癥的發(fā)生率，分析其原因并總結(jié)防治經(jīng)驗。
方法 　回顧性分析2009年1月至2011年9月期間我院收治的57 例高風(fēng)險腹主動脈瘤患者的臨床資料（高風(fēng)險定義為年齡≥60歲、美國麻醉醫(yī)師協(xié)會分級3或4級、且至少有一個心臟或肺或腎方面的合并癥）。統(tǒng)計手術(shù)后嚴重并發(fā)癥發(fā)生率，分析術(shù)前合并癥、手術(shù)方式、麻醉方式與術(shù)后嚴重并發(fā)癥的關(guān)系。
結(jié)果 　57例高風(fēng)險腹主動脈瘤患者中，行腹主動脈瘤腔內(nèi)修復(fù)術(shù)（即腔內(nèi)治療）41例，行腹主動脈瘤切除人造血管移植術(shù)（即開放手術(shù)）16例。術(shù)后近期（30d內(nèi)）病死率為1.8% （1/57），術(shù)后嚴重并發(fā)癥發(fā)生率為19.3% （11/57）。其中心血管并發(fā)癥發(fā)生率為8.8% （5/57），呼吸道并發(fā)癥發(fā)生率為8.8% （5/57），急性腎功能衰竭發(fā)生率為1.8% （1/57）。術(shù)前有冠心病者心血管并發(fā)癥發(fā)生率高〔19.0% （4/21）比2.8% （1/36）， χ2=4.387， P＜0.05〕，而心血管并發(fā)癥發(fā)生率與有或無高血壓無關(guān)〔10.3% （4/39）比5.6% （1/18）， χ2=0.340， P＞0.05〕。術(shù)前有肺功能異常者術(shù)后呼吸道并發(fā)癥發(fā)生率高 〔20.0% （4/20）比5.6% （1/18）， χ2= 4.387，P＜0.05〕，有或無慢性阻塞性肺病病史與術(shù)后呼吸道并發(fā)癥發(fā)生率無關(guān)〔13.2% （5/38）比0 （0/19），χ2=2.740，P＞0.05〕。術(shù)前有或無腎功能損傷與急性腎功能衰竭無關(guān)〔0 （0/4）比1.9% （1/53），χ2=0.077，P＞0.05〕。腔內(nèi)治療術(shù)后并發(fā)癥發(fā)生率低于傳統(tǒng)開放手術(shù)〔12.2% （5/41）比37.5% （6/16），χ2=3.980，P＜0.05〕。在術(shù)后呼吸道并發(fā)癥的發(fā)生率上，監(jiān)護麻醉的患者較全身麻醉的患者低〔0（0/20）比19.0% （4/21），χ2=4.221，P＜0.05〕。
結(jié)論 　高風(fēng)險腹主動脈瘤患者術(shù)后嚴重并發(fā)癥以心、肺疾病居多。術(shù)前心肺功能、麻醉及手術(shù)方式的選擇與術(shù)后嚴重并發(fā)癥有關(guān)。術(shù)前對各個系統(tǒng)進行充分的評估，選擇合理的麻醉及手術(shù)方式，術(shù)后積極、有效的對癥、支持治療是降低術(shù)后并發(fā)癥發(fā)生率的關(guān)鍵。

引用本文： 池魁,趙紀春. 高風(fēng)險腹主動脈瘤開放和腔內(nèi)治療術(shù)后嚴重并發(fā)癥的分析及防治. 中國普外基礎(chǔ)與臨床雜志, 2012, 19(5): 512-516. doi: 復(fù)制

1. Dubost C， Allary M， Oeconomos N. Resection of an aneurysm of the abdominal aorta：reestablishment of the continuity by a preserved arterial graft， with result after five months [J]. Arch Surg， 1952， 64(3)：405-408.
2. Wahlgren CM， Malmstedt J. Outcomes of endovascular abdominal aortic aneurysm repair compared with open surgical repair in high-risk patients：results from the Swedish Vascular Registry [J]. J Vasc Surg， 2008， 48(6)：1382-1388.
3. Dindo D， Demartines N， Clavien PA. Classification of surgical complications：a new proposal with evaluation in a cohort of 6 336 patients and results of a survey [J]. Ann Surg， 2004，240(2)：205-213.
4. Allaqaband S， Mortada ME， Tumuluri R， et al. Endovascular stent graft repair of abdominal aortic aneurysms in high-risk patients：a single center experience [J]. J Interv Cardiol， 2004，17(2)：71-79.
5. Parodi JC， Palmaz JC， Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms [J]. Ann Vasc Surg， 1991， 5(6)：491-499.
6. AbuRahma AF， Campbell J， Stone PA， et al. The correlation of aortic neck length to early and late outcomes in endovascular aneurysm repair patients [J]. J Vasc Surg， 2009， 50(4)：738-748.
7. Schouten O， van Waning VH， Kertai MD， et al. Perioperative and long-term cardiovascular outcomes in patients undergoing endovascular treatment compared with open vascular surgery for abdominal aortic aneurysm or iliaco-femoro-popliteal bypass [J].Am J Cardiol， 2005， 96(6)：861-866.
8. Drury D， Michaels JA， Jones L， et al. Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm [J]. Br J Surg， 2005， 92(8)：937-946.
9. Greenberg RK， Sternbergh WC 3rd， Makaroun M， et al. Intermediate results of a United States multicenter trial of fenestrated endograft repair for juxtarenal abdominal aortic aneurysms [J].J Vasc Surg， 2009， 50(4)：730-737.
10. Lovegrove RE， Javid M， Magee TR， et al. A meta-analysis of 21 178 patients undergoing open or endovascular repair of abdominal aortic aneurysm [J]. Br J Surg， 2008， 95(6)：677-684.
11. Sajid MS， Desai M， Haider Z， et al. Endovascular aortic aneurysm repair (EVAR) has significantly lower perioperative mortality in comparison to open repair：a systematic review [J]. Asian J Surg， 2008， 31(3)：119-123.
12. Richardson JD， Main KA. Repair of abdominal aortic aneurysms. A statewide experience [J]. Arch Surg， 1991， 126(5)：614-616.
13. Johnston KW. Multicenter prospective study of nonruptured abdominal aortic aneurysm. Part Ⅱ：variables predicting morbidity and mortality [J]．J Vasc Surg， 1989， 9(3)：437-447.
14. Huber TS， McGorray SP， Carlton LC， et al. Intraoperative autologous transfusion during elective infrarenal aortic reconstruction：a decision analysis model [J]. J Vasc Surg， 1997， 25(6)：984-993.
15. JCS Joint Working Group. Guidelines for perioperative cardiovascular evaluation and management for noncardiac surgery (JCS 2008) — digest version [J]. Circ J， 2011， 75(4)：989-1009.
16. Fleisher LA， Beckman JA， Brown KA， et al. ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery：focused update on perioperative beta-blocker therapy — a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) [J]. Anesth Analg， 2007， 104(1)：15-26.
17. Kahn RA， Moskowitz DM， Marin M， et al. Anesthetic considerations for endovascular aortic repair [J]. Mt Sinai J Med，2002， 69(1-2)：57-67.
18. Vemuri C， Wainess RM， Dimick JB， et al. Effect of increasing patient age on complication rates following intact abdominal aortic aneurysm repair in the United States [J]. J Surg Res， 2004，118(1)：26-31.
19. Szostek M， Krepski K， Ma?ek AK， et al. Complication risk after abdominal aortic aneurysm operations [J]. Pol Merkur Lekarski，1999， 7(40)：172-174.
20. Geisbüsch P， Leszczynsky M， Kotelis D， et al. Open versus endovascular repair of acute aortic transections — a nonrandomized single-center analysis [J]. Langenbecks Arch Surg，2009， 394(6)：1101-1107.
21. 黃建華， 劉光強， 符洋， 等. 腹主動脈瘤手術(shù)切除與腔內(nèi)治療療效的比較 [J]. 中國普通外科雜志， 2008， 17(6)：542-545.
22. Walsh SR， Bhutta H， Tang TY， et al. Anaesthetic specialisation leads to improved early- and medium-term survival following major vascular surgery [J]. Eur J Vasc Endovasc Surg， 2010，39(6)：719-725.
23. Bonfreschi V， Giuliani E， Malagnino FC， et al. Analgesia during abdominal aortic aneurysm endovascular repair：remifentanil vs. fentanyl-midazolam — a randomized controlled trial [J].Eur J Anaesthesiol， 2009， 26(9)：782-787.
24. Ruppert V， Leurs LJ， Steckmeier B， et al. Influence of anesthesia type on outcome after endovascular aortic aneurysm repair：an analysis based on Eurostar data [J]. J Vasc Surg， 2006， 44(1)：16-21.
25. Verhoeven EG， Cinã CS， Tielliu IJ， et al. Local anesthesia for endovascular abdominal aortic aneurysm repair [J]. J Vasc Surg， 2005， 42(3)：402-402.
26. De Virgilio C， Romero L， Donayre C， et al. Endovascular abdominal aortic aneurysm repair with general versus local anesthesia：a comparison of cardiopulmonary morbidity and mortality rates [J]. J Vasc Surg， 2002， 36(5)：988-991.
27. Sugino S， Omote K， Kawamata M， et al. Anesthetic management of endovascular repair for aortic abdominal aneurysm in a patient with severe chronic obstructive pulmonary disease [J].Masui， 2006， 55(12)：1480-1483.
28. Sadat U， Cooper DG， Gillard JH， et al. Impact of the type of anesthesia on outcome after elective endovascular aortic aneurysm repair：literature review [J]. Vascular， 2008， 16(6)：340-345.
29. Parras Maldonado MT， Ramos Lozano R， García Saura PL， et al. Endovascular treatment of a ruptured abdominal aorta aneurysm with local anesthesia， sedation and analgesia [J]. Rev Esp Anestesiol Reanim， 2009， 56(3)：193-194.
30. Lippmann M， Lingam K， Rubin S， et al. Anesthesia for endovascular repair of abdominal and thoracic aortic aneurysms：a review article [J]. J Cardiovasc Surg (Torino)， 2003， 44(3)：443-451.
31. Bettex DA， Lachat M， Pfammatter T， et al. To compare general，epidural and local anaesthesia for endovascular aneurysm repair (EVAR) [J]. Eur J Vasc Endovasc Surg， 2001， 21(2)：179-184.
  1. 1. Dubost C， Allary M， Oeconomos N. Resection of an aneurysm of the abdominal aorta：reestablishment of the continuity by a preserved arterial graft， with result after five months [J]. Arch Surg， 1952， 64(3)：405-408.
  2. 2. Wahlgren CM， Malmstedt J. Outcomes of endovascular abdominal aortic aneurysm repair compared with open surgical repair in high-risk patients：results from the Swedish Vascular Registry [J]. J Vasc Surg， 2008， 48(6)：1382-1388.
  3. 3. Dindo D， Demartines N， Clavien PA. Classification of surgical complications：a new proposal with evaluation in a cohort of 6 336 patients and results of a survey [J]. Ann Surg， 2004，240(2)：205-213.
  4. 4. Allaqaband S， Mortada ME， Tumuluri R， et al. Endovascular stent graft repair of abdominal aortic aneurysms in high-risk patients：a single center experience [J]. J Interv Cardiol， 2004，17(2)：71-79.
  5. 5. Parodi JC， Palmaz JC， Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms [J]. Ann Vasc Surg， 1991， 5(6)：491-499.
  6. 6. AbuRahma AF， Campbell J， Stone PA， et al. The correlation of aortic neck length to early and late outcomes in endovascular aneurysm repair patients [J]. J Vasc Surg， 2009， 50(4)：738-748.
  7. 7. Schouten O， van Waning VH， Kertai MD， et al. Perioperative and long-term cardiovascular outcomes in patients undergoing endovascular treatment compared with open vascular surgery for abdominal aortic aneurysm or iliaco-femoro-popliteal bypass [J].Am J Cardiol， 2005， 96(6)：861-866.
  8. 8. Drury D， Michaels JA， Jones L， et al. Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm [J]. Br J Surg， 2005， 92(8)：937-946.
  9. 9. Greenberg RK， Sternbergh WC 3rd， Makaroun M， et al. Intermediate results of a United States multicenter trial of fenestrated endograft repair for juxtarenal abdominal aortic aneurysms [J].J Vasc Surg， 2009， 50(4)：730-737.
  10. 10. Lovegrove RE， Javid M， Magee TR， et al. A meta-analysis of 21 178 patients undergoing open or endovascular repair of abdominal aortic aneurysm [J]. Br J Surg， 2008， 95(6)：677-684.
  11. 11. Sajid MS， Desai M， Haider Z， et al. Endovascular aortic aneurysm repair (EVAR) has significantly lower perioperative mortality in comparison to open repair：a systematic review [J]. Asian J Surg， 2008， 31(3)：119-123.
  12. 12. Richardson JD， Main KA. Repair of abdominal aortic aneurysms. A statewide experience [J]. Arch Surg， 1991， 126(5)：614-616.
  13. 13. Johnston KW. Multicenter prospective study of nonruptured abdominal aortic aneurysm. Part Ⅱ：variables predicting morbidity and mortality [J]．J Vasc Surg， 1989， 9(3)：437-447.
  14. 14. Huber TS， McGorray SP， Carlton LC， et al. Intraoperative autologous transfusion during elective infrarenal aortic reconstruction：a decision analysis model [J]. J Vasc Surg， 1997， 25(6)：984-993.
  15. 15. JCS Joint Working Group. Guidelines for perioperative cardiovascular evaluation and management for noncardiac surgery (JCS 2008) — digest version [J]. Circ J， 2011， 75(4)：989-1009.
  16. 16. Fleisher LA， Beckman JA， Brown KA， et al. ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery：focused update on perioperative beta-blocker therapy — a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) [J]. Anesth Analg， 2007， 104(1)：15-26.
  17. 17. Kahn RA， Moskowitz DM， Marin M， et al. Anesthetic considerations for endovascular aortic repair [J]. Mt Sinai J Med，2002， 69(1-2)：57-67.
  18. 18. Vemuri C， Wainess RM， Dimick JB， et al. Effect of increasing patient age on complication rates following intact abdominal aortic aneurysm repair in the United States [J]. J Surg Res， 2004，118(1)：26-31.
  19. 19. Szostek M， Krepski K， Ma?ek AK， et al. Complication risk after abdominal aortic aneurysm operations [J]. Pol Merkur Lekarski，1999， 7(40)：172-174.
  20. 20. Geisbüsch P， Leszczynsky M， Kotelis D， et al. Open versus endovascular repair of acute aortic transections — a nonrandomized single-center analysis [J]. Langenbecks Arch Surg，2009， 394(6)：1101-1107.
  21. 21. 黃建華， 劉光強， 符洋， 等. 腹主動脈瘤手術(shù)切除與腔內(nèi)治療療效的比較 [J]. 中國普通外科雜志， 2008， 17(6)：542-545.
  22. 22. Walsh SR， Bhutta H， Tang TY， et al. Anaesthetic specialisation leads to improved early- and medium-term survival following major vascular surgery [J]. Eur J Vasc Endovasc Surg， 2010，39(6)：719-725.
  23. 23. Bonfreschi V， Giuliani E， Malagnino FC， et al. Analgesia during abdominal aortic aneurysm endovascular repair：remifentanil vs. fentanyl-midazolam — a randomized controlled trial [J].Eur J Anaesthesiol， 2009， 26(9)：782-787.
  24. 24. Ruppert V， Leurs LJ， Steckmeier B， et al. Influence of anesthesia type on outcome after endovascular aortic aneurysm repair：an analysis based on Eurostar data [J]. J Vasc Surg， 2006， 44(1)：16-21.
  25. 25. Verhoeven EG， Cinã CS， Tielliu IJ， et al. Local anesthesia for endovascular abdominal aortic aneurysm repair [J]. J Vasc Surg， 2005， 42(3)：402-402.
  26. 26. De Virgilio C， Romero L， Donayre C， et al. Endovascular abdominal aortic aneurysm repair with general versus local anesthesia：a comparison of cardiopulmonary morbidity and mortality rates [J]. J Vasc Surg， 2002， 36(5)：988-991.
  27. 27. Sugino S， Omote K， Kawamata M， et al. Anesthetic management of endovascular repair for aortic abdominal aneurysm in a patient with severe chronic obstructive pulmonary disease [J].Masui， 2006， 55(12)：1480-1483.
  28. 28. Sadat U， Cooper DG， Gillard JH， et al. Impact of the type of anesthesia on outcome after elective endovascular aortic aneurysm repair：literature review [J]. Vascular， 2008， 16(6)：340-345.
  29. 29. Parras Maldonado MT， Ramos Lozano R， García Saura PL， et al. Endovascular treatment of a ruptured abdominal aorta aneurysm with local anesthesia， sedation and analgesia [J]. Rev Esp Anestesiol Reanim， 2009， 56(3)：193-194.
  30. 30. Lippmann M， Lingam K， Rubin S， et al. Anesthesia for endovascular repair of abdominal and thoracic aortic aneurysms：a review article [J]. J Cardiovasc Surg (Torino)， 2003， 44(3)：443-451.
  31. 31. Bettex DA， Lachat M， Pfammatter T， et al. To compare general，epidural and local anaesthesia for endovascular aneurysm repair (EVAR) [J]. Eur J Vasc Endovasc Surg， 2001， 21(2)：179-184.