选择成人巨大房间隔缺损介入治疗封堵器的影响因素

目的 分析选择成人巨大房间隔缺损（ASD）介入治疗封堵器的影响因素。方法 回顾性分析65例接受介入治疗的巨大ASD患者,分析封堵器选择与缺损直径、缺损形态及缺损边缘状况的关系。结果 65例均封堵成功。26例采用直径为40 mm封堵器、24例42 mm、15例≥ 44 mm,三者间缺损最大直径、最小直径及二者比值、封堵器加大值差异均无统计学意义（P均>0.05）。缺损最小直径/缺损最大直径<0.80（n=24）与≥ 0.80（n=41）二者之间缺损最大直径、最小直径及封堵器加大值差异均有统计学意义（P均<0.05）,缺损主动脉缘或后下缘<5 mm（n=45）与≥ 5 mm（n=20）二者之间封堵器直径、封堵器加大值差异有统计学意义（P均<0.05）。结论 介入治疗成人巨大ASD时,缺损直径、缺损形态及其边缘情况均影响封堵器选择。     

植入Pipeline血流导向装置治疗颈内动脉未破裂动脉瘤后动脉瘤不完全闭塞的影响因素

目的 分析植入Pipeline血流导向装置治疗颈内动脉未破裂动脉瘤后动脉瘤不完全闭塞的影响因素。方法 回顾性分析102例接受植入Pipeline血流导向装置的单发颈内动脉未破裂动脉瘤患者,通过随访观察动脉瘤是否完全闭塞;采用单因素分析及多因素logistic回归分析筛选动脉瘤不完全闭塞的影响因素。结果 对102例均成功植入Pipeline。术后随访6~17个月,期间67例动脉瘤完全闭塞（完全闭塞组）、35例未完全闭塞（未完全闭塞组）,组间患者性别、年龄及基础疾病等差异均无统计学意义（P均>0.05）,而既往支架植入史、术中是否联合应用弹簧圈栓塞、动脉瘤颈宽≥10 mm、瘤颈处存在分支血管及入射角度≥150°差异均有统计学意义（P均<0.05）。多因素logistic回归分析显示,既往支架植入史（OR=56.08、P<0.01）、瘤颈处存在分支血管（OR=11.35、P<0.01）和入射角度≥150°（OR=9.60、P<0.01）均为Pipeline血流导向装置治疗颈内动脉未破裂动脉瘤后不完全闭塞的危险因素,术中联合应用弹簧圈栓塞则为其保护因素（OR=0.07、P<0.01）。结论 既往支架植入史、瘤颈处存在分支血管、入射角度≥150°及联合应用弹簧圈栓塞均为植入Pipeline治疗颈内动脉未破裂动脉瘤后动脉瘤不完全闭塞的影响因素。     

经颈内静脉植入输液港:导管尖端处于不同位置时1年内并发症发生率与导管通畅率

目的 对比观察经颈内静脉（IJV）入路植入完全植入式静脉输液港（TIVAP）后,导管尖端处于不同位置时1年内并发症发生率及导管通畅率。方法 回顾性分析2 104例接受经IJV入路植入TIVAP的肿瘤患者,将接受经右IJV入路者（R组,n=1 903）分为导管尖端位于右心房上部［即上腔静脉（SVC）与右心房交界（CAJ）下方0.5～1.0 cm亚组（R1亚组,n=376）］与位于SVC下1/3至CAJ间亚组（R2亚组,n=1 527）,将接受经左IJV入路者（L组,n=201）相应分为L1亚组（n=64）及L2亚组（n=137）;记录2组内各亚组患者基本资料、植入TIVAP 1年内并发症发生率及导管通畅率,并进行亚组间比较。结果 2组内亚组间患者性别、年龄、临床诊断及肿瘤分期,以及气胸/血气胸、局部皮肤损伤、TIVAP感染、导管相关性血栓、药物外渗、导管移位及心律失常等并发症发生率差异均无统计学意义（P均＞0.05）。R1（94.15%）与R2亚组（93.78%）（χ²=0.069,P=0.793）、L1（98.44%）与L2亚组（89.78%）1年内导管通畅率差异均无统计学意义（Yates连续性校正χ²=3.563,P=0.059）。结论 经左或右IJV入路植入TIVAP后,导管尖端位于右心房上部与SVC下1/3与CAJ之间时,1年内并发症发生率及导管通畅率均无明显差异。     

微导丝贯穿法联合臭氧介入治疗输卵管阻塞性不孕症

目的 观察微导丝贯穿法联合臭氧介入治疗输卵管阻塞性不孕症效果。方法 回顾性分析149例输卵管阻塞性不孕症患者资料,其中A组（n=44）接受常规输卵管再通术（FTR）,B组（n=51）接受微导丝贯穿法FTR,C组（n=54）接受微导丝贯穿法联合臭氧FTR治疗;比较治疗后1个月各组输卵管复通率及1年内自然妊娠率。结果 治疗后1个月,A、B、C组输卵管复通率分别为63.38%（45/71）、80.22%（73/91）及92.78%（90/97）,各组依次升高（P均＜0.05）;1年内A、B、C组自然妊娠率分别为20.45%（9/44）、27.45%（14/51）及48.15%（26/54）,C组高于A、B组（P均＜0.05）,且A、B组差异无统计学意义（P=0.427）。结论 微导丝贯穿法联合臭氧介入治疗输卵管阻塞性不孕症效果优于常规FTR及单独微导丝贯穿法FTR。     

YOLOX目标检测模型用于自动识别数字减影血管造影图中的血管腔内介入器械

目的 观察YOLOX目标检测模型用于自动识别数字减影血管造影（DSA）图中的血管腔内介入器械的价值。方法 收集37例接受腹部血管腔内介入治疗患者的DSA资料,截取4 435幅图像作为数据集,并按照9∶1比例将其分为训练集（n=3 991）与验证集（n=444）。对数据集中的6种介入器械进行标记后,以YOLOX算法对训练集数据进行深度学习训练,构建YOLOX目标检测模型;基于验证集评估该模型自动识别DSA图中的介入器械的效能。结果 共对4 435幅DSA图像设置6 668个标签,分别针对Terumo 0.035in泥鳅导丝（n=587）、Cook Lunderquist超硬导丝（n=990）、Optimed 5F带刻度猪尾导管（n=1 680）、Cordis MPA多功能导管（n=667）、Boston Scientific V-18可控导丝（n=1 330）及Terumo 6F长鞘（n=1 414）;训练集分别含上述标签527、875、1 466、598、1 185及1 282个,验证集分别含60、115、214、69、145及132个。YOLOX目标检测模型自动识别验证集中上述器械的像素准确率分别为95.23%、97.32%、99.18%、98.97%、97.60%及98.19%,平均像素准确率达97.75%。结论 YOLOX目标检测模型能够自动识别DSA图中的多种血管腔内介入器械。     

对比观察血管支架植入术与药物治疗青年脑梗死合并大脑中动脉狭窄效果

目的 对比观察脑血管支架植入术与药物治疗青年脑梗死合并大脑中动脉狭窄的效果。方法 71例（30~44岁）脑梗死合并大脑中动脉重度狭窄（狭窄率>70%）患者,分别接受常规口服药物治疗（药物组,n=39）和支架植入术（支架组,n=32）,比较2组相关指标。结果 支架组手术成功率100%,共植入32枚支架。2组患者入组时及随访3、6、12、24个月,改良Rankin量表（mRS）评分、美国国立卫生研究院卒中量表（NIHSS）评分组内比较差异均有统计学意义（P均<0.01）,mRS、NIHSS评分组间比较差异均无统计学意义（P均>0.05）。随访期间药物组终点事件发生率、卒中再发率及再发卒中致残率（mRS评分≥ 2分）分别为20.51%（8/39）、20.51%（8/39）及20.51%（8/39）,支架组分别为6.25%（2/32）、3.13%（1/32）及3.13%（1/32）,2组间终点事件发生率差异无统计学意义（P=0.17）,支架组卒中复发率（P=0.04）及再发卒中致残率（P=0.04）均低于药物组。结论 相比药物治疗,植入支架可降低青年脑梗死合并大脑中动脉狭窄患者卒中复发率及致残率。     

对比冷冻消融与微波消融治疗兔VX2椎旁肿瘤的有效性及安全性

目的 对比冷冻消融（CA）与微波消融（MWA）治疗兔VX2椎旁肿瘤的有效性及安全性。方法 选取48只新西兰大白兔建立VX2椎旁肿瘤模型并随机分为CA组（n=24）及MWA组（n=24）,比较组间完全消融率、生存率、布里斯托尔兔疼痛量表（BRPS）评分及并发症发生率。结果 CA组完全消融率及治疗后21天生存率分别为91.67%（22/24）及33.33%（8/24）,均高于MWA组［66.67%（16/24）及16.67%（4/24）］（P均＜0.05）。CA组治疗后4 h、1天、4天、7天及14天BRPS评分均低于MWA组（P均＜0.001）;2组上述时间点BRPS评分均低于治疗前（P均＜0.05）。CA组并发症发生率（3/24,12.50%）低于MWA组（8/24,33.33%）（P＜0.05）。结论 CA治疗兔VX2椎旁肿瘤的安全性及有效性均优于MWA。     

超声引导下细针穿刺抽吸甲状腺结节标本质量的影响因素

目的 观察超声引导下细针穿刺抽吸（US-FNA）甲状腺结节标本质量的影响因素。方法 选取388例接受US-FNA的甲状腺结节患者（共436个结节）,根据标本背景的血液成分、细胞数目、存留组织框架及细胞破坏程度将其分为诊断优越组（n=325）和非诊断优越组（n=111）,比较其超声特征,主要包括结节最大径、形态、边界、回声、钙化及血供,分析影响US-FNA标本质量的因素。结果 组间甲状腺结节最大径、内部钙化及Adler血供差异均有统计学意义（P均<0.05）。甲状腺结节最大径及钙化为US-FNA标本质量的影响因素（P=0.010、0.002）。结论 超声所见甲状腺结节最大径及钙化为其US-FNA标本质量的影响因素。     

抗血栓治疗对大结肠息肉患者内镜下黏膜切除术后迟发性出血的影响

背景与目的 抗血栓治疗被认为是结肠息肉切除术后出血的危险因素。然而,抗血栓治疗对大结肠息肉患者术后迟发性出血的影响尚未完全明确。因此,本研究探讨抗血栓治疗及其相关因素对大结肠息肉患者行内镜下黏膜切除术（EMR）后迟发性出血的影响,以期提高医生对该类患者围手术期管理的认识。方法 回顾性收集2019年1月—2022年12月因大结肠息肉（>10~20 mm）行EMR的157例患者资料,根据EMR期间是否接受抗血栓治疗、使用抗血栓药物类型、术前是否停用抗血栓药物,分别将患者分为抗血栓组（n=51）与非抗血栓组（n=106）、抗凝组（n=33）与抗血小板组（n=36）、停药组（n=35）与未停药组（n=41）。比较各组间术后迟发性（24 h至30 d内）出血发生率及出血时间点的差异,并通过Kaplan-Meier曲线分析各组间术后30 d累积出血发生率。结果 抗血栓组与非抗血栓组迟发性出血发生率差异有统计学意义（19.61% vs. 5.66%,χ²=7.32,P=0.01）;抗血栓组的出血时间点明显早于非抗血栓组（t=2.17,P=0.047）;抗血栓组术后30 d累积出血发生率明显高于非抗血栓组（χ²=6.18,P=0.01）。抗凝组与抗血小板组迟发性出血发生率差异无统计学意义（24.24% vs. 27.78%,χ²=0.11,P=0.74）,两组在出血时间点、术后30 d累积出血发生率方面差异均无统计学意义（t=0.25,P=0.80;χ²=0.13,P=0.72）。停药组与未停药组迟发性出血发生率差异有统计学意义（14.29% vs. 29.27%,χ²=3.97,P=0.046）,未停药组在出血时间点方面明显早于停药组（t=3.03,P=0.01）;停药组术后30 d累积出血发生率明显低于未停药组（χ²=4.36,P=0.04）。结论 抗血栓治疗可能导致大结肠息肉EMR后迟发性出血发生率升高,但术后迟发性出血发生率与抗血栓药物类型无明显关系。术前适当停药可能是降低患者术后出血的有效策略。     

肾血管平滑肌脂肪瘤自发性破裂危险因素

目的 观察肾血管平滑肌脂肪瘤(RAML)自发性破裂的危险因素。方法 纳入151例接受超选择性栓塞的RAML患者,根据治疗前CT或血管造影是否可见对比剂外溢将其分为破裂组(n=45)及未破裂组(n=106);比较组间患者基本资料及肿瘤影像学表现的差异,以多因素logistic回归分析观察RAML破裂的独立危险因素,构建风险预测模型并以列线图可视化;绘制受试者工作特征(ROC)曲线,评价以各危险因素及模型判断RAML破裂的效能。结果 组间肿瘤最大径、瘤内动脉瘤最大径＞5 mm占比差异均有统计学意义(P均＜0.05)。ROC曲线分析结果显示,以6.32 cm为截断值,根据肿瘤最大径判断RAML破裂的曲线下面积(AUC)为0.684。多因素logistic分析显示,单发肿瘤、直径较大及瘤内动脉瘤最大径≥5 mm(OR=0.37、1.14、5.69,P均＜0.05)是RAML破裂的独立危险因素;以之构建的预测RAML破裂风险模型预测RAML破裂的AUC为0.776,且模型校准曲线与理想曲线的重合度尚可。结论 单发病灶、肿瘤较大且存在≥5 mm的瘤内动脉瘤是RAML自发性破裂的独立危险因素。     

Influence of age, aneurysm size, and patient fitness on suitability for endovascular aortic aneurysm repair

Prior to approval by the U.S. Food and Drug Administration of larger endografts (main body diameters up to 36 mm), small abdominal aortic aneurysms (AAAs, <5.5 cm) were shown to be more suitable for endovascular repair (EVAR) than large AAAs (> or =5.5 cm). The purpose of this study was to assess changes in EVAR suitability with the potential use of larger endografts in unselected consecutive patients. The influence of age, aneurysm size, and patient fitness on EVAR suitability was also assessed. We studied 186 male patients referred for evaluation of nonruptured AAAs who underwent contrast-enhanced computed tomographic scans with three-dimensional reconstructions. Morphologicall AAA features and neck characteristics were measured according to Society for Vascular Surgery reporting standards to determine EVAR suitability. Patient fitness for repair was assessed using the customized probability index, a validated fitness score for vascular surgery procedures. Suitability for EVAR was determined by neck anatomy, iliac artery morphology, and total aortic aneurysm angulation and tortuosity according to the clinicians' experience and current practice. The median age of the study cohort was 72 years (interquartile range [IQR] 65-79 years). The median maximum AAA diameter was 5.4 cm (IQR 4.1-5.9). Median fitness score was +7 (IQR -7 to +14). EVAR suitability for large AAAs significantly increased with larger endografts (35-63%, p<0.001). Changes in EVAR suitability for small AAAs were not significant (69-75%, p=0.06). Maximum AAA diameter was not an independent predictor for EVAR suitability with larger endografts after adjusting for neck anatomy. Aortic neck length (odds ratio [OR]=1.2, 95% confidence interval [CI] 1.1-1.2) and diameter (OR=0.78, 95% CI 0.63-0.96) were the only independent predictors for EVAR suitability with larger endografts. Age, AAA size, and fitness did not differ between patients suitable and unsuitable for EVAR with larger endografts. In conclusion, introduction of larger endografts (up to 36 mm in main body diameter) in the United States has resulted in significantly increased anatomic suitability for EVAR for large AAAs. Conversely, suitability has not significantly changed for small AAAs. Overall, EVAR suitability is not influenced by age, aneurysm size, or patient fitness.     

An intracranial aneurysm in one identical twin, but no aneurysm in the other

Only seven pairs of identical twins with intracranial aneurysms have been reported in the literature. In six of these, both twins had aneurysms, but in one pair only one twin had an aneurysm. We present another such pair of identical twins 21 years of age of whom only one twin had an aneurysm. She presented with a subarachnoid haemorrhage. Four-vessel angiography showed one aneurysm on the internal carotid artery; the aneurysm was clipped. Four-vessel angiography in her identical twin sister revealed no aneurysms. We have reviewed the seven previous reports of identical twins with intracranial aneurysms. We conclude that in case of an aneurysm in one identical twin, the other twin should be examined.     

Anterior inferior cerebellar artery aneurysm, carotid bifurcation aneurysm, and dural arteriovenous malformation of the tentorium in the same patient

An exceptional combination of intracranial vascular malformations is reported: distal anterior inferior cerebellar artery (AICA) aneurysm, carotid bifurcation aneurysm, and dural arteriovenous malformation (DAVM) of the tentorium. The AICA aneurysm was the source of recurrent subarachnoid and cerebellar hemorrhage, revealed only after repeated vertebral angiography. After external drainage of associated hydrocephalus, both aneurysms were successfully clipped and the dural malformation was subtotally embolized. The literature concerning AICA aneurysms, DAVMs, and combined intracranial vascular malformations is reviewed and discussed.     

Endovascular management of ruptured, mycotic abdominal aortic aneurysm

Patients with mycotic aneurysms have a high mortality rate. The standard surgical approach can be exceptionally difficult and fraught with complications. There has been reluctance to insert an endograft into an infected field. We believe that this thought should be challenged and present a case of a successful endovascular repair of a ruptured, mycotic abdominal aortic aneurysm. The patient is a 63-year-old man with severe medical comorbidities and methicillin-sensitive Staphylococcus aureus. He required 6 units of red blood cells on admission. Magnetic resonance angiography (MRA) showed a contained rupture of his distal abdominal aorta, and he underwent emergent endovascular repair. An aortomono-iliac device (12 mm x 10 cm iliac extension limb) was inserted along with coil embolization of his right common iliac artery and a femoral-femoral bypass. He did not require additional transfusions after the procedure and was discharged in good condition. He is on antibiotics and doing well 1 year post-op. Endovascular management of ruptured, mycotic aneurysms is feasible. In fact, it is an attractive approach for a medically compromised patient subset that would carry an exceptionally high mortality rate with traditional surgical repair. Further follow-up is necessary to determine its long-term efficacy.