杨宁介入医学网

        肾动脉瘤治疗的选择包括观察，外科手术，血管内支撑架，血管内栓塞，内科治疗或这些方法的联合治疗。治疗的选择取决于个体化的因素，包括动脉瘤的位置，形态学改变，破裂等因素。



1. 观察

        观察是指对无症状的＜2厘米直径的肾或肾实质内动脉瘤而言[1~4]。每年对已发现的动脉瘤进行影像学随访，随访的内容包括任何的体积变化，数量的变化和动脉瘤形态的变化。

2. 外科

        外科手术包括破裂肾动脉瘤的急诊手术，以及择期肾动脉瘤的手术修补。前者主要是针对已破裂肾动脉瘤控制出血和挽救生命。此情况由于暴露膈下较大血肿使暴露肾动脉较为困难，需要在肾上水平甚至腹腔动脉以上水平的腹主动脉进行暂时性阻断。一旦肾动脉充分暴露，出血得到控制可以松开对腹主动脉的阻断。多数情况下破裂的肾动脉瘤手术由于生命体征不满意不能保留肾脏，肾切除或部分肾切除往往是必须的。只是在生命体征稳定下才可能从容实施肾动脉的重建手术[29]。对于妊娠子宫（ gravid uterus ）的处理原则是一样的，应尽量避免刨宫产（ Cesarean delivery ）以免增加手术时间和新的出血。刨宫产只在胎儿窘迫的风险大于胎儿产，已经危及产妇的生命[30,31]。

        择期手术包括肾动脉瘤切除术后联合不同的血管肾血管重建包括血管局部修补，血管种植，旁路血管移植，体外修补后自体肾移植等，也包括肾切除或部分肾切除。


     

体外肾血管修补后自体肾移植

        主要适应症是有肾血管性高血压，动脉夹层，泌尿系统症状，肾栓塞。其它适应症包括怀孕或计划怀孕的女性，或同时存在肾动脉狭窄。

肾动脉主干假性动脉瘤示意图

肾动脉主干假性肾动脉瘤修补术后示意图

 

肾动脉瘤人工血管移植术示意图

        一般来讲肾动脉瘤，特别是感染性动脉瘤由于出血和爆发败血症，可能有一个致命性的自然病史，同时可引起高血压和血尿，在过去大多数病例需要进行肾切除[27,28]。近年来，包括血管内支架，血管内栓塞作为简单、安全和有效的介入治疗在处理肾动脉瘤和肾实质动脉瘤浮出水面，可能作为外科治疗以外的选择之一[4~26]。详细情况本站另辟栏目专门介绍。

        29%外科治疗病例最终选择肾切除。


外科治疗结果







3. 血管内治疗

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