破裂性腹部大動脈瘤に対し瘤空置バイパス術を行い救命し得た1例

Exclusion Procedure for a Ruptured Abdominal Aortic Aneurysm

要旨　患者は突然の右腰部痛，嘔吐で救急来院した80歳の女性で，腹部CT検査にて最大径7.0cmの腹部大動脈瘤の破裂を認めたため，同日緊急手術となった．経腹腔アプローチにて腹部大動脈まで到達し，中枢側大動脈を遮断し，次いで末梢側の剥離を試みたものの，高度石灰化および腸管癒着のため両側腸骨動脈の剥離ができず，瘤を空置する形でY字型グラフトを中枢側と端々吻合，末梢側は両側総大腿動脈に端側吻合した．瘤は破裂部位を含め縫縮し径を縮め，血栓化を期待することとした．術後は問題なく，現在外来にて経過観察中であり，血栓化は完全ではないが瘤径の拡大は認めていない．瘤空置バイパス術は術式の簡略化と手術侵襲の軽減を図ることができ，今回のようなハイリスク症例の破裂時の緊急避難的な手術術式としての意義があると考えられた．

　An 80-year-old woman came to our hospital complaining of right lower back pain. CT showed an infra-renal abdominal aortic aneurysm(AAA)with 7.0cm as the maximum diameter. The aneurysm had ruptured into the retroperitonial space. An emergent operation was performed. After cross clamp of the infra-renal aorta, it was difficult to clamp the bilateral common iliac arteries because they were severely calcified and had adhered. Because of this, we decided to perform a nonresective procedure without aneurysmectomy. After transection of the aorta, a bifurcated graft was sewn to the neck of the infra-renal aorta. We closed the aorta at the proximal site of the aneurysm. Bilateral legs were anastomosed biliterably to the common femoral arteries. The aneurysm was sewn including at the ruptured point in order that its diameter would be reduced. A year later the excluded aneurysm was incompletely occluded by thrombus, but there was no change in the diameter of the aneurysm. In such a case as this postoperative careful observation is needed for preventing delayed aortic rupture. The exclusion procedure is useful in high risk and emergent cases to minimize operative stress.