腹主动脉瘤

对 AAA 破裂进行开放修复术后，腹腔间隔室综合征 (abdominal compartment syndrome, ACS) 的发生率可能接近 55%。[74]Moll FL, Powell JT, Fraedrich G, et al; European Society for Vascular Surgery. Management of abdominal aortic aneurysms: clinical practice guidelines of the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg. 2011 Jan;41 Suppl 1:S1-58.http://www.ejves.com/article/S1078-5884(10)00560-5/fulltext一项小型回顾性综述报道称，有 34% 的患者在 AAA 破裂的开放修复术后发生 ACS，有 21% 的患者在腔内动脉瘤修复术 (EVAR) 后发生 ACS。[179]Rubenstein C, Bietz G, Davenport DL, et al. Abdominal compartment syndrome associated with endovascular and open repair of ruptured abdominal aortic aneurysms. J Vasc Surg. 2015 Mar;61(3):648-54.http://www.jvascsurg.org/article/S0741-5214(14)01893-X/fulltext一项基于人群的全国性研究（瑞典血管登记研究 [Swedish Vascular Registry]）发现，在 AAA 破裂修复后，开放修复术后的 ACS 发生率为 6.8%，EVAR 后的 ACS 发生率为 6.9%。[180]Ersryd S, Djavani-Gidlund K, Wanhainen A, et al. Editor's choice - abdominal compartment syndrome after surgery for abdominal aortic aneurysm: a nationwide population based study. Eur J Vasc Endovasc Surg. 2016 Aug;52(2):158-65.http://www.ejves.com/article/S1078-5884(16)00168-4/fulltext

Abdominal compartment syndrome

在采用开放修复术的患者中，有 11% 的患者报告出现了非机械性肠梗阻，机械性肠梗阻和结肠炎的发生率均为 1%。[178]Hertzer NR, Mascha EJ, Karafa MT, et al. Open infrarenal abdominal aortic aneurysm repair: the Cleveland Clinic experience from 1989 to 1998. J Vasc Surg. 2002 Jun;35(6):1145-54.[181]Johnston KW, Scobie TK. Multicenter prospective study of nonruptured abdominal aortic aneurysms. I. Population and operative management. J Vasc Surg. 1988 Jan;7(1):69-81.罕有缺血性结肠炎需要进行结肠切除术。

Ileus

在对 AAA 施行 EVAR 和开放修复术之后，急性肾损伤 (AKI) 的发病率显著。[182]Saratzis A, Melas N, Mahmood A, et al. Incidence of acute kidney injury (AKI) after endovascular abdominal aortic aneurysm repair (EVAR) and impact on outcome. Eur J Vasc Endovasc Surg. 2015 May;49(5):534-40.http://www.ejves.com/article/S1078-5884(15)00036-2/fulltext[183]Karthikesalingam A, Bahia SS, Patel SR, et al. A systematic review and meta-analysis indicates underreporting of renal dysfunction following endovascular aneurysm repair. Kidney Int. 2015 Feb;87(2):442-51.[184]Dariane C, Coscas R, Boulitrop C, et al. Acute kidney injury after open repair of intact abdominal aortic aneurysms. Ann Vasc Surg. 2017 Feb;39:294-300.在开放修复术中，这似乎是暂时性的。但在施行 EVAR 之后，致病原因是多因素的，并且肾功能下降比开放手术后更显著（尤其是采用肾上腺固定）。[185]Saratzis A, Bath MF, Harrison S, et al. Long-term renal function after endovascular aneurysm repair. Clin J Am Soc Nephrol. 2015 Nov 6;10(11):1930-6.http://cjasn.asnjournals.org/content/10/11/1930.longEVAR 后的 AKI 可导致中期并发症发病率和死亡率升高。[182]Saratzis A, Melas N, Mahmood A, et al. Incidence of acute kidney injury (AKI) after endovascular abdominal aortic aneurysm repair (EVAR) and impact on outcome. Eur J Vasc Endovasc Surg. 2015 May;49(5):534-40.http://www.ejves.com/article/S1078-5884(15)00036-2/fulltext

Acute kidney injury

在施行 EVAR 后可能持续长达 10 天。[74]Moll FL, Powell JT, Fraedrich G, et al; European Society for Vascular Surgery. Management of abdominal aortic aneurysms: clinical practice guidelines of the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg. 2011 Jan;41 Suppl 1:S1-58.http://www.ejves.com/article/S1078-5884(10)00560-5/fulltext典型症状可能由细胞因子释放而引起的发热、不适感和背痛。

在接受开放修复术的众多患者中，由于肢体缺血而导致的截肢率非常低。[178]Hertzer NR, Mascha EJ, Karafa MT, et al. Open infrarenal abdominal aortic aneurysm repair: the Cleveland Clinic experience from 1989 to 1998. J Vasc Surg. 2002 Jun;35(6):1145-54.

施行 EVAR 后发生脊髓缺血的情况很罕见，EUROSTAR 合作者登记处记录的发生率仅为 0.21％。[186]Berg P, Kaufmann D, van Marrewijk CJ, et al. Spinal cord ischaemia after stent-graft treatment for infra-renal abdominal aortic aneurysms. Analysis of the Eurostar database. Eur J Vasc Endovasc Surg. 2001 Oct;22(4):342-7.http://www.ejves.com/article/S1078-5884(01)91470-4/pdf在一项对 AAA 破裂的紧急腔内处理的回顾性分析中，35 例患者中有 4 例 (11.5%) 在术后发生了脊髓缺血。[187]Peppelenbosch N, Cuypers PW, Vahl AC, et al. Emergency endovascular treatment for ruptured abdominal aortic aneurysm and the risk of spinal cord ischemia. J Vasc Surg. 2005 Oct;42(4):608-14.http://www.jvascsurg.org/article/S0741-5214(05)01065-7/fulltext有报告称存在延迟的脊髓缺血（在接受 EVAR 2 天后出现）。[188]Kwok PC, Chung TK, Chong LC, et al. Neurologic injury after endovascular stent-graft and bilateral internal iliac artery embolization for infrarenal abdominal aortic aneurysm. J Vasc Interv Radiol. 2001 Jun;12(6):761-3.

解剖过程中主髂动脉分支处的自主神经损伤，以及盆腔血液供应减少，可能导致阳痿和逆行射精。在一项临床试验中，有 10% 的男性在开放修复术后的第一年内出现了阳痿。[189]Lederle FA, Johnson GR, Wilson SE, et al; Aneurysm Detection and Management Veterans Affairs Cooperative Study. Quality of life, impotence, and activity level in a randomized trial of immediate repair versus surveillance of small abdominal aortic aneurysm. J Vasc Surg. 2003 Oct;38(4):745-52.http://www.jvascsurg.org/article/S0741-5214(03)00423-3/fulltext

一项病例系列报告显示，在主动脉旁路移植术后，有 10% 的患者出现了吻合口周围动脉瘤。[190]Edwards JM, Teefey SA, Zierler RE, et al. Intraabdominal paraanastomotic aneurysms after aortic bypass grafting. J Vasc Surg. 1992 Feb;15(2):344-50.在 AAA 主股动脉重建术后 10 年时，股动脉吻合口假性动脉瘤的发生率可能高达 20%。[191]Ylönen K, Biancari F, Leo E, et al. Predictors of development of anastomotic femoral pseudoaneurysms after aortobifemoral reconstruction for abdominal aortic aneurysm. Am J Surg. 2004 Jan;187(1):83-7.

接受 EVAR 的患者中，有 24.6% 的患者在术后 15 个月至 9 年随访期内出现主动脉颈扩张。[128]Kouvelos GN, Oikonomou K, Antoniou GA, et al. A systematic review of proximal neck dilatation after endovascular repair for abdominal aortic aneurysm. J Endovasc Ther. 2017 Feb;24(1):59-67.该组患者发生内漏、移位和再次干预的复合临床事件明显多于无主动脉颈扩张的患者。

可能的起因包括植入过程中的感染、牙科手术操作后的血源性播种或内窥镜操作活检。发生率低：一项回顾性队列研究发现，开放修复术后 2 年，移植物感染率为 0.19%，EVAR 术后的感染率为 0.16%。[192]Vogel TR, Symons R, Flum DR. The incidence and factors associated with graft infection after aortic aneurysm repair. J Vasc Surg. 2008 Feb;47(2):264-9.http://www.jvascsurg.org/article/S0741-5214(07)01691-6/fulltext

输尿管阻塞与未治愈病因导致的输尿管被动脉瘤周围炎症性纤维化组织包裹引起，而不是继发于动脉瘤压迫。[193]Hodgson KJ, Webster DJ. Abdominal aortic aneurysm causing duodenal and ureteric obstruction. J Vasc Surg. 1986 Feb;3(2):364-8.输尿管压迫的最常见原因是炎症性动脉瘤。在 18% 的患者中，大面积的腹膜后黏连可能导致输尿管梗阻。下腔静脉也可能受累。[194]Kashyap VS, Fang R, Fitzpatrick CM, et al. Caval and ureteral obstruction secondary to an inflammatory abdominal aortic aneurysm. J Vasc Surg. 2003 Dec;38(6):1416-21.

十二指肠梗阻是十二指肠的腹膜后固定段受主动脉瘤与肠系膜上动脉压迫所致。[193]Hodgson KJ, Webster DJ. Abdominal aortic aneurysm causing duodenal and ureteric obstruction. J Vasc Surg. 1986 Feb;3(2):364-8.

据报道，对 AAA 施行开放修复术后最长 10 年内，移植物肢体阻塞的发生率介于 2.6% 至 3.0% 之间。[195]Conrad MF, Crawford RS, Pedraza JD, et al. Long-term durability of open abdominal aortic aneurysm repair. J Vasc Surg. 2007 Oct;46(4):669-75.http://www.jvascsurg.org/article/S0741-5214(07)00976-7/fulltext[196]Hallett JW Jr, Marshall DM, Petterson TM, et al. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience. J Vasc Surg. 1997 Feb;25(2):277-84.EVAR 术后发生移植物阻塞的风险更高，随访研究报道称发生率高达 7.2%。[197]Cochennec F, Becquemin JP, Desgranges P, et al. Limb graft occlusion following EVAR: clinical pattern, outcomes and predictive factors of occurrence. Eur J Vasc Endovasc Surg. 2007 Jul;34(1):59-65.http://www.ejves.com/article/S1078-5884(07)00078-0/fulltext扭结是 EVAR 术后移植物肢体阻塞的一个危险因素。[198]Faure EM, Becquemin JP, Cochennec F; ENGAGE Collaborators. Predictive factors for limb occlusions after endovascular aneurysm repair. J Vasc Surg. 2015 May;61(5):1138-45.e2.http://www.jvascsurg.org/article/S0741-5214(14)02290-3/fulltext

EVAR 后出现内漏的风险为 24%。[146]Schurink GW, Aarts NJ, vanBockel JH. Endoleak after stent-graft treatment of abdominal aortic aneurysm: a meta-analysis of clinical studies. Br J Surg. 1999 May;86(5):581-7.最常见的是 II 型内漏。发现术后 I 内漏后，可能适合行修复术。内漏不是开放修复术后的并发症。

发生率为 3% 至 29%，最常累及脚趾（蓝趾综合征）。远端栓塞的发生率为 5%，导致危及肢体的缺血、脚趾缺血、腓肠肌坏死。[199]Baxter BT, McGee GS, Flinn WR, et al. Distal embolization as a presenting symptom of aortic aneurysms. Am J Surg. 1990 Aug;160(2):197-201.