22.17
動脈瘤 III: 多職種連携によるケア
動脈瘤の管理は、その大きさや症状に応じて、保存的な薬物療法または外科的治療が行われます。保存療法は通常、小さく無症状の動脈瘤に適用され、大きな動脈瘤や症状のある動脈瘤には外科的修復が必要となることが多いです。
保存的な薬物療法
特に直径5.5cm未満の無症候性腹部大動脈瘤（AAA）には、保存的な薬物…
動脈瘤の管理には、通常は直径5.5センチメートル未満の小さな無症候性動脈瘤の保存的治療が含まれます。
これには、禁煙、高脂血症、高血圧、糖尿病などの状態の管理、身体活動の段階的な増加などのリスク要因の変更が含まれます。
動脈瘤のサイズは、超音波またはCTスキャンを使用して定期的に監視されます。
直径4.0〜5.4センチメートルの小さな動脈瘤は6〜12か月ごとに監視され、4.0センチメートル未満の腹部大動脈瘤は2〜3年ごとに監視されます。
5.5センチメートルを超える無症候性動脈瘤の場合、開腹動脈瘤修復として知られる外科的処置が推奨されます。
これには、腹部切開、罹患した大動脈セグメントからの血栓またはプラークの除去、および動脈瘤の近位端と遠位端への合成移植片の縫合が含まれます。
次に、ネイティブの大動脈壁をグラフトの周りに縫合します。
別の手順である血管内動脈瘤の修復では、大腿動脈を介して挿入された大腿動脈カテーテルを使用して、腹部大動脈瘤内に縫合のない大動脈グラフトを配置します。
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Q1: When is conservative treatment recommended for abdominal aortic aneurysms?
Conservative treatment is recommended for small, asymptomatic abdominal aortic aneurysms measuring less than 5.5 centimeters in diameter. This approach focuses on modifying risk factors such as tobacco cessation, managing hyperlipidemia, hypertension, and diabetes, and gradually increasing physical activity to prevent aneurysm growth and rupture.
Q2: What monitoring schedule is used for different sizes of abdominal aortic aneurysms?
Aneurysm monitoring frequency depends on size. Small aneurysms measuring 4.0 to 5.4 centimeters require ultrasound or CT scans every 6 to 12 months. Aneurysms smaller than 4.0 centimeters are monitored every 2 to 3 years. This surveillance helps detect expansion early, allowing timely intervention when necessary.
Q3: What are the key differences between open aneurysm repair and endovascular repair?
Open aneurysm repair involves a large abdominal incision where the surgeon removes thrombus or plaque and sutures a synthetic graft to the proximal and distal ends. Endovascular aneurysm repair is less invasive, placing a sutureless aortic graft inside the aneurysm via a femoral artery catheter, avoiding major abdominal surgery.
Q4: When is surgical repair recommended for asymptomatic aneurysms?
Surgical repair is advised for asymptomatic aneurysms measuring 5.5 centimeters or larger. At this size threshold, the rupture risk increases significantly, making intervention necessary. The choice between open aneurysm repair and endovascular repair depends on patient factors and anatomical considerations.
Q5: What is endoleak and why is it a concern after aneurysm repair?
Endoleak is the most common complication following abdominal aortic aneurysm repair, involving blood seeping back into the old aneurysm sac. It results from inadequate seal at graft ends, graft fabric tears, or leaks between overlapping segments. This complication can lead to continued aneurysm growth and potential rupture.
Q6: What other complications can occur after aneurysm repair besides endoleak?
Additional complications include aneurysm growth above or below the graft, aortic dissection, bleeding, aneurysm rupture, renal artery occlusion from stent migration, incisional hematoma, infection at the incision site, and graft thrombosis. Angiography is performed after repair to check for leaks and ensure graft patency.
Q7: How does surgical repair differ for iliac artery aneurysms versus saccular aneurysms?
Iliac artery aneurysm repair uses a bifurcated graft that replaces the entire affected segment. For saccular aneurysms, only the bulbous lesion is excised, and the artery is repaired using primary closure by suturing or applying an autogenous or synthetic patch graft. Both approaches aim to restore normal blood flow.