Abdominal Aortic Aneurysm Treatment Today and Tomorrow Feng Xiang, Department of Vascular Surgery, Changhai Hospital, Shanghai Mr. Wang, 80 years old, was lying calmly on the operating table, turning his head to look at the X-ray fluoroscopy monitor next to him, which was displaying the image of the arteriogram he had just undergone, and clearly showed a 6cm diameter abdominal aortic aneurysm in the area of his abdominal aorta. In his groin, the doctor had punctured into his femoral artery through a 1cm long small incision, and sent a catheter with a memory alloy stent and an ultra-thin artificial blood vessel composite into his abdominal aorta through the femoral artery. After reaching the intended site, the catheter began to withdraw slowly, and the memory alloy stent slowly opened up, and then the abdominal aortogram was repeated, and the abdominal aortic aneurysm disappeared miraculously on the monitor. The tumor magically disappeared from the monitor. The surgery was over in just one hour, and Mr. Wang was fortunate enough to witness the removal of a “time bomb” that had been tormenting him for three years by the surgeon’s hands. On the third day after the surgery, Mr. Wang was discharged from the hospital on foot. Feng Xiang, Department of Vascular Surgery, Shanghai Changhai Hospital This is a common scene of vascular surgeons treating abdominal aortic aneurysms today A scene of endoluminal isolation for abdominal aortic aneurysms. Since March 1997, Changhai Hospital was the first hospital in China to carry out endoluminal isolation for abdominal aortic aneurysms, and has successfully cured more than 1,000 patients and achieved good results. Minimally invasive endoluminal isolation has the characteristics of simple operation, small trauma and fast recovery after operation compared with previous open surgery, which completely solved the shortcomings of previous open surgery with large trauma, complicated operation, high complication rate and mortality rate, and thus it is called a technological revolution in the history of abdominal aortic aneurysm treatment. In fact, Mr. Wang has been diagnosed with abdominal aortic aneurysm for 3 years, and has been seeking for medical treatment, but because he is old and weak, and also suffers from hypertension, coronary heart disease, diabetes and other diseases, the risk of surgery is too great, and the major hospitals have refused to operate on him, but the minimally invasive characteristics of endoluminal septostomy have given him a chance to be cured. What is abdominal aortic aneurysm? Abdominal aortic aneurysm should not be called “tumor”, it is the expansion of the abdominal aorta after local weakness under the action of pathological factors (see Fig. 1), which only looks like a “tumor” but is not a tumor in the usual sense, and thus is a kind of It is a benign disease. Aneurysm has a proper name “aneurysm” in English, which is a word of Greek origin, and its original meaning is “expansion”, and when translated into Chinese, the use of the word “aneurysm” has caused many people to think that aneurysm is not a tumor. When translated into Chinese, the word “aneurysm” is used, which has led to misunderstandings and misinterpretations. There are many causes of abdominal aortic aneurysms, the most common being high blood pressure and atherosclerosis, while others include trauma, infection, and may be congenital. The most common presentation of abdominal aortic aneurysm is a pulsatile mass in the upper abdomen or around the umbilicus, sometimes with vague pain or symptoms of pressure from surrounding organs. After the formation of an abdominal aortic aneurysm, the aneurysm will gradually expand and enlarge under the impact of arterial blood flow. According to the principle of physics, the larger the diameter of the abdominal aortic aneurysm, the greater the pressure on the wall of the aneurysm. Generally speaking, aneurysms with a diameter larger than 5cm have a much higher chance of rupture, and rupture of the aneurysm will lead to the death of the patient due to massive blood loss, so the aortic aneurysm is known as the “time bomb inside the body of the patient”. Mr. Wang, mentioned earlier in this article, has been living under tremendous psychological pressure since learning of his abdominal aortic aneurysm, describing himself as “going to sleep every day wondering if he would still wake up tomorrow. The greatest physicist of the 20th century, Albert Einstein, left the world of time and space which he led us to know again, and the famous geologist of China, Prof. Li Siguang, died of ruptured abdominal aortic aneurysm, and even in the western literature, the writers often arrange for the characters who need to disappear suddenly to suffer from abdominal aortic aneurysm. Indeed, abdominal aortic aneurysm, with its high morbidity and mortality rate, is an extremely dangerous disease. In the United States, deaths caused by ruptured abdominal aortic aneurysms account for the tenth cause of death from disease in adult males, and in our country the incidence of aortic aneurysms is rising rapidly with the aging of the population and the change in the dietary structure of the people. Figure 1, CT arteriographic image of an abdominal aortic aneurysm showing a spherical dilated aneurysm forming in the abdominal aorta How have abdominal aortic aneurysms been treated in the past? Surgeons have been trying to treat abdominal aortic aneurysms surgically since the 18th century, but until the advent of artificial blood vessels in the 1950s, the many surgical methods tried failed to achieve a complete cure for abdominal aortic aneurysms, and patients often died of ruptured abdominal aortic aneurysms despite treatment, the most striking example being Albert Einstein, who had an abdominal aortic aneurysm wrapped around his neck in 1948 and died in 1955, but was still suffering from a ruptured abdominal aortic aneurysm. He died of a ruptured abdominal aortic aneurysm in 1955. After the mid-1950s, the emergence of artificial blood vessels made abdominal aortic aneurysm resection and artificial vascular replacement become the classic method of treating abdominal aortic aneurysms. The procedure involves completely dissecting out the abdominal aortic aneurysm from the patient’s abdomen after general anesthesia, blocking the aorta at both ends of the aneurysm and ligating the branch arteries of the aneurysm before resecting the aneurysm, and then restoring the blood flow to the aorta by anastomosing the artificial blood vessels to the broken arteries at both ends of the aneurysm (see figure). Due to the different locations and volumes of the aneurysm, the operation time ranges from 2 hours to more than 10 hours, and the amount of blood transfusion ranges from several hundred milliliters to tens of thousands of milliliters, which is extremely traumatic. Moreover, the blockage of the aorta has a direct impact on the heart, brain, lungs, kidneys, and other important organs, and there is a high incidence of postoperative complication of organ failure. This requires patients to have sound internal organ function before surgery to withstand the blow of such a major surgery, but unfortunately, abdominal aortic aneurysm is also a geriatric disease, abdominal aortic aneurysm average age of onset is around 70 years old, most of these patients coexist with hypertension, coronary artery disease, diabetes mellitus, pulmonary and renal hypoplasia, and other diseases, so the risk of the surgery is greatly increased, and many patients can not tolerate the surgery and Many patients lost the chance to cure abdominal aortic aneurysm because they could not tolerate the surgery. This contradiction has been troubling vascular surgeons and abdominal aortic aneurysm patients for more than 40 years since the introduction of abdominal aortic aneurysm resection with artificial vascular replacement, which often puts the surgeons and patients in a dilemma. Figure 2, Schematic diagram of traditional abdominal aortic aneurysm surgery What is endoluminal abdominal aortic aneurysm repair? This embarrassing situation in the surgical treatment of abdominal aortic aneurysm was fundamentally changed after the 1990s due to the emergence of endoluminal repair. From the pathological changes of abdominal aortic aneurysm, we can know that abdominal aortic aneurysm is the expansion of the abdominal aorta rather than a tumor, therefore, as long as we can prevent the rupture of abdominal aortic aneurysm, we can achieve the purpose of curing abdominal aortic aneurysm without the need to resect it; in the past 20 years, the technology of endovascular memory alloy stents, ultra-thin polyester braided artificial blood vessels, endovascular catheters and other technologies are gradually maturing, and they are increasingly widely used in the clinic; CT, MRI Non-invasive vascular examination techniques such as CT and magnetic resonance angiography have become increasingly accurate; endoluminal isolation of abdominal aortic aneurysm is the product of this combination of advances in knowledge and numerous technological advances. Simply put, abdominal aortic aneurysm endoluminal repair is to first perform CT arteriography and other imaging examinations on patients with abdominal aortic aneurysms to obtain precise data on abdominal aortic aneurysms, and then accordingly select memory alloy stents of the appropriate caliber and length and ultrathin artificial blood vessels sewn into a composite pre-positioned within the catheter. At the time of surgery, a small incision of 3-4 cm in length is made in the groin, or by using the puncture technique with prefabricated vascular sutures, the incision can be less than 1 cm, and the surgery can be performed completely under local anesthesia. Under X-ray fluoroscopy, the catheter is introduced through the femoral artery, and when the artificial blood vessel reaches the diseased aorta, the artificial blood vessel is released from the catheter, and the memory alloy stent opens up to its original caliber at body temperature to fix the artificial blood vessel on the normal aorta at both ends of the diseased aorta (see Fig. 3), and the blood flow flows through the lumen of the artificial blood vessel, and the dilated and weakened abdominal aortic wall is isolated from the high-speed and high-pressure abdominal aortic blood flow. The dilated and weak abdominal aortic wall is isolated from the high velocity and high pressure of the abdominal aorta, thus maintaining the blood flow in the abdominal aorta and preventing the rupture of the abdominal aortic aneurysm, which means that the abdominal aortic aneurysm is completely cured (Figure 4). In the treatment of abdominal aortic aneurysms with endoluminal isolation, bifurcation grafts (metal stents and artificial vessel complexes) are often required because abdominal aortic aneurysms often involve the iliac arteries. Figure 3, Schematic diagram of endoluminal repair of abdominal aortic aneurysm Figure 4, DSA images before and after endoluminal isolation of abdominal aortic aneurysm, showing huge abdominal aortic aneurysm before the treatment and immediate disappearance of the aneurysm after the treatment Figure 6, Memory alloy stent and ultrathin artificial vascular composite Compared with the traditional open mega-invasive abdominal surgery, endoluminal isolation avoids the need for general anesthesia, laparotomy, and blocking of the aorta, which makes the surgery much less invasive, and it can be completed with a puncture only at the thigh The operation can be completed by making a puncture at the root of the thigh. The operation time is greatly shortened, skilled doctors can complete a case in 60 minutes, and most patients do not need blood transfusion. Patients recover quickly after the operation, they can eat on the night of the operation and get out of bed on the next day, and the complication rate and mortality rate are also significantly reduced, which makes many patients who cannot tolerate the traditional operation due to their advanced age and multiple coexisting diseases get a chance to be cured. In addition to the treatment of abdominal aortic aneurysm with endoluminal septostomy mentioned above, this technique can also be used for the treatment of thoracic aortic aneurysm, pseudoaneurysm of the aorta, aortic coarctation, iliac artery aneurysm, and so on. With the continuous improvement of the instruments of endoluminal prosthetic surgery, the indications for its treatment will also be continuously expanded, and more and more patients are being benefited from it.