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文献考察：炎症性腹部大動脈瘤（inflammatory AAA）
１）血管外科 剥離を最小限とする炎症性腹部大動脈瘤の手術
Author：中村栄作(宮崎医科大学 第2外科), 中村都英, 中嶋誠司, 矢野義和, 鍋島一樹, 松崎泰憲, 鬼塚敏男
Source：外科(0016-593X)63巻6号 Page716-719(2001.06)
Abstract：症例1:69歳男.腹痛と背部痛を主訴に入院,腹部CTにてmantle signを伴う80mmの腹部動脈瘤を認め手術適応となる.症例2:73歳男.近医で超音波検査結果,大動脈瘤を指摘され,紹介入院した.CRPは7mg/dlと上昇,腹部MRIやCTで腹部動脈は60mmで手術適応となる.症例3:68歳男.腹部超音波検査で腹部大動脈瘤を診断され,紹介入院,入院時腹部CTで腎動脈以下にmantle signを伴う80mmの腹部大動脈瘤を認め手術適応とした.3症例とも周囲臓器との癒着は高度であったが,慎重な手術操作により良好な結果を得た.動脈瘤中枢側の剥離はもとより,末梢側の剥離も最小限にすることが合併症を少なくすると考えた．
２）World J Surg. 2003 May;27(5):539-44.
Long-term outcome after inflammatory abdominal aortic aneurysm repair: case-matched study.
Bonati L, Rubini P, Japichino GG, Parolari A, Contini S, Zinicola R, Fusari M, Biglioli P.
The purpose of this study was to compare early and late outcomes after inflammatory and noninflammatory abdominal aortic aneurysm (AAA) repair with emphasis on graft-related complications. Of 625 consecutive patients submitted to AAA repair, 18 were classified as having inflammatory AAAs (group 1). The results of this group were compared with those of 54 patients (group 2) retrospectively drawn from patients who underwent aortic replacement for noninflammatory AAAs. A computer-assisted matching system was used to match patients according to date of birth, gender, and surgical priority. All patients of both groups were followed by periodic clinical and instrumental examinations. Patients in group 1 complained more frequently of aneurysm-related symptoms (72% vs. 20%; p = 0.0001), and their erythrocyte sedimentation rate was elevated more often (78% vs. 19%; p
３）Acta Chir Belg. 1997 Dec;97(6):286-92.
Inflammatory abdominal aortic aneurysms. A retrospective study of 110 cases.
Lacquet JP, Lacroix H, Nevelsteen A, Suy R.
OBJECTIVE: The purpose of this study is to review our experience with the surgical treatment of 110 patients with an inflammatory abdominal aortic aneurysm (IAAA). Furthermore, we focus especially on 37 ureteral obstructions. PATIENTS AND METHODS: Between 1978 and 1996 we treated 110 patients for an IAAA. It concerned 101 men and nine women with mean age of 66.8 years. Emergency surgery was performed in 32 patients (13 ruptures) and elective surgery in 78 patients (only 23 asymptomatic). The IAAA diagnosis was made by CT scan preoperatively in 40% of the patients. Compression of 37 ureters in 23 patients (14 bilateral, 9 unilateral) was noticed and ureteral stenting was performed preoperatively in nine patients (12 ureters). The surgical approach was median laparotomy (88 patients) or retroperitoneal approach (21 patients). One patient was treated with an endovascular Min-Tec Stentor aortic graft by femoral approach. Suprarenal clamping was necessary in 44 patients. Ureterolysis of 23 ureters was performed. Three peroperative iatrogenic lesions were successfully treated intraoperatively. RESULTS: Fatal complications occurred in nine patients (8%), five patients after urgent surgery and four patients after elective surgery, all of them related to technical problems. Non fatal complications occurred in 22 patients, renal insufficiency was most important in ten patients (two permanent dialysis). The mean follow-up was 4.5 years (range, 0.5 to 15 years). Late survival was 68% at 5 years and 42% after 10 years. Seven patients presented late graft related complications, one fatal. In 14 surviving patients with 21 ureterolysed ureters, one needed a nefrectomy and one a bilateral Boari-plasty. In eight surviving patients with 11 stented ureters, one patient needed a small bowel interposition for ureteral stricture. After CT evaluation, all ureteral stents were removed 3 to 6 months after surgery. CONCLUSIONS: 1. Surgery for IAAA is quite complex. Mortality and morbidity are often associated with emergency or combined vascular and non vascular procedures. 2. When carefull operative repair is performed with minimal dissection of structures from the aneurysmal wall, excellent results can be expected. 3. Ureteral compression should be treated by ureteral stenting, preoperatively, to facilitate ureterolysis or even to avoid it. Regular follow-up CT control is recommended.PMID: 9457319
上記３文献のまとめ：炎症性腹部大動脈瘤は，大動脈瘤周囲線維化，近隣臓器との癒着，大動脈前壁側壁の著しい線維化肥厚およびリンパ球を主体とした慢性炎症細胞浸潤によって特徴づけられる．発生機序は不明．病理所見としては中膜は菲薄化し外膜は著明な線維性肥厚（ＣＴではmantle signと呼ばれる）を示す．発生頻度は大動脈瘤全体の2.5〜10％に見られ必ずしもまれな疾患ではない．60歳以上に好発し，男女比は9:1と圧倒的に男性に多い．大動脈瘤周囲の線維化巣が尿管を巻き込むことにより，23％に水腎症が生じる．術中所見は，動脈瘤壁は光沢のある白色を示し，周囲臓器との癒着が見られる．造影CTで瘤壁のマントル状の肥厚，周囲臓器との癒着を認め，壁肥厚は特に前壁と側壁に強い．CRP高値と血沈の亢進を認める場合が多い．治療は瘤切除と人工血管置換術が基本である．
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