覆膜支架治疗37例Stanford B型胸主动脉夹层的疗效分析

目的:分析覆膜支架腔内修复治疗Stanford B型胸主动脉夹层的临床疗效。方法:对2015年1月至2016年12月收治的37例因Stanford B型胸主动脉夹层行覆膜支架腔内修复术患者的病历资料进行回顾性分析,其中男性29例,女性8例。术前诊断依据临床表现及CT血管造影(CTA),术中造影再次评估病变部位及解剖位置,切开股动脉,行覆膜内支架置入,封堵原发破口,手术成功后再次造影检查。结果:37例患者共置入支架37枚,全部获得成功。术中造影见少量内漏4例,3例经支架近端球囊扩张后内漏消失,1例无需特殊处理。患者临床症状均明显改善,降主动脉及腹主动脉真腔明显扩大。结论:采用覆膜支架腔内修复术治疗Stanford B型胸主动脉夹层安全、创伤小、恢复快,临床效果显著。     

血管腔内覆膜支架治疗胸主动脉夹层68例

目的探讨直筒型和分支型覆膜支架治疗急、慢性Stanford B型胸主动脉夹层的方法及效果。方法对天津胸科医院治疗68例Stanford B型胸主动脉夹层的临床资料作回顾性分析。结果使用直筒型覆膜支架52只,分支型覆膜支架22只,在不影响左上肢血流的前提下完全封堵动脉内膜破口,真腔血流恢复正常,近期疗效满意。结论使用覆膜支架腔内隔离术治疗Stanford B型胸主动脉夹层,符合其病理解剖特点,能很好的封闭内膜破口,具有创伤小、适应证宽、治疗效果确切、康复迅速等优点,为高龄高危患者提供了治疗机会。     

带膜支架置入治疗胸主动脉夹层

目的探讨带膜支架置入治疗胸主动脉夹层的指征、方法及疗效.方法 5例Stanford B型亚急性期主动脉夹层患者,在局麻、数字减影血管造影术(DSA)监控下,切开股动脉,将带膜支架置入胸主动脉内膜破口处,封闭破口,置入后重复造影.结果患者原发主动脉夹层破口完全封闭,真腔血流恢复正常,术后1月及6月用多普勒超声和CT血管造影(CTA)复查显示无内漏及移位等并发症,假腔血栓形成.结论 Stanford B型主动脉夹层适合带膜支架介入治疗,具有技术可靠,安全性高,术后恢复快等优点,临床应用前景良好.     

国产覆膜支架治疗Stanford B型主动脉夹层

目的评价国产主动脉覆膜支架治疗Stanford B型主动脉夹层患者的院内及中期临床疗效。方法应用国产覆膜支架行主动脉腔内隔绝术治疗B型主动脉夹层患者34例,经股动脉置入覆膜支架封堵胸主动脉破裂口,置入Aegis或Hercules国产支架后,造影检查证实疗效。术后平均随访(19±17)个月。结果34例手术均获成功。32例置入1枚支架,2例分别置入主体和短支架各1枚,平均支架直径(33.5±3.5)mm,平均支架长度(96.5±17.6)mm。1例术后2h死于夹层破裂。3例术后存在原发性内漏。2例肾功能不全。出院后随访,2例分别于术后5个月和9个月发生继发性内漏,1例1年时升主动脉再次发现夹层,1例6个月后发生截瘫,2例死亡。结论国产主动脉覆膜支架治疗Stanford B型主动脉夹层患者具有良好的临床疗效。     

StanfordB型胸主动脉夹层腔内隔绝术治疗的经验探讨

目的探讨主动脉腔内隔绝术在治疗Stanford B型主动脉夹层（aorticdissection，AD）的价值。方法回顾性分析我院2005—2008年行腔内隔绝术的17例Stanford B型主动脉夹层患者的资料。结果所有患者均完成带膜支架置入，术后1个月CTA随访14例假腔完全血栓化，夹层破裂死亡1例，出现新发破口2例，内漏1例。结论带膜支架腔内隔绝术治疗Stanford B型胸主动脉夹层是一种安全有效的方法，但术前破口定位。术中真腔确认及支架定位是手术成功的关键。     

国产覆膜血管内支架置入术治疗老年Stanford B型主动脉夹层的临床疗效观察

目的探讨国产覆膜血管内支架置入术对老年Stanford B型主动脉夹层治疗的临床疗效及安全性。方法对7例Stanford B型的老年主动脉夹层患者进行增强CT扫描或MRI检查明确诊断，并行主动脉造影，应用QCA血管定量分析软件进行测量，选取合适型号支架，置人大血管内封堵主动脉夹层原发破口，重复造影观察支架位置，检查有无内漏。术后1w及6个月行CT随访，观察内漏情况、支架移位和假腔变化。结果本组7例老年患者支架置入全部获得成功，成功率100％，无严重并发症及死亡病例。术后即刻造影：全部患者夹层近端破口封闭，恢复真腔血流，1例见少量近端内漏，1例累及左锁骨下动脉开口病例应用国产覆膜血管支架也成功完成手术，即封堵夹层破口同时也封堵了左锁骨下动脉开口，未行旁路移植，但也未出现相应部位缺血的表现。全部患者行CT随访，3例主动脉夹层消失，余者假腔内血栓形成。结论国产覆膜支架置入术治疗老年Stanford B型主动脉夹层安全可行，并具有创伤小、并发症少、治疗费用较低等优点，近期疗效满意。     

带膜支架置入治疗胸主动脉夹层

目的探讨带膜支架置入治疗胸主动脉夹层的指征、方法及疗效。方法5例Stan-ford B型亚急性期主动脉夹层患者,在局麻、数字减影血管造影术(DSA)监控下,切开股动脉,将带膜支架置入胸主动脉内膜破口处,封闭破口,置入后重复造影。结果患者原发主动脉夹层破口完全封闭,真腔血流恢复正常,术后1月及6月用多普勒超声和CT血管造影(CTA)复查显示无内漏及移位等并发症,假腔血栓形成。结论Stanford B型主动脉夹层适合带膜支架介入治疗,具有技术可靠,安全性高,术后恢复快等优点,临床应用前景良好。     

腔内隔绝术治疗112例Stanford B型主动脉夹层动脉瘤患者疗效观察

目的评价主动脉夹层腔内隔绝术治疗Stanford B型主动脉夹层动脉瘤的院内及长期临床疗效。方法选择行主动脉腔内隔绝术治疗Stanford B型主动脉夹层患者112例。经股动脉切开置入覆膜支架封堵胸主动脉破裂口,置入后冠状动脉造影检查证实疗效,术后随访平均(39±18)个月。分析其临床特点及疗效。结果手术成功112例,共置入覆膜支架119枚。左锁骨下动脉完全被封闭8例,合并严重狭窄病变的冠心病患者完成PCI 16例,主动脉腔内隔绝术后综合征19例,术后1个月内夹层破裂死亡3例。随访3个月,所有患者内膜破裂口封闭,胸降主动脉和腹主动脉真腔扩大,假腔内血栓形成,支架位置、形态正常。术后明显残余内漏10例,3个月自行封闭。术后6个月,再发升主动脉夹层3例,其中行升主动脉外科手术1例,截瘫1例,胃癌多器官转移死亡1例。术后1年迟发性内漏1例。结论腔内隔绝术治疗Stanford B型主动脉夹层动脉瘤的院内及长期疗效满意。     

主动脉夹层合并冠心病联合介入26例疗效评价

目的评价冠心病合并Stanford B型主动脉夹层的患者行冠脉介入治疗(PCI)和覆膜支架联合介入治疗的疗效和安全性。方法收集2002年4月至2010年10月沈阳军区总医院完成的26例覆膜支架联合PCI治疗Stan-ford B型主动脉夹层合并冠心病患者,首先完成主动脉夹层覆膜支架置入术,3～7 d后完成PCI。观察近期及远期疗效。结果经桡动脉行主动脉造影:其中1例2个破口,夹层破口位于左锁骨下动脉外缘分别为15 mm和100 mm;其余25例均为单破口,夹层破口位于左锁骨下动脉外缘10 mm以下8例、10～30 mm 11例,>30～100 mm 6例。置入26枚支架,8例覆膜支架近心端部分或完全封闭左锁骨下动脉,术后左上肢桡动脉波动稍有减弱,但无上肢和脑缺血的症状。覆膜支架置入成功率100%。术后即刻造影:16例近端破口完全封堵,13例少量残余内漏。冠状动脉造影证实单支病变16例,2支病变8例,3支病变2例。靶病变平均狭窄(85.6±15.0)%,靶血管参考直径(2.8±0.3)mm。对32支靶血管共置入36枚支架。支架平均长度(25.5±13.6)mm。PCI即刻成功率100%,无PCI相关严重并发症发生。随访期12～114个月[平均(60±35)个月],26例均存活,无迟发内漏或需二次手术者及不良心脏事件发生。结论覆膜支架联合PCI治疗Stanford B型主动脉夹层合并冠心病安全可行,手术成功率高,术后患者恢复快,冠脉PCI的抗凝治疗未对大动脉覆膜支架术后构成不良影响,近、远期疗效可靠。     

两段式覆膜支架治疗B型主动脉夹层的研究

目的:探讨两段式覆膜支架腔内修复术(TEVAR)治疗Stanford B型主动脉夹层(TBAD)的疗效。方法:分析2013年3月至2015年3月间,在本中心采用两段式覆膜支架TEVAR术治疗的61例TBAD患者的临床影像及术后随访资料。适应证:1胸降主动脉段主动脉弯曲变形;2胸降主动脉存在多发破口;3主动脉远端锚定区真腔因假腔挤压而过细。结果:应用两段式覆膜支架TEVAR术治疗的TBAD共61例。术后平均随访(23.6±7.4)个月,围手术期死亡1例(1.6%),支架远端新发破口1例(1.6%),支架远端贴壁不良3例(4.9%),支架段假腔完全血栓化率91.8%(55/61),其中支架段假腔完全消失率41.8%(23/55),主动脉完全重塑率7.3%(4/55)。结论:采用两段式覆膜支架腔内修复术治疗Stanford B型主动脉夹层实现了主动脉夹层腔内治疗远端锚定区的精确选择,近中期疗效安全满意,中、远期疗效尚需远期随访。     

覆膜支架植入治疗急性期主动脉夹层的临床研究

目的:探讨应用覆膜支架治疗急性期主动脉夹层的疗效及安全性。方法:对20例急性期StanfordB型主动脉夹层患者行覆膜支架植入治疗、随访并评价疗效。结果:20例患者均成功植入覆膜支架,5例出现内漏,4例重复扩张后内漏消失,1例再植入支架后内漏消失。术中及术后无严重并发症发生。结论:覆膜支架植入术对于急性期StanfordB型主动脉夹层患者,是一种安全、有效的治疗方法。     

Usefulness of transesophageal echocardiographic monitoring to improve the outcome of stent-graft treatment of thoracic aortic aneurysms

The stent-graft procedure is becoming an alternative to surgery for treatment of many diseases of the descending thoracic aorta. This study evaluated the role of transesophageal echocardiography (TEE), used in combination with fluoroscopy and angiography, in monitoring the outcome of stent-graft placement. Twenty-two consecutive patients were submitted to stent-graft positioning in the descending aorta for various pathologies (7 patients had type B aortic dissections, 6 had thoracic aneurysms, 2 had thoraco-abdominal aneurysms, and 7 had post-traumatic aortic aneurysms). Before stent-graft deployment, TEE changed the proximal site of stent positioning initially identified by angiography in 33% of patients (5 of 15) with aortic aneurysms because of calcifications or atheromas that could interfere with stent adhesion to the aortic wall and that were not seen on angiography. In 28% of patients (2 of 7) with aortic dissection, TEE showed the guidewire in the false lumen, allowing an immediate repositioning. After stent-graft deployment, color Doppler TEE showed a perigraft leak in 7 patients, whereas angiography detected a perigraft leak in only 2 patients (p = 0.02). In 4 of these patients, further balloon expansions resulted in resolution of the leak. In the remaining 3 patients, additional stent-graft positioning was necessary. Considering the total patient cohort, TEE yielded relevant information, resulting in procedure changes in 59% (13 of 22). In conclusion, TEE provided additional information with respect to angiography in all phases of stent-graft treatment, improving immediate outcome and reducing complications.     

Rapid progression of discrete type A intramural hematoma: prevention of a "procedure-related" complication by intraoperative transesophageal echocardiography.

PURPOSE: To report a case illustrating the utility of transesophageal echocardiography (TEE) before planned stent-graft placement for chronic type B aortic dissection. CASE REPORT: A 64-year-old man with acute aortic syndrome and an 8-year-old interposition graft in the distal aortic arch for acute type B dissection was referred for dissection of the descending thoracic aorta down to the aortic bifurcation; the false lumen was dilated to 65 mm and was partially thrombosed. The ascending aorta showed discrete, eccentric, 4-mm wall thickening that was not considered clinically significant. Stent-graft closure of the entry tear in the proximal descending thoracic aorta was elected. However, as the endovascular procedure was about to commence, TEE showed striking eccentric thickening of the aortic wall of up to 18 mm. The endovascular procedure was stopped, as it was decided to urgently replace the ascending aorta. The next day, the patient underwent successful ascending aortic replacement and simultaneous antegrade stent-graft implantation over the descending thoracic aortic entry tear via the open aortic arch. The postoperative course was uncomplicated, and the patient was discharged 19 days after surgery. He remains well at 6 months after the procedure. CONCLUSIONS: Our case demonstrates that dissection of the ascending aorta may occur not only due to endograft-induced intimal injury, but may also occur due to underlying but undiagnosed or underestimated disease of the ascending aorta or arch. Besides procedural guidance, intraoperative TEE is a useful tool to detect such disease to avoid subsequent "procedure-related" complications.     

覆膜支架腔内治疗急性胸主动脉综合征

目的 评价覆膜支架腔内治疗急性胸主动脉综合征的有效性和安全性。方法 2001年5月至2005年12月应用覆膜支架治疗57例急性胸主动脉综合征患者,其中急性主动脉B型夹层45例,穿透性粥样硬化性溃疡（PAU）或假性动脉瘤9例,创伤性胸主动脉瘤3例。建立数据库,分析其临床特点、疗效及随访结果。结果 57例患者覆膜支架置入技术成功率100％。5例有近端内漏,1例术中出现升主动脉夹层,未予特殊处理,随访结果良好;1例术后7天出现升主动脉夹层并发心包填塞死亡。5例PAU或主动脉夹层合并冠心病患者,在应用覆膜支架成功完全封闭破口后立即行冠状动脉介入治疗成功。1例出现术后一过性双下肢无力,经静脉滴注山莨菪碱和甘露醇2天后痊愈。1例支架覆盖左锁骨下动脉开口导致左椎动脉缺血,嗜睡2天后自行好转。术后重症监护病房时间1～8（平均3．5）天,术后平均住院10天。术后30天内死亡2例,1例死于升主动脉夹层破裂,1例死于急性肾衰竭。术后30天内死亡率3．5％。术后平均随访（25．3±13．1）（13—55）个月。1例于术后3个月死于大咯血,1例死因不明。1例因近端内漏行二次腔内修复术。5例患者因降主动脉覆膜支架远端再发现破口,行二次腔内修复术。术后截瘫发生率为0,无支架移位、狭窄等并发症。术后住院及随访期内总死亡率为7．0％。与传统手术相比,腔内治疗急性胸主动脉综合征具有创伤小、严重并发症少、住院时间较短的优势。结论 覆膜支架是治疗急性胸主动脉综合征优良且有效的方法,也可用于外科手术高风险患者,近中期随访结果良好,远期结果有待于进一步随访。     

经胸超声心动图对急性Stanford A型主动脉夹层的临床诊断价值

目的探讨经胸超声心动图(TTE)在诊断Stanford A型主动脉夹层中的准确性。方法收集Stanford A型主动脉夹层患者共35例,回顾性分析经胸超声心动图的检查结果;并与增强CT血管造影(CTA)检查结果进行比较。结果 TTE、CTA对Stanford A型主动脉夹层的诊断率分别为91.3%、100%。TTE还能观察主动脉瓣损害、心包积液、心脏功能等情况。结论 TTE是诊断Stanford A型主动脉夹层的可靠方法,为临床急救提供有效依据。     

床旁经胸超声心动图在急性主动脉夹层Stanford细化分型中的应用价值

目的:本文旨在评价床旁经胸超声心动图在急性主动脉夹层(aortic dissection,AD)Stan-ford细化分型中的应用价值。方法:回顾分析经手术证实的52例急性主动脉夹层患者,男性35例,女性17例;年龄18～71岁,平均(52±11)岁的手术结果和经胸超声心动图表现及主动脉夹层采用Stanford细化分型方法。超声心动图分析的内容包括:内膜片、破口、主动脉瓣反流程度、冠状动脉、主动脉弓部3血管分支及窦管交界形态,主动脉窦部、弓部及胸腹主动脉内径。结果:52例AD Stanford细化分型如下:A1S型2例,A1C型1例,A2S型2例;A2C型9例,A3S型2例,A3C型14例,B1S型3例,B2S型5例,B2C型2例,B3S型10例,B3C型2例。经胸超声心动图结果:除3例漏诊外其余49例分型如下:A1S型4例,A1C型1例,A2S型1例;A2C型4例,A3S型5例,A3C型15例,B1S型3例,B1C型1例,B2S型4例,B2C型1例,B3S型8例,B3C型2例。结论:经胸超声心动图有助于诊断AD Stanford细化分型,具有重要的临床应用价值。     

Endovascular treatment of thoracic aortic disease: mid-term follow-up.

OBJECTIVE: The aim of this study was to evaluate the mid-term follow-up in a cohort of patients with acute or chronic descending aortic disease treated by stent-graft repair. BACKGROUND: Since 1999, endovascular stent-graft placement has been reported as an alternative treatment to surgical approach for a variety of thoracic aortic diseases; however, results beyond initial short-term follow-up are not widely available for the broad range of applications. METHODS: From March 2001, 43 consecutive patients with traumatic aortic transection (group A = 16) and complicated type B aortic dissection or aneurysm (group B = 27) underwent stent-graft implantation. All patients underwent computed tomography (CT) scan as preoperative assessment and in 26 a transesophageal echo (TEE) exam was performed. RESULTS: Technically successful stent-graft deployment was achieved in all patients. No patient required surgical conversion and no cases of paraplegia occurred. The overall in-hospital mortality was 9.3%. A residual endoleak (type II) was detected in one group B patient who was managed conservatively. The mean follow-up was 29 +/- 8 months (range 10-48 months). No patient died during late follow-up after hospital discharge. At 12 months, one patient (2.5%) who had stent graft repair of an aortic dissection developed an asymptomatic type I endoleak. Three asymptomatic patients with chronic dissection had a persistent retrograde perfusion of the thoracic false lumen via a distal tear(s) in the dissection septum. CONCLUSION: Our results of stent-graft treatment of complicated and uncomplicated diseases of the descending aorta confirms that this alternative to open repair is a safe, less invasive, and relatively low risk approach. Medium-term follow-up results suggest that it is effective and durable therapy with low associated mortality and morbidity rates.     

Value of transesophageal echocardiography in the diagnosis of acute aortic dissection]

We describe our experience of six patients with clinical suspicion of acute aortic dissection (AAD) who were studied consecutively by transesophageal echocardiography (TEE) from April to July of 1991. All of them were previously submitted to transthoracic echocardiogram. The diagnosis was correctly established by TEE in five cases, confirmed by aortography and/or surgery (four cases), or by autopsy (one case). In one patient the diagnosis of AAD was excluded by TEE, and posteriorly by nuclear magnetic resonance. Four patients had a Stanford type A, and one patient a type B dissection. The site of entry was identified in three cases; the intimal entry tear of the type B dissection, not observed by TEE, was localized in the aortic arch by aortography. In three of the four type A dissection cases, a thrombus in the false lumen and an aortic regurgitation were found. No other noninvasive methods were used after the diagnosis of AAD by TEE. The surgical repair was successful in three cases, one of which, without previous necessity of aortography. In our experience, TEE increased extraordinarily the diagnosis efficacy of AAD, making possible an earlier therapeutic approach, and probably contributing to the improvement of the prognosis of this pathology.     

Diagnostic potential of combined transthoracic echocardiography and x-ray computed tomography in suspected aortic dissection.

BACKGROUND: Transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) are considered optimal diagnostic methods in the setting of suspected aortic dissection. However, although less sensitive as single modalities, transthoracic echocardiography (TTE) and contrast-enhanced computed tomography (x-ray CT) are more widely available and less costly. HYPOTHESIS: This study was undertaken to compare the diagnostic performance and reliability of the combined use of TTE and x-ray CT with TEE and/or MRI findings in the setting of suspected aortic dissection. METHODS: The diagnostic power of combined TTE and x-ray CT was compared with both single use of TTE and x-ray CT and with TEE and/or MRI in a series of 168 consecutive patients with suspected aortic dissection (AD). Of these, 28 women and 58 men (mean age 53 +/- 16 years) underwent TTE and x-ray CT prior to TEE (n = 52) and/or MRI (n = 69). Diagnostic results of combined TTE/x-ray CT were retrospectively but independently reevaluated in blinded fashion; diagnostic findings were validated by angiography (n = 63), surgery (n = 52), or autopsy (n = 7). RESULTS: Type A dissection was found in 29 patients (34%), type B dissection in 10 (12%), whereas aortic dissection was excluded in 47 (55%). With 95%, the sensitivity of TTE and x-ray CT was significantly enhanced when used in a combined access compared with 67 and 79%, respectively, when used as single methods (95%; p < 0.05). Sensitivity and specificity (95 and 91%, respectively) of combined TTE/x-ray CT evaluation were not different from TEE and/or MRI (100 and 96%, respectively; NS). Thrombus formation, side-branch involvement, aortic regurgitation, pericardial effusion or mediastinal hematoma were also detected with similar sensitivities and specificities both by combined TTE/x-ray CT and TEE and/or MRI. CONCLUSION: This first controlled study comparing the combined information of TTE and x-ray CT with TEE and/or MRI revealed a similar diagnostic potential of both diagnostic strategies in the setting of suspected aortic dissection. Thus, in an environment with access to color Doppler TTE and x-ray CT only, the information from both tests should be combined to decide on diagnostic management of these patients.     

食管超声心动图在重危心脏病人诊断治疗中的价值

目的　为评价食管超声心动图 (TEE)在重危心脏病人诊断治疗中的价值 ,对 3 7例收住监护病房的重症心血管病人进行了经胸超声心动图 (TTE)和TEE检查 ,其中男 2 5例 ,女 1 2例 ,平均年龄57( 1 9～ 85)岁。入选对象包括怀疑夹层动脉瘤 2 3例、心脏瓣膜功能异常 9例、感染性心内膜炎 3例 ,心内分流 2例。结果　所有病人均可耐受TEE检查 ,无并发症发生 ,TEE较TTE可提供更高的阳性诊断结果 ,阳性率分别为 65 0 %和 3 8 0 % ,在怀疑夹层动脉瘤者中 ,TEE检出夹层撕裂膜 1 4例 ;而TTE仅检出 7例 ,且图象欠清 ,检出部位有限。在 4例人工机械瓣膜功能异常者中 ,TEE发现瓣膜部位血栓形成 3例。结论　在对心脏大血管疾病的诊断中 ,TEE阳性诊断率高于TTE ,尤其在怀疑夹层动脉瘤及人工机械瓣膜病变时 ,应行TEE检查。即使在重危病人 ,TEE也是一种安全有效的诊断手段。