85例Stanford B型主动脉夹层腔内修复治疗体会

目的 探讨胸主动脉腔内修复术(TEVAR)治疗Stanford B型主动脉夹层(AD)方法与疗效.方法 回顾性分析2010年1月至2016年4月采用TEVAR治疗的85例Stanford B型AD患者临床资料.85例患者均常规行左肱动脉穿刺,右侧股动脉直切口,升主动脉DSA造影明确AD破口位置、真假腔及与重要器官血管开口位置关系;置入覆膜血管内支架,封堵原发破口,升主动脉造影复查观察近端破口封闭情况及主动脉弓部分支血管、真假腔血流变化情况.结果 84例患者TEVAR手术成功,成功率100％;1例术前麻醉过程中突发AD破裂死亡.9例部分覆盖左锁骨下动脉,1例左锁骨下动脉“烟囱”支架完全封闭左颈总动脉和左锁骨下动脉,2例行无名动脉至左颈总动脉和左锁骨下动脉转流.Ⅰ型内漏2例,无住院期间死亡.术后随访3个月至3年,患者均存活,远端再发新破口2例.结论 TEVAR术治疗Stanford B型AD安全有效,严格把握手术指征、术中精细操作及加强术后院外管理是手术成功、提高远期生存率关键.     

主动脉腔内隔绝术治疗慢性复杂降主动脉夹层疗效分析

目的探讨主动脉腔内隔绝术治疗慢性复杂降主动脉夹层的疗效及安全性。方法回顾性分析自2002年2月至2014年3月沈阳军区总医院收治的86例慢性复杂降主动脉夹层患者临床资料,主动脉腔内隔绝术后近期、远期疗效及并发症发生率。结果所有86例患者手术成功率为100%,共植入带膜支架91枚,其中植入单枚带膜支架81例,植入2枚支架5例。支架平均直径(34.0±4.2)mm,平均长度(126.0±33.2)mm。造影剂少许内漏3例;三度房室传导阻滞合并阵发性房颤植入永久起搏器1例;因破口邻近左锁骨下动脉开口,带膜支架近心端部分封闭左锁骨下动脉18例(20.9%),完全封闭左锁骨下动脉10例(11.6%),术后均无椎基底动脉缺血症状及左上肢血供异常。联合冠状动脉介入治疗7例(8.1%),住院期间无心脏不良事件发生。57例患者接受随访,平均随访时间(62.8±34.7)个月,随访期内9例死亡,病死率为10.5%(9/86)。其中,2例(2.3%)因夹层相关疾病死亡,3例(3.5%)心源性死亡。术后6个月复查主动脉CTA,所有随访患者支架贴壁良好,无变形或移位,真腔内径扩大,假腔内径缩小,血肿部分完全吸收,3例内漏患者内漏自行封闭。结论主动脉腔内隔绝术治疗慢性复杂降主动脉夹层安全、有效。     

3D打印在复杂主动脉疾病个体化腔内治疗中的应用价值

【摘要】目的：探讨3D打印技术在复杂主动脉疾病个体化腔内治疗中的应用价值。方法：搜集3例复杂主动脉病变,包括病变邻近主动脉弓远端的Stanford B型主动脉夹层（病例1）,病变累及升主动脉但原发破口位于降主动脉的逆撕Stanford A型主动脉夹层（病例2）和解剖迂曲的肾动脉下型腹主动脉瘤（病例3）。通过3D打印模型制定个体化腔内治疗方案。结果：根据3D打印模型制定个体化手术方案,病例1行左锁骨下动脉+左颈总动脉开窗,病例2行单纯腔内修复,病例3行腔内隔绝术;3例患者术中造影均显示无内漏,开窗血管血流通畅,无支架移位、截瘫、神经系统并发症发生。术后随访1年,3例均无内漏,假腔或瘤体血栓机化,无主动脉相关事件发生。结论：3D打印技术有助于复杂主动脉疾病最优化、个体化腔内治疗方案的制定,临床应用前景广泛。     

血管腔内隔绝术治疗降主动脉夹层动脉瘤

目的：探讨血管腔内隔绝术治疗降主动脉夹层动脉瘤的技术方法和疗效。方法：对10例降主动脉夹层动脉瘤患者的临床资料进行分析,其中2例为DeBakeyШa型,8例为DeBakeyШb型。1例夹层动脉瘤仅累及腹主动脉,合并真性动脉瘤。影像学资料显示全组有3例在不同部位有2个以上撕裂口。结果：1例腹主动脉混合型动脉瘤按腹主动脉瘤腔内隔绝术进行,2例将人工带膜支架封闭左锁骨下动脉口,另7例均顺利进行主动脉腔内隔绝术。随访2~16个月,全部病例均存活。结论：血管腔内置入带膜支架型人工血管是治疗主动脉夹层动脉瘤的简便、安全、有效的方法。     

带膜支架治疗胸主动脉夹层和真性动脉瘤的经验分析

目的探讨血管腔内治疗主动脉夹层和真性动脉瘤的技术方法和疗效。方法24例主动脉夹层和(或)真性动脉瘤患者的临床资料进行分析。StanfordB型23例,4例在不同部位有2个以上撕裂口。真性动脉瘤1例。全组均以带膜支架型人工血管腔内植入行隔绝术。结果除2例患者术后出现内漏外,其余患者带膜支架植入后破口完全封闭。真腔血流恢复正常。手术成功率100%,无术中转开胸手术,无截瘫及瘤体破裂等严重并发症,无围手术期死亡。随访1~20个月,24例均经螺旋CT增强扫描和5例DSA复查,证实无支架移位等严重并发症发生,原2例内漏患者术后2个月后复查DSA,内漏均消失。结论带膜支架腔内置入治疗胸主动脉StanfordB型夹层动脉瘤和真性动脉瘤具有技术可靠,创伤小,术后恢复快,手术死亡率低,手术成功率高和生存率高的优点,尤其在亚急性期或慢性期的夹层动脉瘤均应为首选的治疗方法。     

单分支型主动脉覆膜支架治疗Stanford B型主动脉夹层的临床价值

【摘要】 目的 探讨单分支型主动脉覆膜支架在Stanford B型主动脉夹层单纯腔内隔绝治疗中的临床价值。 方法 2017年7月至2018年10月采用国产CastorTM单分支型主动脉覆膜支架行单纯腔内隔绝治疗19例Stanford B型主动脉夹层患者,观察术后即时血管造影结果。术后1个月门诊随访,术后6个月复查主动脉CTA。以手术成功率、假腔消失率和分支支架通畅率为有效性终点指标,观察相应不良事件。 结果 19例患者支架均释放成功,技术成功率100%。围手术期无不良事件发生。随访期患者无死亡,4例门诊随访时出现左上肢缺血症状,经对症治疗后缓解。无严重内漏发生,分支支架通畅率100%,夹层假腔均出现血栓化,假腔直径平均缩小（10.3±1.2） mm（肺动脉分叉平面）。 结论 单分支型主动脉支架对于近端破口距左锁骨下动脉开口＜15 mm或逆撕至左锁骨下动脉根部的Stanford B型主动脉夹层,是有效的单纯腔内隔绝方法。     

逆行性A型主动脉夹层腔内隔绝治疗效果观察

目的 观察逆行性A型主动脉夹层的腔内隔绝治疗效果，探讨逆行性A型主动脉夹层腔内隔绝治疗的策略。方法 选取湖南中医药大学第一附属医院2016年10月至2020年11月近端内膜破口位于降主动脉的逆行性A型主动脉夹层患者19例，行主动脉覆膜支架植入术，并于术后1周、3个月、半年、1年随访观察治疗效果。结果 全组随访无一例患者死亡，2例患者支架近端主动脉弓部出现局限性溃疡，2例出现升主动脉夹层，1例支架远端出现夹层，其余14例患者均恢复良好，无相关并发症。结论 近端内膜破口位于降主动脉的逆行性A型主动脉夹层患者，经保守治疗后择期行腔内隔绝手术的治疗策略近中期效果理想。     

远端破口在Stanford B型主动脉夹层预后中的研究进展北大核心CSCD

胸主动脉腔内修复术(TEVAR)是目前治疗Stanford B型主动脉夹层(TBAD)的首选术式。TEVAR主要封闭TBAD近端破口,对远端破口进行定期随访观察。鉴于远端破口的存在对夹层预后会产生不利的影响,本文介绍了远端破口的解剖学特征评估方法、远端破口对夹层预后的影响以及相关血流动力学的研究进展,在此基础上进一步综述了远端破口的介入干预方法及其远期疗效。     

腔内修复治疗累及左锁骨下动脉的主动脉夹层动脉瘤

目的 探讨累及左锁骨下动脉的主动脉夹层动脉瘤腔内修复治疗的手术方式及疗效.方法 回顾性分析2004年1月至2014年12月采用不同腔内修复术式治疗56例主动脉夹层动脉瘤患者临床资料,其中男42例,女14例.采用“烟囱”技术重建左锁骨下动脉血流26例(A组),分支支架技术重建10例(B组),复合手术重建20例(C组).术中使用国产覆膜支架26例,进口覆膜支架30例;全身麻醉48例,局部麻醉8例.结果 手术全部成功(100％),无手术死亡患者.A组植入裸支架11例,覆膜支架15例;C组4例先植入胸主动脉覆膜支架,直接覆盖左锁骨下动脉,再作腋-腋动脉人工血管旁路移植术;16例先作腋-腋动脉人工血管旁路移植术,再行主动脉腔内修复覆盖左锁骨下动脉.3组患者出院时CTA检查显示支架形态均良好,无明显移位,组间差异无统计学意义(P＞0.05).内漏发生在A组有4例(15.4％),B组1例(11％),C组1例(5％),组间差异均无统计学意义(P＞0.05).52例(92.9％)患者获平均23.5个月随访,死亡5例(9.6％),原因为心肌梗死(2例)、肿瘤(3例).47例CTA随访发现6例仍有部分内漏,24例远端胸腹主动脉仍有夹层但未扩大,未作特殊处理,目前均在随访中.结论 “烟囱”技术、分支支架技术和复合手术修复治疗累及锁骨下动脉的主动脉夹层动脉瘤是安全有效的.     

三明治技术在腹主动脉瘤累及髂总动脉腔内治疗中保留髂内动脉的疗效分析

【摘要】 目的 分析三明治技术应用于腹主动脉瘤（AAA）累及髂总动脉腔内治疗保留髂内动脉的近期疗效。 方法 回顾性分析重庆医科大学附属第二医院2016年6月至2018年7月采用主动脉腔内修复术（EVAR）治疗的9例AAA累及髂总动脉患者（累及单侧髂总动脉3例，双侧6例），术中均接受髂内动脉三明治重建。术后观察和随访围手术期死亡率、腔内修复效果、内漏、支架一期通畅情况及手术相关并发症发生情况。 结果 9例患者EVAR术和髂内动脉三明治重建技术均获成功，围手术期无死亡。术中即刻造影显示9例支架均获通畅，瘤腔均成功修复。出现1例Ⅰ型内漏，2例Ⅲ型内漏，随访时自行消失；1例左上肢急性缺血，再次予急诊肱动脉修复术；3例左肱动脉切口处血肿形成，2例右股动脉穿刺点处血肿形成。术后1周、3个月、6个月复查CTA分别显示支架通畅9例、8例、8例，均无肠缺血、脊髓缺血或瘫痪症状。 结论 三明治技术在AAA累及髂总动脉腔内治疗中保留髂内动脉安全可行，术后臀肌跛行发生率低，近期随访支架通畅率可，值得临床推广，但远期效果尚需进一步随访及更大临床样本验证。     

经皮开窗术治疗主动脉夹层引起的缺血

目的 评价经皮开窗术治疗主动脉夹层引起的内脏及下肢缺血。方法 6例主动夹层并发内脏及下肢缺血患者行经皮开窗术，所有患者皆是Stanford B型夹层，累及的血管有肾动脉（3条）、肠系膜动脉（1条）和下肢动脉（6条）。4例行单纯经皮开窗术，1例行开窗及左肾动脉支架置入治疗，1例行开窗及腹主动脉和双侧髂总动脉支架置入治疗。1例患者于开窗后1个月行支架移植物复合体（stent—graft）腔内隔绝术。结果 所有6例患者血管重建均成功，其中4例缺血症状消失，2例明显减轻。随访4～12个月，平均7．6个月，1例患者术后3个月死于主动脉破裂出血，余5例仍存活。无严重的手术相关并发症。结论 经皮开窗术或经皮开窗结合支架置入是1种安全、有效的治疗主动脉夹层引起的内脏及下肢缺血的方法。     

Treatment of Stanford type B aortic dissection with stent-grafts: preliminary results

PURPOSE: To evaluate the feasibility and safety of endovascular stent-graft placement in treating Stanford type B aortic dissection. MATERIALS AND METHODS: Seven patients underwent endovascular stent-graft placement for type B aortic dissection. Five patients had acute and two had chronic dissection. In five patients, the proximal entry tear was within 2 cm of the origin of the left subclavian artery, and in two patients it was beyond this site. In three patients, the noncovered proximal portion of the stent-graft was placed across the origin of the left subclavian artery. The efficacy of the procedure was assessed at follow-up studies 3, 6, 12, and 24 months after intervention. RESULTS: The procedure was technically and clinically successful in six patients (86%). The left subclavian artery remained patent in all patients. In two patients with involvement of aortic branches, endovascular stent-graft placement restored adequate blood flow to the compromised branches. One patient was readmitted 1 month later because the dissection extended into the ascending aorta. In all but this patient, closure of the entry tear and thrombosis of the false lumen along the stent-graft were achieved. All false lumina shrank considerably. The mean follow-up time was 14 months (range, 1-25 months). CONCLUSION: Type B aortic dissections within and beyond 2 cm of the origin of the left subclavian artery can be treated safely and effectively by means of endovascular stent-graft placement.     

Use of aortic cuffs to exclude iliac artery aneurysms during AneuRx stent-graft placement: initial experience.

PURPOSE: As many as 39% of patients who undergo aortic endografting for abdominal aortic aneurysm disease will have ectasia of the iliac arteries that will require intervention. Coil embolization of the internal iliac artery and extension of the graft to the external iliac artery is one solution to this problem. However, 19%-41% of these patients experience buttock claudication, which may be permanent, after unilateral embolization. The authors examined an alternative: the use of larger-sized aortic cuffs to seal the iliac limb. Outcomes and short-term results are presented in this article. MATERIALS AND METHODS: From October 1999 to August 2000, 144 AneuRx stent-grafts were placed at the authors' institution. Among the population receiving stent-grafts, 14 patients had 15 aortic cuffs placed across the distal iliac graft limbs to seal them and preserve flow to the internal iliac artery. One patient had bilateral cuffs placed. Five patients had embolization of the contralateral internal iliac artery because of bilateral disease. Patients were followed with computed tomography (CT) at 1, 6, and 12 months to evaluate for endoleaks. RESULTS: One- and 6-month endoleak rates, determined from only those patients with follow-up CT, were 0% and 10%, respectively. One type II endoleak was first discovered 9 months after graft placement. It sealed spontaneously at 15-month follow-up. One patient among the five who had internal iliac artery embolization had claudication. Mean CT follow-up was 7.8 months (range, 1-15). One patient declined CT but was alive and well 11 months after endografting. One patient moved across the country and declined follow-up. CONCLUSION: Placement of aortic cuffs in dilated iliac arteries can preserve flow to the ipsilateral internal iliac artery and provide an adequate seal. Additionally, the option of later treatment is maintained. Patients with bilateral iliac ectasia can undergo stent-graft placement without bilateral internal iliac artery embolization. Longer-term follow-up in larger numbers of patients will be important to determine the ultimate durability of this technique.     

应用覆膜支架治疗自发性外周动脉夹层9例

目的 探讨应用覆膜支架腔内隔绝自发性外周动脉夹层的安全性及有效性.方法 收集9例自发性外周动脉夹层患者,病变在髂动脉6例,锁骨下动脉3例.术前均行CTA检查,明确外周动脉夹层的部位和程度,预定覆膜支架.所有患者经Seldinger穿刺股动脉后进一步造影明确病变,依据造影结果植入覆膜支架.结果 9例患者中,病变在右侧髂总动脉3例,右侧髂外动脉l例,左侧髂总动脉2例,左侧锁骨下动脉3例.夹层长度0.9～3.3 cm,平均1.7 cm.动脉夹层起始部距靶血管开口距离0.5～5,6 cm,平均2.3 em.所有患者均成功植入覆膜支架,1例覆膜支架覆盖左侧非优势椎动脉,术中无明显并发症发生.随访3～32个月,平均18个月,所有患者均无相关并发症发生,彩色多普勒超声复查示支架通畅.结论 应用覆膜支架腔内隔绝自发性外周动脉夹层是一种安全有效的治疗方法.     

64层螺旋CT血管成像技术在主动脉病变腔内支架隔绝术后随访中的临床应用价值

目的 探讨64层MSCTA技术在主动脉病变腔内支架隔绝术后随访中的临床应用价值.方法 30例主动脉夹层(AD)及5例腹主动脉瘤(AAA)患者腔内支架隔绝术后接受了44次64层MSCTA检查.35例患者的图像后处理及分析采用MPR、MIP及VR技术.在全面观察分析图像的基础上,重点观察AD及AAA的转归及并发症发生情况.结果 (1)30例AD患者中,28例假腔内大量血栓形成,2例少最血栓形成.5例AAA患者支架外瘤体完全血栓化.(2)1例无名动脉受累的AD患者,术后3次CTA随访发现无名动脉内血栓形成.1例肠系膜上动脉内血栓形成患者术后15 d随访CTA发现血栓未溶解,3个月后再次复查则发现血栓溶解.1例术后随访发现右髂外动脉出现内膜撕裂.5例AAA患者中,1例右髂内动脉闭塞,1例右髂总动脉远端支架内血栓柃塞.(3)14例AD患者有内漏发生,其中Ⅰ型内漏8例、Ⅲ型内漏6例,1例Ⅲ型内漏3个月后再次复查,内漏消失.结论 64层MSCTA以其快速、无创、准确性高等优点,结合多种后处理方法可以对腔内隔绝术的疗效作出较为客观的评价,已成为主动脉病变腔内支架隔绝术后随访首选的影像检查方法之一.     

Treatment of chronic aortic dissection by transluminal endovascular stent-graft placement: preliminary results.

PURPOSE: To investigate efficacy of stent-graft repair for the treatment of patients with chronic aortic dissection. MATERIALS AND METHODS: Fifteen patients with chronic aortic dissection were treated with endovascular stent-grafts. Entry tears were located in the descending thoracic aorta in all patients. The mean maximum diameter of the descending thoracic aorta was 47 mm +/- 8. The mean diameter of the true lumen at the same level was 20 mm +/- 5. The mean interval between diagnosis and stent-graft procedure was 32 months +/- 91. Stent-grafts were fabricated from expanded polytetrafluoroethylene and Z-stents. RESULTS: Stent-grafts were placed successfully in all patients. Two stent-grafts were required in one patient. Entry closure and thrombosis of the false lumen of the descending thoracic aorta were also achieved in all patients. No procedure-related complications were observed except for postimplantation syndrome, including fever and leukocytosis. The diameter of the true lumen was significantly increased (mean, 31 mm +/- 6) at the level of the descending thoracic aorta (P <.01) and the diameter of the aorta was significantly decreased (mean, 44 mm +/- 8) at the same level (P <.01). There were no deaths and no instances of aortic rupture during the subsequent average follow-up period of 24 months. Secondary stent-graft procedures were required to treat the abdominal component of dissection during follow-up in one patient. CONCLUSIONS: Stent-graft repair of chronic aortic dissection is a safe and effective method and may be an alternative to surgical graft replacement in selected patients. However, further evaluation is mandatory before this method is widely employed.     

胸主动脉夹层动脉瘤腔内隔绝术手术入路的探讨

目的 探讨为胸主动脉夹层动脉瘤(TAD)行腔内隔绝术(EVE)选择合适的导入动脉。方法 以彩超，CTA或MRA为检查手段，评估导入动脉(股动脉、髂总动脉、腹主动脉下段等)的直径大小(≥8mm)、有否硬化斑块、狭窄、是否被夹层累及、有否扭曲及其程度，从而选择具体的手术入路。结果 本组37例TAD行EVE术所选择经股动脉手术入路23例、经髂总动脉手术入路14例。未选择经腹主动脉下段手术入路。即时操作成功率为100％。结论 合理的选择导入动脉作为手术入路，是EVE手术治疗TAD顺利完成的要点。     

Stanford B型主动脉夹层支架置入术前MSCTA的诊断价值

目的探讨Stanford B型主动脉夹层支架置入术前多层螺旋CT(MSCTA)检查的诊断价值。资料与方法分析26例Stanford B型主动脉夹层(AD)患者MSCTA表现及临床介入资料。结果通过MSCTA检查发现破裂口情况、主要血管分支假腔供血情况、真假腔形态、双侧髂股动脉情况、并发症等信息,并以此对介入支架置入治疗术前评估及术后预判,与介入实际情况相比较,真实一致。结论 MSCTA对Stanford B型主动脉夹层支架置入术前诊断具有重要意义。     

血管内支架置入术治疗Stanford B型主动脉夹层

目的：总结主动脉血管支架置入术治疗Stanford B型主动脉夹层的临床经验。方法：术前对15例Stanford B型主动脉夹层患者进行主动脉全程薄层增强CT扫描及血管成像，以获得主动脉夹层病变解剖学特征。在局麻下行主动脉造影，并与CT结果比较，选取支架血管型号。全麻下切开左股动脉或右股动脉，置入支架血管，封堵原发破口，重复造影检查有无内漏。术后1周及1年行CT随访，观察有无内漏、支架移位和假腔变化。结果：15例均获临床成功。1例见少量近端内漏，未发生其他并发症。CT随访，5例主动脉夹层消失，余者假腔内血栓形成。结论：与传统手术相比，腔内隔绝术治疗Stanford B型主动脉夹层具有创伤小、并发症少、安全性高等优点，近期疗效满意。