主动脉夹层或瘤的腔内隔绝术临床评价(附23例报道)

目的:评价应用腔内血管支架治疗腹主动脉瘤的优点。方法:对24例患者行DSA和带膜血管腔内支架植入隔绝手术治疗,其中Stanford B型夹层动脉瘤19例,真性腹主动脉瘤4例,假性腹主动脉瘤1例。所有病例均采用TALENTTM带膜支架移植物系统。术后对所有患者行螺旋CT随访。结果:除1例因胸主动脉夹层破口位于左锁骨下动脉开口处,无法放置腔内血管支架而行开胸手术外,余23例均顺利放入,术后患者症状完全消失,全部患者在随访期间均未出现术前症状,未见相关并发症。结论:应用带膜支架治疗胸主动脉Stanford B型夹层、真性和假性腹主动脉瘤,其效果较单纯开放式手术效果好且不良反应小,值得在临床上推广和应用。     

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。     

内支架置入术治疗胸腹主动脉瘤的临床评价

目的：探讨胸腹主动脉瘤的ESG治疗临床疗效。方法：对10例患者分别行CTA、MRA、DSA检查和ESG治疗，其中Stanford B型夹层动脉瘤6例，真性腹主动脉瘤2例，肾动脉开口以下腹主动脉瘤2例（行分体式支架），所有病例均采用带膜支架。结果：8例行一体式支架腔内隔绝术，2例行分体式支架腔内隔绝术，均获成功。顺利植入，术后造影提示动脉瘤消失．无内漏发生。患者症状完全消失，全部患者在随访期间均未出现术前症状，未见相关并发症。结论：应用ESG治疗胸腹主动脉瘤安全、有效、创伤小、术后恢复快，长期疗效尚待进一步观察。     

主动脉夹层动脉瘤的血管内支架治疗

目的评价血管内支架置入治疗主动脉夹层动脉瘤的安全性和临床疗效。方法48例Stanford B型主动脉夹层动脉瘤患者行腔内修复术。所有患者在DSA下行左肱动脉穿刺插管、造影,了解主动脉真、假腔,夹层裂口及其与重要血管分支位置关系。腹股沟区纵切口显露股动脉,送入人工血管输送器至病变处,准确定位后,释放人工血管进行腔内修复。术后复查造影,观察真、假腔血液动力学变化,内脏及下肢动脉供血的改变。结果48例患者一次性成功置入人工血管支架,2例支架未能完全封堵漏口,内漏明显,手术成功率95.8%。支架置入后假腔血压下降,机体脏器缺血状况改善,临床症状好转或消失。结论支架性人工血管腔内修复术治疗主动脉夹层动脉瘤安全可行、效果明显,值得临床进一步推广。     

StanfordB型主动脉夹层动脉瘤的微创腔内治疗

为探讨腔内隔绝术治疗StanfordB型主动脉夹层动脉瘤适应证的选择及并发症的防治原则,回顾了1998年至2000年对32例StanfordB型主动脉夹层动脉瘤实施的微创腔内隔绝术（即经股动脉将支架－人造血管复合移植导入主动脉封闭夹层裂口）。移植物均为直型,长度95－130mm,口径28－40mm。手术操作成功率100％。术后死亡1例,其余无心、肺、肾及截瘫等严重并发症,说明腔内隔绝术治疗StanfordB型主动脉夹层动脉瘤安全、有效,为治疗为病的首选方法。     

覆膜支架腔内修复术治疗主动脉病变的价值

目的:评价覆膜支架腔内修复术治疗主动脉病变的应用价值及临床意义。方法:21例主动脉疾病患者,包括:Stanford B型夹层13例(65%),真性动脉瘤3例(15%),假性动脉瘤2例(10%),弓降部穿透性溃疡1例(5%),胸主动脉瘤合并局限性夹层1例(5%),胸主动脉瘤合并Stanford B型夹层1例(5%),全部接受TSGP。共应用3种类型大动脉覆膜支架,分别为:美国锐乐(10例)、国产先健(10例)及COOK公司血管支架(1例)。结果:17例分别置入1个支架,2例分别置入2个支架,2例分别置入主体支架1个、短支架2个,所有支架释放成功率100%。患者无截瘫及瘤体破裂等严重并发症,无围手术期死亡。支架释放后即刻造影复查,19例无明显渗漏和假腔显影(90%);2例少许内漏,其中1例术后7 d CTA复查内漏消失,1例为Ⅱ型内漏,建议随访观察;1例术后8月随访,支架近端新发内漏并逐次增多。结论:TSGP治疗主动脉夹层、真性及假性动脉瘤、穿透性溃疡成功率高、创伤小,近中期效果良好,但远期随访及效果评价有待进一步观察。     

带膜支架治疗Stanford B型胸主动脉夹层的疗效分析

目的分析带膜支架腔内隔绝术治疗Stanford B型胸主动脉夹层的短期和中长期疗效。方法对2005年1月至2013年12月全麻下行带膜支架治疗的183例Stanford B型胸主动脉夹层患者的资料进行回顾性分析,包括术后住院期间的临床症状、术后并发症、ICU留观时间、住院时间、30 d病死率、出院后复查支架塌陷情况、位置和形态、夹层假腔直径情况、内漏等并发症及生存率、生存质量等。结果 183例患者带膜支架腔内隔绝术手术均成功,术后平均ICU留观时间为(3.08±1.93)d,平均住院时间为(7.08±1.67)d,术后30 d病死率为1.09%;出院后定期影像学复查所有患者均无支架塌陷、移位,形态正常,未出现夹层复发、破裂和逆向撕裂,未发现长期存在的内漏。随访过程中死亡4例,其中3例诊断为脑梗死。患者5年生存率为97.82%,生存质量无明显下降。结论腔内隔绝术治疗Stanford B型胸主动脉夹层具有良好的短期疗效和稳定的中长期疗效。     

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。     

多层螺旋CT造影在主动脉病变腔内修复术后随访的价值

目的:探讨多层螺旋CT血管造影(multi-detector rowspiral computed tomography angiography,MDCTA)及后处理技术在主动脉覆膜支架腔内修复术(transluminal stent-graft placement,TSGP)术后随访的临床应用价值。方法:21例接受TSGP主动脉疾病患者,包括:Stanford B型夹层13例,真性动脉瘤3例,假性动脉瘤2例,弓降部穿透性溃疡1例,胸主动脉瘤合并局限性夹层1例,胸主动脉瘤合并Stanford B型夹层1例,术后采用MDCTA进行随访,平均随访13个月(1~24个月)。采用轴位图像与多种重建图像相结合来显示支架形态、术前术后主动脉管腔情况的变化和有无并发症。结果:13例主动脉夹层覆膜支架置入后:所有患者均真腔扩大,假腔减小或消失并伴血栓形成,支架未发现移位或断裂;共3例(14%)随访中发现内漏,1例Ⅱ型内漏,建议随访观察;1例术后8个月复查新发现支架近端Ⅰ型内漏,密切随访2个月后患者出现胸痛,复查CT内漏增多,转外科治疗。1例腹主动脉瘤术后1月复查发现Ⅲ型内漏。所有患者介入术后CT随访图像均满足临床诊断需要。结论:MDCTA对主动脉覆膜支架置入术后随访较其他检查手段具有多方面的优越性,能及时观察术后疗效、发现并发症,对主动脉疾病覆膜支架腔内修复术后随访具有重要价值。     

Stanford B型胸主动脉夹层动脉瘤合并肾缺血的诊治(附3例报告)

为探讨合并肾缺血的StanfordB型胸主动脉夹层动脉瘤的诊断和处理 ,分析 1996年 1月至 2 0 0 0年 4月收治的StanfordB型胸主动脉夹层动脉瘤 2 9例 ,其中合并肾缺血 3例 ,为急性期 2例 ,慢性期 1例。急性期 1例发病后第 3天死亡 ,另 1例同时合并肾缺血和双下肢缺血 ,经夹层隔膜开窗术缓解 ;慢性期 1例经腔内隔绝术治愈夹层后肾缺血自行缓解。提示合并肾缺血的StanfordB型胸主动脉夹层动脉姑息性转流手术有助于缓解症状 ,提高生存率 ;对于慢性StanfordB型胸主动脉夹层动脉瘤合并肾缺血的患者 ,腔内隔绝术在治愈夹层动脉瘤的同时恢复了真腔供血 ,肾缺血可同时治愈     

主动脉瘤腔内修复术一期治愈Stanford A型主动脉夹层并腹主动脉瘤一例

Stanford A型主动脉夹层是一种灾难性疾病,病死率极高[1]。治疗主要以手术为主,即升主动脉或主动脉弓置换术,但手术创伤大,手术病死率达14%～21.6%[2]。自1991年     

Air medical transport of suspected aortic emergencies

PURPOSE: To review and characterize 4 years of experience with suggested nontraumatic aortic emergencies (dissections/ruptures) transported by a new, provincially dedicated rotor-wing air medical program METHODS: Retrospective 4-year review of air medical program's mission records and review of related hospital records. Patients listed as suspected aortic emergencies (nontraumatic) in the air medical records were included. Mission records were reviewed for EMS diagnosis, blood pressures before and after transport, transport times, and mortality. Hospital records were reviewed for diagnosis, interventions/treatment, and mortality. Blood pressures below 80 mmHg systolic were considered hemodynamically unstable. RESULTS: A cohort of 34 patients were identified, of whom 31 (91%) arrived at the hospital alive. Twenty-five patients (74%) arrived hemodynamically stable, with a mean out-of-hospital time of 60 minutes, and nine patients (26%) were hemodynamically unstable (mean out-of-hospital time was 54 minutes). No significant difference arose in times between these two groups (P = 0.16). Overall mortality was 53% (18). Differences in transport time between survivors and deaths was not statistically significant (P = 0.93). The diagnoses on admission to hospital: 14 (41%) were RAAA, five (15%) AAA no rupture, eight (24%) aortic dissections, and four (12%) had no aortic pathology. Seventeen patients (50%) received emergent surgical intervention. The EMS diagnosis was correct in 76% of cases. CONCLUSION: Our program transported 34 suspected aortic emergencies of which 17 were immediate surgical candidates on arrival. Aortic emergencies are not infrequent within our program. Specific policies and procedures based on continuing quality review should be in place to optimize the transport and care of these patients.     

Standford B型主动脉夹层腔内修复术后主动脉重塑效果

目的 系统性回顾Standford B型主动脉夹层腔内修复术(TEVAR)后主动脉重塑结果.方法 检索已发表的评估TEVAR术后主动脉重塑文献,系统性回顾Standford B型主动脉夹层形态学测量方法及结果.共纳入19篇文献,其中仅3篇文献采用三维重建软件进行测量.各文献测量变量多为夹层真腔、假腔直径或面积,仅有少数文献计算了真假腔体积.结果 各文献测量的主动脉平面、术后随访时间及测量方法不同,无法进行数据整合.但总体趋势为急性B型夹层患者术后主动脉重塑效果(胸主动脉假腔血栓化比率为80％～90％)优于慢性患者(38％～91.3％),且更具有一致性;降主动脉术后假腔完全血栓化比率高于腹主动脉,降主动脉近端的主动脉重塑效果良好,膈肌角平面以下重塑效果较差.结论 尽管TEVAR术后主动脉重塑的描述方式各异,但多数文献显示夹层累及主动脉范围广者术后重塑效果差,与夹层远端裂口旷置有关.覆膜支架长度、治疗时间等因素对术后重塑均有影响.统一的评估标准有利于评估主动脉重塑效果,并为临床决策提供更有力的科学支持.     

Feasibility of aortic pulse pressure and pressure wave velocity MRI measurement in young adults

PURPOSE: To investigate the feasibility of assessing, noninvasively, aortic pulse pressure (APP) and pulse wave velocity (PWV) in the ascending aorta of young adults by means of velocity-encoded magnetic resonance (MR) imaging. MATERIALS AND METHODS: In a series of 11 healthy volunteers, velocity-encoded MR imaging provided pairs of magnitude and phase-contrast images. Blood flow velocity and aortic cross-sectional area (CSA) were determined with a 30-msec temporal resolution. A model analysis revealed that variation in aortic CSA and in maximal blood flow velocity throughout systole could be used to estimate APP and, hence, to derive PWV by means of two different methods. RESULTS: Mean +/- SD values of the APP for the series were 54.2 +/- 16.4 mmHg (range 32.2-84.1 mmHg). The ascending aortic PWV mean +/- SD values were 5.03 +/- 1.10 m/second and 5.37 +/- 1.23 m/second according to the two methods, and both estimates were not significantly different (95% confidence level). CONCLUSION: These results are in agreement with previously published data, suggesting that APP and PWV can be determined, noninvasively, in young adults using MRI.     

开窗支架移植物治疗累及主动脉弓部的主动脉夹层2例

累及主动脉弓部主动脉夹层极易破裂,即使采用外科治疗,也具有极高的风险和死亡率[1].本文报告2例成功应用开窗覆膜支架技术治疗累及主动脉弓部的主动脉夹层病例.术后患者康复迅速,近期随访结果良好. 临床资料 患者1:男,52岁.突发背部撕裂样疼痛2h,伴出汗,持续不能缓解,既往有高血压史1年,血压最高约200/100 mmHg.查体:T 365℃,P84次/min,R20次/min,BP左上肢116/84mmHg、右上肢122/80 mmHg,双肺未闻及湿啰音.心率84次/min,心律齐,未闻及心脏杂音.辅助检查心电图示窦性心律;超声心动图显示心脏形态结构及收缩功能未见明显异常;主动脉CTA见累及主动脉弓部的主动脉夹层,夹层破口局限于左锁骨下动脉开口的降主动脉弓小弯侧,破口距左锁骨下动脉开口约1 cm,逆撕至升主动脉,胸主动脉在距腹腔干约4 cm,和左肾动脉开口约2 cm的腹主动脉可见一破口.     

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.     

局部麻醉穿刺下完全无对比剂腔内修复腹主动脉瘤1例

目的 探讨对比剂过敏高危腹主动脉瘤患者接受局部麻醉穿刺下完全无对比剂主动脉腔内修复术(EVAR)的可行性.方法 对1例对比剂过敏腹主动脉瘤患者,在不使用对比剂、局部麻醉穿刺条件下实施EVAR术.结果 手术获成功.术后MRI随访结果显示,患者腹主动脉瘤完全隔绝,无内漏,覆膜支架内血流通畅,双侧肾动脉显影良好.结论 局部麻醉穿刺下完全无对比剂EVAR术治疗对比剂过敏伴全身麻醉禁忌高危腹主动脉瘤患者安全有效,但严格掌握适应证、术前充分评估是手术成功的关键.     

主动脉腔内修复术中髂内动脉保留技术

主动脉腔内修复术(EVAR)是腹主动脉瘤的主要治疗手段,腹主动脉瘤伴发髂动脉瘤时保留髂内动脉已成为共识,可避免发生臀肌缺血、乙状结肠缺血及男性性功能障碍等并发症.随着近年腔内器械不断更新,EVAR术中保留髂内动脉成为可能.目前EVAR术髂内动脉重建术包括腔内髂分支支架技术、三明治技术、髂总动脉覆膜支架喇叭口技术、髂外动脉-髂内动脉腔内分流技术(反向“烟囱”技术)以及弹簧圈栓塞技术,该文就此作一总结.     

Long-Term Follow-Up After Endovascular Treatment of Acute Aortic Emergencies

Purpose To investigate the long-term outcome and efficacy of emergency treatment of acute aortic diseases with endovascular stent-grafts. Methods From September 1995 to April 2007, 37 patients (21 men, 16 women; age 53.9 ± 19.2 years, range 18–85 years) with acute complications of diseases of the descending thoracic aorta were treated by endovascular stent-grafts: traumatic aortic ruptures (n = 9), aortobronchial fistulas due to penetrating ulcer or hematothorax (n = 6), acute type B dissections with aortic wall hematoma, penetration, or ischemia (n = 13), and symptomatic aneurysm of the thoracic aorta (n = 9) with pain, penetration, or rupture. Diagnosis was confirmed by contrast-enhanced CT. Multiplanar reformations were used for measurement of the landing zones of the stent-grafts. Stent-grafts were inserted via femoral or iliac cut-down. Two procedures required aortofemoral bypass grafting prior to stent-grafting due to extensive arteriosclerotic stenosis of the iliac arteries. In this case the bypass graft was used for introduction of the stent-graft. Results A total of 46 stent-grafts were implanted: Vanguard/Stentor (n = 4), Talent (n = 31), and Valiant (n = 11). Stent-graft extension was necessary in 7 cases. In 3 cases primary graft extension was done during the initial procedure (in 1 case due to distal migration of the graft during stent release, in 2 cases due to the total length of the aortic aneurysm). In 4 cases secondary graft extensions were performed—for new aortic ulcers at the proximal stent struts (after 5 days) and distal to the graft (after 8 months) and recurrent aortobronchial fistulas 5 months and 9 years after the initial procedure—resulting in a total of 41 endovascular procedures. The 30-day mortality rate was 8% (3 of 37) and the overall follow-up was 29.9 ± 36.6 months (range 0–139 months). All patients with traumatic ruptures demonstrated an immediate sealing of bleeding. Patients with aortobronchial fistulas also demonstrated a satisfactory follow-up despite the necessity for reintervention and graft extension in 3 of 6 cases (50%). Two patients with type B dissection died due to mesenteric ischemia despite sufficient mesenteric blood flow being restored (but too late). Two suffered from neurologic complications, 1 from paraplegia and 1 from cerebral ischemia (probably embolic), 1 from penetrating ulcer, and 1 from persistent ischemia of the kidney. Five of 9 (56%) patients with symptomatic thoracic aneurysm demonstrated endoleaks during follow-up and there was an increase in the aneurysm in 1. Conclusion Endovascular treatment is safe and effective for emergency treatment of life-threatening acute thoracic aortic syndromes. Results are encouraging, particularly for traumatic aortic ruptures. However, regular follow-up is mandatory, particularly in the other pathologies, to identify late complications of the stent-graft and to perform appropriate additional corrections as required.     

新型双环状主动脉瓣支架研制及实验研究

目的 探讨开胸穿刺心尖经导管植入双环状主动脉瓣支架置换动物主动脉瓣的可行性和有效性.方法 自主研制新型双环状主动脉瓣支架.选择健康实验山羊3头,侧开胸小切口显露心尖,穿刺左心室心尖建立轨道,透视下沿加硬导丝经22 F输送鞘管将双环状支架送至主动脉瓣上方,利用张开的支架外环准确定位于主动脉瓣窦底,随后扩张球囊释放支架,置换动物主动脉瓣.术后即刻观察评估实验效果.结果 3头实验羊经导管主动脉瓣植入(TAVI)术均获得成功,术后即刻DSA及解剖学评价表明人工主动脉瓣膜植入位置理想,代替原瓣膜工作.结论 新型双环状主动脉瓣支架经心尖途径TAVI术可行,效果理想.