复杂DeBakey Ⅲ型夹层腔内隔绝术后1年的疗效及其影响因素

目的观察和分析复杂DeBakey Ⅲ型夹层行腔内隔绝术(TEVAR)后1年的疗效及其影响因素。方法搜集2013年1月~2015年7月诊断DeBakey Ⅲ型患者40例,术后随访1年,分为假腔内血栓完全形成组及部分形成组,两组行对比分析。结果行多重线性回归分析,假腔内血栓形成与手术时间(B=-0.058,P=0.000)、多发破口(B=-0.031,P=0.032)呈线性相关。假腔内血栓完全形成与手术时间行Pearson分析(r=-0.731,P=0.000)。结论 DeBakey Ⅲ型患者行TEVAR术后假腔内血栓形成与手术时机的选择、多发破口密切相关。     

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。     

主动脉腔内修复术治疗DeBakey ⅢA型主动脉夹层9例疗效观察

目的 探讨主动脉腔内修复术（TEVAR）治疗DeBakev Ⅲ A型主动脉夹层的疗效.方法 选择DeBakey Ⅲ A 型主动脉夹层患者9例,先行保守治疗4周,然后行TEVAR.治疗过程中采用全主动脉64排CTA观察胸腔积液、心包积液、主动脉弓及升主动脉假腔内血栓、降主动脉夹层的变化.结果 术后9例患者均恢复较好,痊愈出院;随访6～30个月,无不良事件发生.结论 DeBakey Ⅲ A主动脉夹层患者经保守治疗后行TEVAR治疗有显著疗效.     

B型主动脉夹层的主动脉腔内修复联合远端限制性支架术中及远期临床效果评价

目的:研究主动脉腔内修复术(TEVAR)联合远端限制性支架(RS)治疗B型主动脉夹层的中、远期临床效果。方法:对2010年6月至2018年12月,哈尔滨医科大学附属第二医院血管外科接受TEVAR或TEVAR+RS治疗的B型主动脉夹层患者资料进行回顾性分析。结果:共239例患者纳入研究,男性185例,女性54例,年龄24～80岁,平均年龄(54.2±10.7)岁。TEVAR组111例,TEVAR+RBS组128例。手术成功率100%。TEVAR+RS组较TEVAR组支架远端新发破口(dSINE)发生率明显降低[14/111(12.6%)vs. 2/128(1.6%),P=0.0007],同时主动脉假腔重构也明显优于TEVAR组。结论:应用胸主动脉腔内修复术联合RS治疗B型主动脉夹层,不仅能够有效地减少dSINE发生,并且有利于主动脉夹层假腔重构,具有良好的中-长期疗效。     

DeBakeyⅢ型主动脉夹层腔内隔绝术后远端主动脉重建影响因素分析

目的应用计算机断层扫描及影像分析软件评估血流动力学因素对DeBakeyⅢ型主动脉夹层腔内隔绝术后远端主动脉重建的影响及预后。方法回顾性分析2014年1月至2018年8月于青海大学附属医院接受主动脉腔内隔绝术的200例DeBakeyⅢ型主动脉夹层患者的临床资料和影像学数据,对患者进行定期随访,利用单因素分析和多元Logistic回归分析对发生支架远端主动脉负性重建的危险因素进行分析。结果所有患者均顺利完成手术,吻合率88.5%。随访(1.5±0.4)年,随访期内30例(21.8%)患者支架远端主动脉出现负性重建。单因素分析发现假腔有分支灌注、夹层总长度、破口数及内漏影响主动脉重建(P0.05);多元Logistic回归分析显示,假腔有分支灌注和破口数是患者术后支架远端主动脉负性重建的独立危险因素。结论假腔有分支灌注和破口数是影响DeBakeyⅢ型主动脉夹层腔内隔绝术后患者远端主动脉负性重建的危险因素。     

他汀抑制急性B型主动脉夹层患者介入术后腹主动脉段的扩张趋势

目的:探讨对急性Stanford B型主动脉夹层患者行胸主动脉腔内修复术(TEVAR)后应用他汀是否对腹主动脉段扩张的趋势具有抑制作用。方法:纳入2018年1月-2019年5月武汉亚洲心脏病医院急性B型主动脉夹层行TEVAR术患者120例,术后随机分为他汀组与对照组(各60例)。术前与术后1年均行CT检查。结果:术前2组在基线资料方面具有可比性(P均 0. 05),在手术方式、支架平均直径及平均长度方面比较,差异无统计学意义(P均 0. 05)。1年后CT随访结果显示,2组术后胸主动脉段重塑良好,胸主动脉段假腔血栓化比例均达到100%。在腹主动脉段,他汀组术后腹主动脉最大直径略小于对照组,但差异无统计学意义(P 0. 05);他汀组术后1年腹主动脉最大直径的增长值明显小于对照组(P 0. 05)。结论:对于急性B型主动脉夹层行TEVAR术成功的患者,术后应用他汀有助于减缓腹主动脉段扩张趋势。     

覆膜支架远端联合裸金属支架治疗B型主动脉夹层效果的系统评价

急性主动脉夹层是一种常见的致死性主动脉疾病.经胸主动脉腔内修复术（TEVAR）已广泛应用于治疗B型主动脉夹层.该项术式的原理是覆膜支架封闭原发破口从而增加真腔血流灌注量.Szeto等[1]研究资料显示,应用TEVAR治疗B型复杂型夹层,其患者30 d死亡率（2.8％）低于开胸手术.但是,目前在慢性复杂型B型主动脉夹层患者中应用覆膜支架的适应证仍存在争议.Ito等[2]认为,使用裸金属支架可促进支架段假腔血栓化进程.Tsai等[3]研究提示,假腔完全血栓化的患者预后较假腔部分血栓化的患者好,即完全封闭假腔能够改善夹层患者的预后.所以,在夹层患者中联合使用近端覆膜支架及远端裸金属支架可促进真腔扩大及假腔血栓化[4],减少动脉瘤样改变及破裂从而降低再次手术的发生率.     

主动脉腔内修复术治疗非外伤性DeBakey Ⅲ型主动脉夹层急性破裂效果观察

目的 观察主动脉腔内修复术(TEVAR)治疗非外伤性DeBakeyⅢ型主动脉夹层急性破裂的疗效.方法 对5例非外伤性DeBakeyⅢ型主动脉夹层急性破裂患者行TEVAR治疗.结果 5例均急诊成功行TEVAR,1例术后第1天放血性胸水后死亡,另4例临床治愈.4例术后随访6～12个月,无不良事件发生.结论 非外伤性DeBakeyⅢ型主动脉夹层急性破裂行急诊TEVAR可降低患者病死率.     

StanfordB型主动脉夹层胸主动脉腔内修复术后Ⅰ型内漏的治疗

目的:比较Stanford B型主动脉夹层胸主动脉腔内修复术(TEVAR)后Ⅰ型内漏应用支架象鼻术及再次TEVAR术治疗的临床效果。方法:回顾首都医科大学附属北京安贞医院2009-03-2013-01收治的Stanford B型主动脉夹层TEVAR术后Ⅰ型内漏患者的临床资料。根据手术方式不同,将20例患者分为2组:支架象鼻术组12例和再次TEVAR术组8例,术后平均随访(6.53±7.60)个月。结果:2组患者除性别外(P=0.049),其他基线资料无统计学差异;支架象鼻术组患者手术时间明显长于再次TEVAR术组(P=0.007),而术后残余内漏发生率明显低于再次TEVAR术组(P=0.014);2组患者随访期间死亡率无明显统计学差异(P=1.000)。结论:Stanford B型主动脉夹层胸主动脉TEVAR术后Ⅰ型内漏应用支架象鼻术较再次TEVAR术具备更好的内漏封闭效果,但远期效果仍需进一步观察。     

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。     

Clinical outcome of emergency surgery for complicated acute type B aortic dissection

BACKGROUND: The aim of the present study was to review the clinical profile and outcome of emergency surgery for complicated acute type B aortic dissection. METHODS AND RESULTS: A total of 34 consecutive patients requiring surgical treatment for complicated acute type B aortic dissection between 2003 and 2010 were examined. The median age was 64.0 years (range, 19-82 years). Indication for emergency surgery was aortic rupture in 11 patients, rapid expansion of the dissecting aorta in 5, dissection involving a non-dissecting aneurysm in 6, and organ malperfusion in 12. All of 3 patients with open aortic rupture died during surgery. Operative mortality was 9.7% (central operation, 14.2%; peripheral operation, 7.1%; thoracic endovascular aneurysm repair, 0%). There were 2 aortic ruptures within 1 week after operation. Two patients suffered from persistent organ malperfusion after emergency surgical relief of ischemia and died. The 1- and 5-year survival rates were 74.1 ± 8.1% and 64.8 ± 11.2%. The actual rate of freedom from aortic events at 1- and 5- years was 83.0 ± 7.0% and 58.7 ± 11.4%. Conclusions: Emergency surgery for complicated acute type B dissection still has a high mortality rate for patients with open rupture and critical visceral ischemia. Medical treatment is best given immediately after admission, and adequate surgical treatment without delay is crucial.     

Evolution of aortic dissection after surgical repair

Patients after aortic dissection repair still have long-term unfavorable prognosis and need careful monitoring. The purpose of this study was to analyze the evolution of aortic dissection after surgical repair in correlation to anatomic changes emerging from systematic magnetic resonance imaging (MRI) follow-up. Between January 1992 and June 1998, 70 patients underwent surgery for type A aortic dissection. Fifty-eight patients were discharged from the hospital (17% operative mortality) and were followed by serial MRI for 12 to 90 months after surgery. In all, 436 postoperative MRI examinations were analyzed. In 13 patients (22.5%) no residual intimal flap was identified, whereas 45 patients (77.5%) presented with distal dissection, with a partial thrombosis of the false lumen in 24. The yearly aortic growth rate was maximum in the descending aortic segment (0.37 +/- 0.43 cm) and was significantly higher in the absence of thrombus in the false lumen (0.56 +/- 0.57 cm) (p <0.05). There were 4 sudden deaths, with documented aortic rupture in 2. Sixteen patients underwent reoperation for expanding aortic diameter. In all but 1 patient, a residual dissection was present (in 13 without any thrombosis of the false lumen). Close MRI follow-up in patients after dissection surgical repair can identify the progression of aortic pathology, providing effective prevention of aortic rupture and timely reoperation. Thrombosis of the false lumen appears to be a protective factor against aortic dilation.     

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.     

Endovascular stent-grafts for acute and chronic type B aortic dissection: comparison of clinical outcomes

Within the recent months, endovascular repair of aor- tic aneurysms has become a rather interesting alternative to patients considering open surgery. In the past, the proce- dure was typically and more solely reserved to a selected group of elderly patients with several co-morbidities. Currently, there are a number of ongoing trials that are com-     

Preoperative antithrombin III activity predicts outcome after surgical repair of acute type A aortic dissection

BACKGROUND: Acute Stanford type A aortic dissection is associated with substantial perioperative morbidity and mortality. A sepsis-like state may lead to antithrombin (AT) III consumption and deficiency. The impact of preoperative AT III activity on outcome in patients undergoing emergency surgery is yet unknown. METHODS: We measured preoperative AT III activity in 99 consecutive patients undergoing emergency aortic surgery for Stanford type A aortic dissection during a 4-year period in a retrospective study. Cardiovascular co-morbidities, risk factors and surgical data were recorded and patients were followed for 30-day mortality, and occurrence of multiple organ failure (MOF). RESULTS: During the first 30 days, 15 patients (15%) died, and 8 patients (8%) had MOF. Median AT III levels (IQR) in 30-day non-survivors versus survivors were 64% (52-72) versus 90% (75-97) (p<0.001), and in patients with versus without MOF were 66% (52.3-77.3) versus 88% (72-96) (p=0.018), respectively. Adjusted odds ratios for 30-day mortality and MOF for AT III activity (per % increments) were 0.92 (p=0.007), and 0.96 (p=0.012), respectively, indicating a significant inverse relationship between AT III activity and outcome. CONCLUSION: There is a strong inverse association between preoperative AT III activity and adverse outcome in patients undergoing surgical repair of acute Stanford type A aortic dissection. Larger studies are necessary to determine a cut-off value for AT III and to assess whether patients with low AT III levels benefit targeted therapeutic interventions.     

Interventional Management of Aortic Dissection

BACKGROUND: Modern high-resolution imaging techniques have provided new insights into the pathogenesis of aortic dissection during recent years. Distinct pathologic entities or potential precursors of classic false-lumen aortic dissection such as intramural hematoma or penetrating atherosclerotic ulcer have been identified. As a result, a novel classification according to Svensson used in addition to the standard differentiation according to DeBakey or Stanford has been introduced. Due to improved diagnostic imaging, preoperative mortality has decreased but mortality remains substantial (up to 1.4% per hour within the first 2 days) related to complications of aortic dissection such as aortic rupture, bleeding, pericardial tamponade, critical branch vessel ischemia, multiorgan failure, and myocardial infarction. EXAMINATIONS: Transesophageal echocardiography, angiography, magnetic resonance imaging or computed tomography as well as intravascular ultrasound are used for a complete vascular "staging" of patients with aortic dissection after initial stabilization (with or without surgery).New catheter-based interventional techniques have been developed to improve the poor prognosis of aortic dissection: 1 Percutaneous balloon fenestration (PTF) of the intimal flap improves perfusion in case of bowel, limb, or renal ischemia. 2. Aortic stent-graft placement allows for occlusion of the intimal entry tear by implantation of a membrane-covered, self-expanding stent-graft to initiate progressive thrombus formation within the false lumen. Compared to the traditional surgical approaches, both techniques have a low complication rate. The development of these techniques may help to further improve to decrease patients' morbidity and mortality.     

Type A dissection following endovascular thoracic aortic stent-graft repair.

PURPOSE: To describe our experience with endovascular stent-graft repairs in the thoracic aorta focusing on the secondary complication of type A dissection. METHODS: Between January 1996 and April 2004, 73 patients were treated for traumatic thoracic aortic rupture (n=15), type B dissection (n=22), or atherosclerotic descending thoracic aortic aneurysms (TAA, n=36). A retrospective review of the records found 5 (6.8%) patients (3 men; median age 64 years, range 43-87) who experienced a type A dissection at a median 20 days (range 2-124) after thoracic stent-graft repair for 3 type B dissections, 1 TAA, and a late type I endoleak that appeared 28 months after initial stent-graft repair of a traumatic dissection. RESULTS: In 3 patients (2 dissections, 1 endoleak), a tear in the aortic wall at the proximal stent-graft was responsible for a retrograde type A dissection. Underlying disease was the cause of the type A dissection in the 2 other patients (1 dissection, 1 TAA) and was unrelated to the stent-grafts. Three patients underwent open surgery at 3, 26, and 124 days after stent-graft placement; 2 procedures were successful, but the third patient died 3 months later due to multiorgan failure. Two type A dissections were untreated: one patient died from cardiac tamponade 14 days after successful stent-graft exclusion of the type I endoleak; the other patient refused further treatment and survived. The procedure-related mortality following acute retrograde type A dissection was 40%. CONCLUSIONS: Endovascular stent-graft repair of the thoracic aorta is associated with lower morbidity and mortality rates than surgical repair, although potentially lethal complications, acute or delayed, may occur.     

B型主动脉夹层累及肠系膜上动脉缺血侧支循环通路开放的初步研究

目的:探讨B型主动脉夹层累及肠系膜上动脉缺血灌注不良时侧支循环形成的临床意义。方法:回顾性分析2015年9月至2018年10月,就诊于我科的B型主动脉夹层累及肠系膜上动脉缺血灌注不良的15例患者影像学资料,男性14例,平均年龄51.4岁(38~66岁)。分析患者腔内修复手术前后主动脉CTA图像,测量肠系膜上动脉水平主动脉真腔和假腔面积,分别对肠系膜上动脉缺血灌注不良的类型、侧支循环通路开放情况及术后肠系膜上动脉灌注归转状况进行评估。结果:术前主动脉CTA显示,7例肠系膜上动脉属动力型缺血,其中3例侧支循环通路开放(2例腹腔干-肠系膜上动脉循环通路、1例肠系膜下动脉-肠系膜上动脉循环通路);8例肠系膜上动脉属静力型缺血,其中7例侧支循环通路开放(5例肠系膜下动脉-肠系膜上动脉循环通路、2例为腹腔干-肠系膜上动脉循环通路)。15例患者均成功行腔内修复术。术后主动脉CTA显示,肠系膜上动脉开口水平主动脉真腔面积占比增加(52.5%vs.33.4%,P<0.005)。7例属动力型缺血和6例属静力型缺血患者灌注改善且侧支循环通路未再开放。另2例属静力型缺血患者肠系膜上动脉灌注类型维持不变且侧支循环通路仍开放。结论:对于B型夹层累及肠系膜上动脉缺血灌注不良患者,侧支循环通路的开放缓解肠系膜上动脉缺血灌注不良状况。主动脉腔内修复术不仅可以有效隔绝夹层原发破口防止破裂而且能改善肠系膜上动脉缺血灌注情况。     

Rate of paraplegia and mortality in elective descending and thoracoabdominal aortic repair in the modern surgical era

BACKGROUND: The risk of paraplegia and hospital death is the major concern in the surgical repair of descending and thoracoabdominal aortic pathologies. For specific indications, the evolving technology of endovascular stent grafting is becoming increasingly popular. We reviewed our results for elective surgical repair of various aortic pathologies with respect to this innovative therapeutic background. METHODS: From July 1993 to April 2006, 56 patients (mean age 55 +/- 16 years, range 25 to 80 years, 62.5 % males) underwent elective surgical repair of the descending (n = 37, 66.1 %) and thoracoabdominal aorta (n = 19, 33.9 %), including seven reoperations and five cases of previous endovascular stent grafting. The underlying pathologies were: degenerative aneurysm (n = 21), type B aortic dissection (n = 24), and Marfan's syndrome with a chronic type B dissection and an increase in the diameter of the descending aorta (n = 11), respectively. Most patients were operated using deep hypothermic circulatory arrest. RESULTS: Thirty-day mortality was 5.4 % (n = 3). Two patients died of myocardial infarction, one after coronary stent occlusion. Another patient died due to ventricular disruption at the side of the left ventricular apical vent. The rate of paraplegia was 3.6 % (n = 2) with one case of complete and one of incomplete paraplegia. Survival at five years was 78 %. CONCLUSIONS: If modern surgical principles are used in elective descending and thoracoabdominal aortic repair, surgery can be performed with a low postoperative risk for hospital death or paraplegia. These results should be taken into account when evaluating alternative therapeutic strategies in patients with similar pathologies.     

Factors influencing outcome after emergency surgical repair of acute type A aortic dissection.

OBJECTIVE: We retrospectively reviewed our more recent experience with acute type A aortic dissection in order to identify possible risk factors influencing current surgical results. METHODS: Between January 1990 and January 1998, 122 patients (86 males and 36 females; mean age 60 +/- 12 years) underwent emergency repair of acute type A aortic dissection using a standard surgical approach. Seventy-four (61%) patients required isolated replacement of the dissected ascending aorta, 27 (22%) required additional replacement of the aortic arch and 21 (17%) required total aortic root replacement. Surgical outcome was evaluated in terms of operative mortality and morbidity. Results of patients presenting with preoperative complications (Group C) (i.e. cardiac tamponade, cerebral stroke, cardiogenic shock, acute myocardial infarction, anuria or visceral ischemia) were compared with those of uncomplications cases (Group U) and with a calculated risk of expected operative mortality (EOM-rate) based on an analysis of each patient set of preoperative risk factors. Sixteen preoperative and 18 perioperative variables were also analyzed to identify conditions influencing morbidity and mortality. RESULTS: Fifty-seven patients (47%) presented with preoperative complications (Group C) and 65 (53%) did not (Group U). Overall operative mortality was 22% (27 patients). Mortality within subgroups was 40 and 6% for complicated and uncomplications cases, respectively (p < 0.001). The 85% of the overall mortality occurred in Group C patients. During the experience, the operative mortality rate actually observed ranged from 0 to 38% and was similar to the calculated expected risk, thus proving a direct relationship with the amount of complicated cases operated on each year. Multivariate analysis revealed that older age and hemopericardium significantly increased the risk of operative death, while male gender, preoperative complications, postoperative bleeding, duration of circulatory arrest and aortic cross-clamp time significantly predicted morbidity (p = 0.02). CONCLUSIONS: Current results of emergency repair of acute type A aortic dissection are strictly dependent on the number of complicated cases referred for operation. Earlier diagnosis and prompt referral before development of preoperative complications appear essential to improve surgical results.