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。     

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。     

Stanford B型主动脉夹层多型支架介入治疗的临床体会

目的 应用多种类型支架行Stanford B型主动脉夹层介入治疗,探讨扩大介入治疗适应证的可行性.方法 回颐性分析2004年5月-2009年12月,18例Stanford B型主动脉夹层患者行介入性腔内修复术治疗的临床资料.根据CTA和DSA结果,个体化选择合适覆膜支架,透视下将覆膜支架经股动脉导入封闭夹层破口.术后CTA随访观察内漏、支架移位、假腔变化等.结果 18例中2例放置分体式主动脉覆膜支架、1例放置分支型覆膜支架、2例放置预留孔型主动脉覆膜支架,13例放置普通主动脉覆膜支架.1例封堵左锁骨下动脉、2例不全封堵左锁骨下动脉均未出现左上肢和椎基底动脉缺血症状;1例因解剖变异右锁骨下动脉起自主动脉弓而行旁路手术.术后发生8例(44.4%)即刻I型内漏,其中1例腔内修复术后持续I型内漏再次放置支架后进展为Standford A型主动脉夹层瘤而行升主动脉人工血管置换术,其余CTA随访内漏逐渐消失;所有患者均无支架移位、断裂、塌陷以及术后截瘫及脑血管意外发生.结论 采取不同方法延长近端锚定区的距离、应用分体式主动脉支架可扩大介入治疗Standflord B 型主动脉夹层的适应证,且近期疗效好,中、远期疗效有待进一步观察.     

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。     

覆膜血管内支架治疗急性StanfordB型主动脉夹层动脉瘤8例报告

目的:观察覆膜血管内支架治疗急性Stanford B型主动脉夹层动脉瘤的临床疗效.方法:应用覆膜血管内支架腔内隔绝术.结果:8例病人覆膜支架均一次释放成功,无释放多个支架的病例.2例患者因破口距LSA<1.5 cm封堵了LSA,均无脑供血不足及截瘫发生.结论:覆膜支架腔内隔绝术治疗Stanford B型急性主动脉夹层动脉瘤,封闭了夹层近端破口,扩大了主动脉真腔,改善了腹腔脏器血供是一种安全有效的方法.     

直视下置入三分支主动脉弓覆膜支架在治疗Stanford A型主动脉夹层中的应用

目的:总结直视下置入三分支主动脉弓覆膜支架在治疗Stanford A型主动脉夹层中的临床经验.方法:在对16例Stanford A型主动脉夹层患者进行急诊外科手术治疗时有13例术中直视下行三分支主动脉弓覆膜支架置入,并对治疗过程进行总结分析.结果:13例行三分支主动脉弓覆膜支架置入的患者,全部治愈出院,出院3月后复查256排螺旋CT,近心端假腔闭合,远端12例血栓形成,1例残余3 cm长假腔.结论:直视下置入三分支主动脉弓覆膜支架在治疗Stanford A型主动脉夹层时,可简化手术操作,减少出血风险,术后并发症少,有良好的治疗效果.     

血管覆膜支架置入治疗胸主动脉夹层动脉瘤

目的:介绍覆膜支架血管内置入治疗胸主动脉夹层动脉瘤(TADA)的初步经验。方法:本组4例Debakey B型胸主动脉夹层动脉瘤,经CT或MR增强检查确诊。经股动脉置入覆膜支架,封堵胸主动脉破裂口,置入后造影检查证实疗效,术后随访采用彩超或增强CT检查。结果:4例患者共成功置入7个支架,1例术后支架远端出现内漏,6个月后内漏自行封闭;1例并发的腹主动脉瘤随访2个月无变化;随访2~18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。结论:覆膜支架血管内置入治疗胸主动脉夹层动脉瘤的近期疗效满意。     

动脉覆膜支架腔内隔绝治疗Stanford A型主动脉夹层临床效果

【摘要】 目的 探讨应用主动脉覆膜支架腔内隔绝术治疗Stanford A型主动脉夹层的临床效果。方法 回顾性分析2016年6月至2018年10月在湖南中医药大学第一附属医院接受主动脉弓部开窗支架技术全腔内隔绝升主动脉、主动脉弓及降主动脉近段治疗的14例Stanford A型主动脉夹层患者临床资料。观察术后随访1年临床疗效。结果 14例患者均顺利完成手术。术后1年5例治疗效果理想。术后早期死亡1例,支架近端再发夹层4例,发生Ⅰ型、Ⅱ型内漏各1例,Ⅲ型2例。 结论 对于不能外科修复的A型主动脉夹层,可谨慎选择主动脉弓部开窗支架技术行全腔内修复治疗,但须根据患者自身情况和血管病变特点严格把握适应证。     

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。     

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。     

Elective endovascular treatment of descending thoracic aortic aneurysms and chronic dissections with stent-grafts

PURPOSE: To report our experience of endovascular stent-graft placement in patients with descending thoracic aortic dissections and aneurysms and to evaluate the feasibility, safety, and clinical outcomes of the treatment. MATERIALS AND METHODS: Stent-grafts were placed in the descending thoracic aortas of 23 patients with saccular aneurysms (n = 11) and Stanford type B chronic aortic dissections of the descending thoracic and abdominal aorta (n = 12). All stent-grafts were individually constructed of self-expandable stainless steel stents covered with polytetrafluoroethylene. Vascular access was achieved through the femoral artery in all patients. Clinical status of each patient was monitored and postoperative CT was performed within 1 month of the procedure and at 3-12-month intervals after the procedures. RESULTS: Successful exclusion of the primary entry tears of dissections and the inlets of saccular aneurysms was achieved in all but two patients with aortic dissection. The overall technical success rate was 91.3% (dissection: 10 of 12 = 83%; aneurysm: 11 of 11 = 100%). All patients in whom technical success was achieved showed complete thrombosis and significant decrease in diameter of the thoracic false lumen (preoperative: 5.3 cm +/- 0.9; postoperative: 4.3 cm +/- 0.9; P = .004) or aneurysm sac (preoperative: 5.3 cm +/- 1.7; postoperative: 2.8 cm +/- 2.5; P = .001). In addition, five patients demonstrated complete resolution of the dissected thoracic false lumen (n = 2) and aneurysm sac (n = 3). However, in all patients with aortic dissection, the abdominal aorta was not significantly changed in size (P = .302) and shape and their false lumen flows remained persistent. Immediate postoperative complications were detected in 12 patients (52%); 10 had fever, leukocytosis, and elevation of C-reactive protein, another had wound infection, and another had transient abdominal pain. Three patients died 2, 3, and 12 months after the procedure: one from septic shock, another from underlying mediastinitis, and the other from an unexplained cause. The remaining 20 patients were well after the procedure (1-9 days; mean, 3 days), without any stent-graft-related complications or discomfort (follow up period: 10-65 mo; mean: 25.1 mo +/- 15.6). The cumulative survival rate after the stent graft was 100% at 30 days and 91% at 12 months. CONCLUSIONS: For treatment of aortic dissection and saccular aneurysm of the descending thoracic aorta, endovascular stent-graft repair may be a technically feasible and effective treatment modality.     

Descending thoracic aortic aneurysm: thoracic CT findings after endovascular stent-graft placement.

PURPOSE: To evaluate the usefulness of thoracic computed tomography (CT) after placement of an endovascular stent-graft for the treatment of descending thoracic aortic aneurysm. MATERIALS AND METHODS: From 1992 to 1996, 85 patients with thoracic aortic aneurysm underwent stent-graft placement. In 63 patients, thoracic CT scans were obtained both before and within 10 days after placement. The CT findings were retrospectively studied, and their clinical effect analyzed. In 20 of 63 patients, long-term follow-up CT findings were also evaluated. RESULTS: After stent-graft placement in the 63 patients, CT demonstrated an increase in pleural effusion in 46 (73%), periaortic changes in 21 (33%), perigraft leak in 13 (21%), atelectasis in six (10%), mural thrombus within the stent-graft in two (3%), and new aortic dissection in one (2%). The mean maximum diameter of the aneurysm was 58.8 mm before and 60.0 mm after stent-graft insertion. Sixty-two (98%) patients were successfully treated until discharge. Interventional procedures were performed to eliminate the leakage into the aneurysm sac in 10 patients with perigraft flow depicted at CT. Other complications were managed conservatively. CONCLUSION: Thoracic CT is useful in the treatment of patients after stent-graft insertion for the management of descending thoracic aortic aneurysm.     

Endovascular treatment of thoracic aortic aneurysms: a review

Open surgical repair is considered the traditional treatment for patients with thoracic aortic aneurysms (TAA). In view of the persistent perioperative mobidity and mortality, endovascular stent-graft placement as a minimally invasive and potentially safer treatment for aneurysm of the descending aorta was introduced in 1992. Since then, progress has been made and several institutions have substantiated the safety and effectiveness of stent grafts in the repair of descending TAAs or type-B aortic dissections. Currently, both custom-designed, home-made, and commercially available stent grafts are used. Prior to placement of the endoprosthesis, three major prerequisites must be considered: the localization and morphology of the aneurysm; the distal vascular access of sufficient size; and a limited tortuosity of the abdominal and thoracic aorta. Although short-term results are encouraging, severe complications, including paraplegia, cerebral strokes, and aortic rupture, have been encountered. The long-term durability of currently available stent-graft systems is nonexistent and material fatigue are of major concern to both surgeons and radiologists. Nevertheless, endovascular stent-graft placement could become the procedure of choice in a substantial number of patients with descending TAA.     

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.     

胸主动脉覆膜支架并左锁骨下动脉烟囱术疗效分析

目的探讨胸主动脉覆膜支架植入术在支架近端锚定区不足时左锁骨下动脉的处理方法及支架直接覆盖左锁骨下动脉开口并左锁骨下动脉"烟囱"术的可行性。方法回顾分析2009年12月-2011年4月收治的支架近端锚定区不足的15例胸主动脉病变患者(B型夹层6例,假性动脉瘤1例,动脉瘤4例,穿透性溃疡4例),其中13例病变距左锁骨下动脉锚定区小于15 mm,2例大于15 mm。采用胸主动脉覆膜支架并左锁骨下动脉烟囱术治疗,观察脑及上肢缺血并发症发生情况。术后评价内漏、左锁骨下动脉显影等结果。结果 15例患者均成功地在主动脉内植入覆膜支架1枚,并在左锁骨下动脉植入"烟囱"支架1枚,术后患者均未出现神经系统并发症及左上肢严重缺血症状。术后5 d～3个月复查,主动脉覆膜支架形态良好,未发现I型内漏,"烟囱"支架内血流通畅。结论胸主动脉覆膜支架植入术中近端锚定区不足时,直接覆盖左锁骨下动脉开口并左锁骨下动脉"烟囱术"以延长锚定区并保持左锁骨下动脉通畅,更为安全。     

Endovascular treatment of aortic type B dissection and penetrating ulcer using commercially available stent-grafts.

OBJECTIVE: The purpose of our study was to investigate the clinical experience and efficiency of translumenl endovascular stent-graft insertion using commercially available vascular endoprotheses. We studied seven patients with descending aortic dissection (type B) and four patients with penetrating aortic ulcer over a median follow-up period of 254 days during the years 1997-2000, using cross-sectional CT to evaluate the extent of the dissection, the distance between the entry tear and the left subclavian artery, and the diameter of the true lumen and the false lumen. CONCLUSION: Endovascular treatment of acute and chronic aortic type B dissections and penetrating ulcer is a minimally invasive method with a low complication rate that could be considered a feasible alternative to surgical repair. Depending on the length of the dissection, we recommend the placement of two overlapping stent-grafts in the thoracic aorta to stabilize the affected thoracic aorta over a longer distance. This might provide a reliable sealing of the entry tear and should prevent further communication between the true lumen and the false lumen.     

Urgent thoracic aortal dissection and aneurysm: treatment with stent-graft implantation in an angiographic suite

The aim of this study was to evaluate the feasibility of endoluminal stent-graft placement in an angiographic suite for the treatment of emergent type-B aortic dissections and ruptured thoracic aortal aneurysms. Twenty-six patients with either urgent type-B dissection (n=8) or aneurysms (n=18) of the descending thoracic aorta were chosen for stent-graft implantation. All patients received a multidetector-row CT angiography of the whole aorta and pelvic arteries prior to stent-graft implantation. All procedures were performed in a fully equipped digital subtraction angiography (DSA) suite under general anesthesia. In 20 patients Talent LPS tube grafts and in 4 patients an Excluder graft were used. Access was achieved via surgical cut-down in the left (n=7) or right (n=19) groin. Sealing was successful in 24 patients. The proximal covered portion of the stent graft was placed across the left subclavian artery in 2 patients. Procedural success was achieved in 23 of 24 patients. One patient required a second stent-graft placement before the aneurysm was sealed. One patient with an acute perforation of the descending aorta died due to cardiac failure prior to stent-graft implantation. In 1 patient stent-graft delivery failed due to severe calcification of both common iliac arteries. Endoluminal treatment of both urgent type-B aortic dissections and thoracic aortal aneurysms with stent graft is an attractive alternative treatment to surgical repair. The placement of stent grafts in an angiographic suite is a safe and feasible method with good clinical effectiveness and, so far, good clinical outcome.     

分体式支架-移植物治疗主动脉病变的初步报告

目的 介绍分体式支架-移植物（separating stent—graft）及其早期应用体会。方法 器械采用12F输送器，先后1次性经皮穿刺置入主动脉分体式支架-移植物的外、内两部分。4例患者为主动脉夹层StanfordB型、胸主动脉瘤与腹主动脉瘤。结果 1例夹层破口被封闭，病灶被隔绝；1例胸主动脉瘤病灶被隔绝，有轻度内瘘；2例腹主动脉瘤，瘤体均被隔绝。结论 分体式支架-移植物治疗主动脉夹层与主动脉瘤是1种有效、方便、更安全、更微创的治疗方法。     

Descending thoracic aortic diseases: stent-graft repair

PURPOSE: To evaluate endovascular treatment of descending thoracic aorta with commercially available self-expanding stent-grafts. MATERIALS AND METHODS: Seventy patients with aortic dissection, intramural hemorrhage, degenerative and posttraumatic aneurysm, penetrating atherosclerotic ulcer, and pseudoaneurysm underwent endovascular treatment. Eleven patients had impending rupture and were treated on an emergency basis. Stent-grafts were customized or selected on the basis of spiral computed tomographic (CT) or magnetic resonance (MR) imaging measurements. Preprocedure diagnostic angiography was performed in patients with aortic dissection and in other selected patients. All procedures were performed in an operating room and monitored with digital subtraction angiography (DSA) and transesophageal echocardiography (TEE). Follow-up was at 1, 3, 6, and 12 months after treatment and yearly thereafter. RESULTS: Stent positioning was technically successful in 68 cases. At DSA and TEE, complete aneurysm or false-lumen exclusion was achieved in 66 (97%) cases. No intraoperative mortality or complications occurred. In-hospital complications included transient monoparesis (one patient) and extension of dissection into ascending aorta (one patient) that was repaired surgically. Early endoleak was observed in five (7%) patients: In three (type 2), endoleak resolved spontaneously; in one (type 1), it was persistent; and in one (type 1), treatment was converted to surgery. At long term, one (1%) patient died of aortic rupture; another, of respiratory insufficiency. Five (7%) late endoleak (type 1, one caused by migration of the stent) cases were observed. In three (4%), endovascular treatment was successful; in two (3%), surgery was performed. In one patient with persistent postimplantation syndrome, treatment was converted to surgery after successful aneurysm sealing. Procedure failure (ie, aortic disease-related mortality or conversion to surgery) occurred in six (9%) patients. CONCLUSION: Endovascular stent-graft repair is less invasive in patients with chronic and acute descending thoracic aortic aneurysm and dissection.     

RETRACTED ARTICLE: Combined Interventional and Surgical Treatment for Acute Aortic Type A Dissection

Surgical repair and endovascular stent-graft placement are both therapies for thoracic aortic dissection. A combination of these two approaches may be effective in patients with type A dissection. In this study, we evaluated the prognosis of this combined technique. From December 2003 to December 2006, 15 patients with type A dissection were admitted to our institute; clinical data were retrospectively reviewed. Follow-up was performed at discharge and approximately 12 months after operation. Endovascular stent-graft placement by interventional radiology and surgical repair for reconstruction of aortic arch was performed in all patients. Total arch replacement for distal arch aneurysm was carried out under deep hypothermia with circulatory arrest; antegrade-selected cerebral perfusion was used for brain protection. Four patients concomitantly received a coronary artery bypass graft. Hospital mortality rate was 6.7%; the patient died of cerebral infarction. Neurological complications developed in two patients. Multi-detector-row computed tomography scans performed before discharge revealed complete thrombosis of the false lumen in six patients and partial thrombosis in eight patients. At the follow-up examination, complete thrombosis was found in another three patients, aortic rupture, endoleaks, or migration of the stent-graft was not observed and injuries of peripheral organs or anastomotic endoleaks did not occur. For patients with aortic type A dissection, combining intervention and surgical procedures is feasible, and complete or at least partial thrombosis of the false lumen in the descending aorta can be achieved. This combined approach simplified the surgical procedures and shortened the circulatory arrest time, minimizing the necessity for further aortic operation. Jin-Cheng Liu and Jin-Zhou Zhang contributed equally to this work.