胸主动脉腔内修复术中原位开窗重建左锁骨下动脉

目的:探索一种新的安全有效全腔内重建左锁骨下动脉(LSA)的方法。方法:针对2例胸主动脉腔内修复术中需要重建LSA的患者,采用目前市售的介入器材并改进,先释放胸主动脉覆膜支架覆盖LSA,再于LSA开口处行体内穿刺破膜、球囊扩张并置入左锁骨下动脉支架,原位开窗重建LSA。结果:患者2例均取得技术成功,主体支架无移位,无内漏;重建的LSA通畅,无内漏。结论:原位开窗的方法可以有效的重建LSA,长期疗效有待进一步随访。     

胸主动脉腔内修复扩展近端锚定区的探讨

目的探讨胸主动脉腔内修复(EVR)近端锚定区不足的两种处理。方法回顾分析近端锚定区<15mm的9例DeBakeyⅢ型主动脉夹层动脉瘤(ADA)和1例胸降主动脉瘤(DTAA)患者的治疗经过、结果和并发症。其中DTAA患者和3例ADA患者行辅助性右左颈总动脉、左颈总左锁骨下动脉旁路联合腔内修复(EVR)治疗(联合治疗组),另6例ADA患者直接行EVR,覆盖左锁骨下动脉开口(直接修复组)。结果10例患者都取得技术成功。DTAA病例动脉旁路术后无并发症,EVR术后并发脑梗塞、成人呼吸窘迫综合征、上消化道大出血、肾功能衰竭,第12天死亡。9例ADA患者功能围手术期无与血管有关的并发症。直接修复组中2例术后早期出现头晕,静滴甘露醇4～5d后缓解。9例患者都获随访,随访期3～12个月(平均9个月),未发生神经系统或肢体缺血性并发症,术后3个月CT证实所有病例原发破口封闭,胸主动脉假腔内完全血栓形成,真腔扩大。结论处理胸主动脉EVR近端锚定区不足时,辅助性动脉旁路和直接覆盖左锁骨下动脉开口是可行的,可以拓展EVR在DeBakeyⅢ型ADA和DTAA中的应用。     

主动脉扩张性疾病血管腔内治疗后脑卒中的原因分析

目的探讨主动脉夹层、主动脉瘤等主动脉扩张性疾病患者血管腔内治疗后脑卒中的发生原因及预防方法。方法对8例主动脉夹层、主动脉瘤患者血管腔内治疗后脑卒中患者的临床资料进行回顾性分析,其中1例为Stanford A型主动脉夹层,2例为Stanford B型主动脉夹层,2例为胸腹主动脉瘤,1例为胸主动脉瘤,1例为胸主动脉假性动脉瘤,1例为腹主动脉瘤。结果 8例患者均成功植入支架,其中5例在植入主动脉支架的同时封堵了左锁骨下动脉(LSA)开口。脑血管意外发生的平均时间为术后(2.50±2.00)天,6例发生脑梗死,2例脑出血,1例死亡。患者术前、术后的血压水平比较,差异具有统计学意义[收缩压:(132.80±10.99)mmHg vs(110.09±23.18)mmHg,P0.05;舒张压:(74.21±3.86)mmHg vs(60.17±12.93)mmHg,P0.05]。2例脑出血的患者术中均使用超过6000 U肝素。结论术前、术后血压水平差异过大、对LSA盲目进行封堵、肝素用量过大、腔内操作不熟练等是导致主动脉疾病血管腔内治疗术后脑卒中的主要因素。     

胸主动脉疾病腔内修复术中封闭左锁骨下动脉的可行性分析

目的 探讨胸主动脉疾病腔内修复术中封闭左锁骨下动脉的可行性及效果.方法 2005年10月-2012年3月广州军区武汉总医院心胸外科对行胸主动脉腔内修复术需要封闭左锁骨下动脉的患者在术前进行脑循环、颈动脉、椎基底动脉及Willis环检查,如右侧椎动脉血供良好,颈动脉、Willis环无狭窄则选择在腔内修复术中直接封闭左锁骨下动脉.术后观察颅脑及上肢缺血并发症发生情况.结果 40例患者封闭了左锁骨下动脉,手术均获成功,28例术后未出现左上肢窃血症状和神经系统并发症,12例出现了轻微的左上肢窃血症状及神经系统并发症,但无需手术干预.结论 在有意封闭左锁骨下动脉前,必须注意潜在性主动脉弓上各分支动脉的病变和变异,这样才可能保证胸主动脉疾病患者进行主动脉腔内修复术时安全、有效.     

胸主动脉瘤及夹层腔内修复术中左锁骨下动脉的处理

目的探讨胸主动脉瘤及夹层腔内修复术中左锁骨下动脉的处理方法。方法2000年6月至2005年12月,54例胸主动脉瘤及夹层患者的近端锚定区小于15mm,需处理左锁骨下动脉。腔内修复术在X线透视下进行,支架型血管通过输送系统携带到病变部位,根据病变特点对左锁骨下动脉采取一期完全覆盖（40例）、部分覆盖（3例）、完全覆盖后腔内重建（1例）、完全覆盖前外科重建（10例）等方法处理,观察治疗后效果。结果所有患者术中均应用数字减影血管造影进行脑循环评估。40例一期完全覆盖左锁骨下动脉;10例腔内覆盖前行右锁骨下动脉．左锁骨下动脉或左颈总动脉-左锁骨下动脉旁路术;3例覆盖左锁骨下动脉开口1／2～4／5后再通过球囊扩张、支架植入重建左锁骨下动脉;1例完全覆盖左锁骨下动脉后应用腔内人造血管开窗技术重建左锁骨下动脉。所有辅助技术均取得成功,未出现严重脑及上肢并发症。腔内修复术后近端Ⅰ型内漏发生率17％（9／54）。一期完全覆盖左锁骨下动脉患者术后早期窃血综合征发生率20％（8／40）,左肱动脉平均收缩压（63±24）mmHg（1mmHg=0．133kPa）。结论通过辅助腔内或腔外技术,可对短颈胸主动脉瘤及夹层病变进行有效的腔内修复术;对左锁骨下动脉的处理方式根据椎基底动脉、Willis环及双侧颈动脉状况来确定。     

裂口位于主动脉弓远端Stanford A型主动脉夹层的腔内修复

目的总结腔内修复术治疗裂口位于主动脉弓远端Stanford A型主动脉夹层的临床经验。方法2001年1月至2006年6月在中山大学附属第一医院血管外科通过股动脉入路行主动脉腔内修复术,对21例内膜撕裂口位于主动脉弓远端和近端降主动脉的Stanford A型主动脉夹层进行血管腔内治疗,根据椎动脉造影确定是否重建左锁骨下动脉。结果全组21例中,急性夹层13例,慢性夹层8例,均接受了血管腔内带膜支架修复术,手术成功率100%。17例同时封闭了左锁骨下动脉,其中4例行左锁骨下动脉重建。4例发生内漏,1例术后发生脑梗死。平均随访22.3个月(6~65个月),所有病例均存活。假腔内完全血栓形成12例,部分血栓形成9例。结论主动脉腔内修复术治疗内膜撕裂口位于主动脉弓远端和近端降主动脉的Stanford A型主动脉夹层是有效和安全的,具有微创、成功率高和并发症少等特点。     

急性B型主动脉夹层的腔内治疗

目的 讨论腔内修复术(endovascular repair,EVR)对治疗急性B型主动脉夹层(acuteaortic dissection,AAD)的安全性及有效性.方法 回顾性分析2002年2月至2008年3月收治的39例急性B型主动脉夹层患者的临床资料.EVR按常规方法进行,2例需覆盖左颈总动脉而行旁路术,其中1例同时无名动脉支架型血管(stent graft,SG)开窗术;1例因肢体严重缺血同期行左下肢截肢术.13例完全覆盖左锁骨下动脉,1例覆盖迷走右锁骨下动脉,5例部分覆盖左锁骨下动脉(leftsubclavian artery,LSA).术后全部病例均经CTA(computer tomography angiography)随访,并监测支架覆盖段(Ll)及支架远端(L2)主动脉段的假腔变化.结果 所有支架释放到预定位置;30 d死亡率10.3%.术后1个月L段假腔血栓率100%,完全血栓率77.8%(21/27例),部分血栓率22.2%(6/27例),其中18.5%(5/27例)达到血栓完全吸收、主动脉重塑;L2段假腔血栓率28%,完全血栓率8%(2/25例),部分血栓率20%(5/25例).结论 急性B型主动脉夹层腔内修复术治疗效果肯定,30 d内死亡主要与术前伴随的并发症有关.     

胸主动脉腔内治疗中左锁骨下动脉封闭前左椎动脉的功能评估

目的 探讨更科学的左椎动脉功能评估方法,以减少胸主动脉腔内治疗中一期封堵左锁骨下动脉(LSA)引起后脑缺血而造成的致命风险.方法 患者清醒状态下,从左眩动脉人路用Fogarty 导管暂时封闭LSA开口15分钟,监测生命体征包括脉搏、血压、呼吸,观察患者是否出现头晕、头痛、恶心呕吐,以及左上肢是否出现麻木、疼痛等急性缺血症状.从2006年至2008年,本院对4例瘤颈小于15 mm的Stanford B型胸主动脉夹层和胸主动脉瘤的患者,在腔内治疗中封堵LSA,在手术前对左椎动脉功能进行评估.结果 4例患者在暂时封堵试验中,无后脑及左上肢急性缺血症状,未出现生命体征改变,手术中一期封堵LSA,手术无内漏,术后无后脑及左上肢急性缺血表现.结论 暂时封堵LSA试验是对左椎动脉功能评估的有益尝试,是影像学评估的重要补充.     

胸主动脉腔内修复术中覆盖左锁骨下动脉的回顾性分析

胸主动脉瘤和主动脉夹层是危及生命的疾病,发病1周内病死率为60％ ～ 70％[1].近年来,胸主动脉腔内修复术(TEVAR)已成为治疗胸主动脉瘤和B型主动脉夹层的重要方法.有选择性地覆盖左锁骨下动脉(LSA)是较常采用的扩大近端锚定区的方法[2],但仍存在争议.我们回顾性分析2004年5月至2012年1月TEVAR手术患者的资料,探讨LSA封堵的可行性.     

合并严重冠心病的短锚定区主动脉弓降部疾病的腔内修复

目的:探讨合并严重冠心病,已经接受或近期可能接受冠状动脉旁路移植手术须保留左锁骨下动脉,且近端锚定区又不足的主动脉弓降部疾病患者腔内修复治疗的策略及注意事项。方法:回顾性分析2016年4月—2016年7月期间阜外医院血管外科中心收治的9例合并严重冠心病、近端锚定区不足的主动脉弓降部疾病患者资料,其中男7例,女2例,平均年龄60(37~76)岁,均行胸主动脉腔内修复术治疗,均需保留左锁骨下动脉,从而保留作为冠脉前降支桥血管最佳来源的左侧乳内动脉。结果:手术成功率100%,无手术死亡,所有患者左侧乳内动脉均保留成功。术后发生I型内漏1例(1/9),随访3个月后内漏消失;术后4个月因冠状动脉回旋支狭窄行经皮冠状动脉成形术1例(1/9)。所有患者均获得门诊或电话随访,随访时间6(4~7)个月,所有患者临床症状消失或明显减轻,生活质量改善,无随访死亡病例。结论:对于已经接受左侧乳内动脉-冠脉前降支搭桥或即将接受冠脉搭桥手术的主动脉弓降部疾病患者,在实施胸主动脉腔内修复手术时可采取个性化措施保留左锁骨下动脉,进而保留左乳内动脉,必要时可以采用"烟囱"等技术辅助。     

Early and mid-term results of endovascular treatment of thoracic aorta diseases: a single-center experience

We conducted an analysis to assess early and mid-term outcomes of patients after thoracic endovascular aortic repair (TEVAR) for type B thoracic aorta dissection, descending thoracic aneurysm, or traumatic aortic transection. From January 2016 through December 2018, twenty-seven patients (23 male, 4 female, mean age of 57 years) affected by type B dissection (n = 13 [48.2%]), thoracic aneurysm (n = 9 [33.3%]), and post-traumatic aortic isthmus rupture (n = 5 [18.5%]) were treated using TEVAR with and without left subclavian artery revascularization. All procedures were performed in a hybrid operating room using general (n = 12) or regional (n = 15) anesthesia. A combined brachial artery and bilateral femoral artery access was used in all patients. To achieve adequate proximal thoracic aorta landing zone length, coverage of the left subclavian artery with proximal endovascular plug occlusion was performed in 17 patients (62.9%); including 4 patients undergoing carotid–subclavian artery bypass before TEVAR stent-graft deployment. Primary procedural success rate was 96.3%; 1 patient had a Type Ib endoleak that was treated by distal stent graft extension. Four adverse outcomes occurred in the immediate postoperative period, including 2 cases of left upper arm acute ischemia (7.4%), ischemic stroke (3.7%), and asymptomatic iliac artery dissection (3.7%). During a mean follow-up of 18 months, no graft-related deaths or endoleak occurred. One patient developed symptomatic subclavian steal syndrome 1 month after operation and underwent a left carotid–subclavian artery bypass with symptom resolution. One patient died 6 months after TEVAR due to neoplasm. Our experience indicates TEVAR is a safe and less invasive alternative to open surgery for a spectrum of thoracic aorta diseases, especially for urgent conditions and in patients with high-risk surgical comorbidities.     

累及弓部主动脉夹层手术方式选择及疗效

目的:探讨累及主动脉弓部主动脉夹层手术方式选择及疗效。方法:收集2010年2月—2015年5月因主动脉弓部夹层在广州军区武汉总医院心胸外科接受手术治疗病例资料,分析其手术方式选择及理由,不同术式并发症发生率等。结果:检索出符合条件的病例92例,其中仅行胸主动脉腔内修复术(TEVAR)36例,预开窗血管支架的TEVAR 2例,封闭左锁骨下动脉的TEVAR 31例,不开胸主动脉弓分支血管旁路术+TEVAR17例(左颈总动脉-左锁骨下动脉旁路术4例,右颈总动脉-左颈总动脉-左锁骨下动脉旁路术3例,右颈总动脉-左颈总动脉术、封闭左锁骨下动脉10例),开胸主动脉弓置换术6例。2例开胸主动脉弓置换术患者术后死亡,其余术后无严重并发症发生。结论:对于累及主动脉弓部夹层,开胸主动脉弓置换术是一种成熟的治疗方式;TEVAR是的一种快速、有效、经济、术后并发症少的手术方式,并可以通过开窗、分支血管旁路术等方式扩大其应用范围。     

Left subclavian artery coverage during TEVAR: is revascularization necessary?

Thoracic endovascular aortic repair (TEVAR) has rapidly become a viable and accepted treatment option for atherosclerotic aortic aneurysms as well as a variety of other aortic pathologies including ulcers, dissection, coarctation and disruption. Left subclavian artery (LSA) coverage is often necessary to achieve proximal seal in up to 40% of patients treated with TEVAR. The management of the LSA in this cohort of patients remains controversial. Studies in support of routine pre-operative LSA revascularization show that coverage of the LSA during TEVAR is associated with an increased risk of stroke, paraplegia and arm ischemia. Other studies show that intentional coverage of the LSA without revascularization is not associated with increased morbidity and lends support to those who advocate more selective LSA revascularization during TEVAR (i.e. in those patients with patent LIMA-coronary bypass, dominant or isolated left vertebral artery, or a functioning left upper extremity (LUE) dialysis arteriovenous fistula). This paper is intended to review the literature comparing routine and selective LSA revascularization after TEVAR to determine the best management strategy.     

累及主动脉弓部病变的完全腔内治疗:95例中长期随访结果

目的探讨完全腔内技术治疗累及主动脉弓部病变的中长期随访结果。方法回顾性分析2010年1月~2017年12月95例应用完全腔内技术处理累及主动脉弓部病变的临床资料,其中烟囱支架技术81例,“开窗”技术8例(原位4例,体外4例),分支支架技术6例。结果共植入胸主动脉覆膜支架主体95枚,重建主动脉弓部分支动脉124支,其中无名动脉7支,左颈总动脉36支,左锁骨下动脉81支。2例原位开窗失败中转烟囱技术重建分支。术中Ⅰ型内漏11例(11.6%),其中5例弹簧圈栓塞后消失,6例轻微内漏随访观察。技术成功率91.6%(87/95)。围术期死亡3例(3.2%),一过性截瘫1例(1.1%),脑梗死2例(2.1%),急性心肌梗死2例(2.1%),急性肺损伤1例(1.1%)。存活92例中随访83例,随访率90.2%。1例术后4个月死于脑梗死,1例术后6个月因多器官功能衰竭死亡,其余81例随访时间28~106(58.9±17.9)月,其中73例>36个月。8例因Ⅰ型内漏行二次手术栓塞,未见支架移位、狭窄、闭塞等并发症。结论通过多种完全腔内技术重建各主动脉弓部的分支血管,为累及主动脉弓部病变提供微创治疗机会,中长期随访结果满意。     

胸主动脉腔内修复术封堵左锁骨下动脉的前瞻性研究

目的 探讨胸主动脉腔内修复术(TEVAR)封堵左锁骨下动脉的安全性和可行性.方法 2007年12月至2008年12月共111例胸主动脉病变患者进入本研究.根据术中封堵左锁骨下动脉的情况分为完伞封堵、封堵<50%、封堵>50%和未封堵组.术前及术后第1、3、5和30天随访测量患者双卜肢的血压差值,同时评估有无脑卒中、偏瘫和截瘫以及左上肢缺血等情况.结果 完全封堵55例(49.6%),封堵<50%18例(16.2%),封堵>50%7例(6.3%),未封堵31例(27.9%).所有患者TEVAR均成功,无脑卒中、截瘫及偏瘫发生.完全封堵组与其余3组相比,双上肢血压差值的差异有统计学意义(P<0.01).术后1周内完全封堵组中13例出现与左上肢活动无关的头晕,其中5例伴黑矇;7例出现左上肢间歇性跛行症状.结论 TEVAR中,为延长近端锚定区对左锁骨下动脉的封堵是安全可行的,但在某些情况下应行血管重建,以提供更为持久的修复效果.     

When is safe to cover the left subclavian and celiac arteries. Part I: left subclavian artery

Over the last 15 years the endovascular repair of thoracic aortic pathologies has been developing as the treatment of choice, but it requires appropriate anatomy. Proximal and distal landing zones are essential for fixation and sealing. In order to extend the proximal landing zone for the stent-graft and achieve an adequate seal, the left subclavian artery (LSA) is often covered, with or without concomitant subclavian artery revascularization. In this article the authors review the LSA anatomy and consequences of LSA coverage as scenery for a discussion of the ramifications of LSA coverage during endovascular thoracic aortic repair (TEVAR). Summari-zing the currently available literature, the authors reveal that there is no consensus regarding a preparatory left carotid-subclavian bypass or a transposition of the left subclavian artery to the left common carotid artery. Various management strategies are offered.     

Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation?

Thoracic endovascular aortic repair (TEVAR) has emerged as a promising therapeutic alternative to conventional open aortic replacement but it requires suitable proximal and distal landing zones for stent-graft anchoring. Many aortic pathologies affect in the immediate proximity of the left subclavian artery (LSA) limiting the proximal landing zone site without proximal vessel coverage. In patients in whom the distance between the LSA and aortic lesion is too short, extension of the landing zone can be obtained by covering the LSA's origin with the endovascular stent graft (ESG). This manoeuvre has the potential for immediate and delayed neurological and vascular symptoms. Some authors, therefore, propose prophylactic revascularisation of the LSA by transposition or bypass, while others suggest prophylactic revascularisation only under certain conditions, and still others see no requirement for prophylactic revascularisation in anticipation of LSA ostium coverage. In this review about LSA revascularisation in TEVAR patients with coverage of the LSA, we searched the electronic databases MEDLINE and EMBASE historically until the end date of May 2010 with the search terms left subclavian artery, covering, endovascular, revascularisation and thoracic aorta. We have gathered the most complete scientific evidence available used to support the various concepts to deal with this issue. After a review of the current available literature, 23 relevant articles were found, where we have identified and analysed three basic treatment concepts for LSA revascularisation in TEVAR patients (prophylactic, conditional prophylactic and no prophylactic LSA revascularisation). The available evidence supports prophylactic revascularisation of the LSA before ESG LSA coverage when preoperative imaging reveals abnormal supra-aortic vascular anatomy or pathology. We further conclude that elective patients undergoing planned coverage of the LSA during TEVAR should receive prophylactic LSA transposition or LSA-to-left-common-carotid-artery (LCCA) bypass surgery to prevent severe neurological complications, such as paraplegia or brain stem infarction.     

TEVAR and periscope graft technique to treatment of huge aneurysm of aortic isthmus: Case report

IntroductionThoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of thoracic aortic aneurysms. Innovative techniques as chimney and periscope grafts can improve the outcomes of procedure. Herein, we report a case in emergency of huge Thoracic aortic aneurism.Presentation of caseAn 86-year-old male with hypertension, diabetes mellitus, was referred to our hospital for chest pain. CT-angiography showed a huge aneurysm of aortic isthmus with signs of rupture. The patient was considered unfit for open surgery and an endovascular approach was chosen. This patient underwent endovascular repair with TEVAR, using the periscope graft technique to preserve patency in left subclavian artery (LSA).DiscussionSymptomatic ischemia from LSA coverage has been reported to occur in only a modest 6–10% of patients and is often sacrificed with impunity given coverage rates between 10 and 50%. In this case reported the lack of revascularization of LSA increased the risk of neurological manifestations or stroke. Periscope technique is feasible and safe to maintain perfusion to the subclavian artery, with a 93% primary patency at 2 years.ConclusionsOur experience using TEVAR with periscope graft technique as solution to address thoracic aneurysm of aortic isthmus was feasible and safe.     

Early Outcomes of Left Subclavian Artery Revascularization Using Castor Single-Branched Stent-Graft in the Treatment of Type B Aortic Dissection or Intramural Hematoma

Background: More evidence was required to guide the management of left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR). The present study aimed to compare the outcomes of LSA coverage with LSA revascularization. Another purpose of this study was to share our experience of LSA revascularization with castor single-branched stent-graft.Methods: From January 2016 to December 2019, 134 patients with type B aortic dissection (TBAD) or intramural hematoma (IMH) were enrolled and divided into two groups, the LSA-covered group (n = 61) and the LSA-revascularized group (with castor single-branched stent-graft, n = 73). The results, such as in-hospital and 30-day mortality, stroke, paraplegia, left arm ischemia, operation time, endoleak, were compared between the two groups.Results: The incidence of 30-day stroke in the LSA-covered group (8.2%) was significantly higher compared with the LSA-revascularized group (0%, P = 0.018). 30-day ischemia of left arm occurred in more patients in the LSA-covered group (11.5%, P = 0.003). No statistical difference was found in the incidences of paraplegia, endoleak, in-hospital mortality, and 30-day mortality.Conclusions: LSA should be revascularized during TEVAR to reduce the incidences of stroke and left arm ischemia. Castor single-branched stent-graft was feasible and safe for treating TBAD or IMH.     

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??Endovascular repair of Stanford B dissection with branched stent-graft??An analysis of 11 cases YANG Jue??FU Wei-guo??XU Xin??et al. Department of Vascular surgery??Zhongshan Hospital??Fudan University??Shanghai 200032??China
Corresponding author??FU Wei-guo??E-mail??fu.weiguo@zs-hospital.sh.sn
Abstract Objective To summarize experience of thoracic endovascular aortic repair (TEVAR) in patients with proximal short landing zone with branched stent-graft. Methods A total of 11 patients with Stanford B dissection who underwent TEVAR with left subclavian artery ??LSA?? revascularization by single-branched stent-graft from July 2013 to February 2014 were retrospectively reviewed. Routine postoperative follow-up with computed tomography angiography (CTA) was performed to assess TEVAR and LSA patency??endoleak??dissection exclusion and complications in 1 and 6 months. Results TEVAR with single-branched stent-graft was successfully performed in 10 patients??and 1 patients failed by unsuccessful deployment of branched stent and replaced by another stent-graft with coverage of LSA. The mean operative time was??130.0±36.0??minutes. No major complications occurred. All patients were followed up in 1 and 6 months postoperatively. Type ?? endoleak was noted in 1 patient and 1 patient had an asymptomic LSA stent occlusion by CTA. Thrombosis formed in the aortic false lumen of the graft exclusion segment in all the patients??and the average diminution was 12mm. Conclusion Branched stent-graft is a feasible and effective option for LSA revascularization with proximal landing zone ??20 mm during TEVAR.