杂交技术治疗主动脉弓降部病变的临床研究

目的:探讨杂交技术治疗主动脉弓降部病变的效果。方法:采用杂交技术(解剖外旁路联合血管腔内修复术)手术治疗10例患者,包括累及主动脉弓部分支的B型主动脉夹层4例和主动脉弓降部真性动脉瘤6例。其中左颈总动脉至左椎动脉旁路1例,右颈总动脉至左颈总动脉旁路5例,右颈总动脉至左颈总动脉及左颈总动脉至左锁骨下动脉旁路1例和升主动脉至无名动脉及左颈总动脉旁路3例。均经股动脉入路植入覆膜支架。结果:10例患者均获得技术成功,1例发生少量I型内漏,未处理。术后1例因脑梗塞伴肺炎、肾功能衰竭不治自动出院;其余9例均痊愈出院。9例随访时间3～33个月,均恢复正常生活,术后3个月CTA示:覆膜支架无移位,1例内漏已消失,无新的内漏发生,夹层假腔或动脉瘤腔内已有血栓形成,远端夹层假腔无明显扩大,旁路人工血管通畅。结论:杂交手术避免体外循环损害,减轻外科手术创伤,提高了治疗效果,是治疗累及分支的主动脉弓降部病变的重要方法。     

采用胸分支型主动脉支架人工血管对主动脉弓降部夹层行腔内修复治疗

目的探讨采用胸分支型主动脉支架人工血管治疗累及左锁骨下动脉的主动脉弓降部夹层的临床效果。方法自2004年2月至2004年6月,采用血管腔内胸分支型主动脉支架人工血管治疗主动脉弓部夹层14例。14例均为StanforB型主动脉夹层,原发破裂口距左锁骨下动脉开口2～13mm,平均8．7mm。分支型支架由主动脉段支架和分支段支架组成,支架直径较相应支撑部位动脉直径大15％～20％。治疗在血管造影室进行,应用定位导丝、在透视下将分支型主动脉支架人工血管送人并连续释置入主动脉弓和左锁骨下动脉。结果支架释放全部成功。14例患者共放置14只分支型主动脉支架和2只可弯曲型支架人工血管,封闭夹层破裂口,夹层真腔全部恢复正常直径。无远端动脉并发症发生,无死亡病例。全部患者术后恢复正常活动。结论胸分支型主动脉支架人工血管适合于修复破裂口位于左锁骨下动脉开口旁的主动脉弓部夹层。     

杂交技术治疗主动脉弓部病变的近远期结果

目的 探讨杂交技术治疗主动脉弓部病变的近、远期结果.方法 将我科2002年10月至2011年3月期间的28例胸主动脉瘤或夹层累及主动脉弓的患者纳入本研究.男22例,女6例;平均年龄68岁.15例为动脉粥样硬化性胸主动脉瘤,13例为主动脉夹层.术后3、6、12个月及每年进行CT血管造影或B超随访.主要研究内容是手术死亡率、并发症发生率及远期生存率.结果 12例开胸行全弓旁路术,左侧颈总-左侧锁骨下动脉旁路3例,右侧颈总-左侧颈总-左侧锁骨下动脉旁路11例,右侧颈总-左侧颈总动脉旁路2例.技术成功率为92.9%(26/28),并发症发生率为35.7%(10/28),手术死亡率为7.1%(2/28),脑卒中发生率为7.1%(2/28).随访时间(36±3)个月,1年通畅率为100%,3年通畅率为92.9%(26/28),5年通畅率85.7%(24/28);1年生存率为89.3%(25/28),3年生存率为71.4%(20/28),5年生存率为60.7%(17/28).结论 主动脉夹层弓部病变杂交手术的近、远期结果满意,进一步降低并发症发生率将会提高患者生存率.     

一期杂交手术治疗主动脉弓部疾病的远期结果

目的:回顾分析我院接受杂交手术(Hybrid arch repair,HAR)治疗主动脉弓部疾病的远期预后结果。方法:2009年1月至2018年1月,共87例患者因主动脉弓部疾病于北京安贞医院接受HAR治疗,男76例,女11例;年龄(62.2±9.6)岁。2例为0区,46例为1区,39例为2区。结果:5例(5.7%)手...     

主动脉弓扩张性疾病的腔内治疗

主动脉弓的近端为无名动脉(头臂干)在主动脉上的起始部前端,远端为左锁骨下动脉起始部以远约2 cm的主动脉峡部(在左锁骨下动脉与肺动脉韧带之间)[1]。自1991年腹主动脉瘤腔内隔绝术成功后,腔内治疗已逐步应用于腹主动脉非分支区(N3区)、胸降主动脉非分支区(N2区)及腹主动脉分支区     

杂交技术与传统开放手术治疗主动脉弓部疾病:孰优孰劣?

开放全主动脉弓部置换联合象鼻支架置人术是治疗累及主动脉弓部夹层/动脉瘤的标准术式.近年来随着腔内介入技术的发展,结合弓上血管去分支和导丝导管技术的杂交手术可缩短甚至避免体外循环或者深低温停循环,理论上能有效降低围术期各类风险,为无法接受开放手术的高危患者提供了新的治疗选择.然而,目前对于开放手术和杂交技术在治疗主动脉弓...     

鞘转流系统辅助下胸主动脉腔内修复术联合原位激光开窗治疗主动脉弓部病变的临床结果

目的:探讨胸主动脉腔内修复术（TEVAR）联合原位激光开窗（ISLF）处理主动脉弓部病变的有效性和安全性,并分析通过鞘临时转流系统在术中维持脑灌注的临床结果。方法:回顾性分析2017年1月至2019年12月在上海交通大学医学院附属第九人民医院接受TEVAR联合ISLF完成了累及主动脉弓部病变的腔内修复术并应用血管鞘进行...     

正确评价应用于主动脉弓部疾病的开窗技术

自1994年Dake 等报告腔内修复技术治疗胸降主动脉病变以来,胸主动脉腔内修复术(thoracic endovascular aneurysm repair,TEVAR)已逐步成为胸主动脉病变的常规治疗手段。与传统开放手术相比,TEVAR显著降低了手术创伤和死亡。但主动脉弓病变涉及弓上分支的重建问题,一直是TEVAR的痛点。一方面,传统开放手术修复主动脉弓部病变的高死亡率(6%~20%)和高卒中率(12%)[1],促使腔内微创修复技术迫在眉睫;另一方面,发展腔内重建主动脉弓技术又面临巨大挑战,举步维艰。尽管经过20余年的技术积累和器材改进,目前TEVAR处理主动脉弓病变仍处于探索阶段,远没有达到实际临床需求。应用完全腔内重建弓部分支血管的方法主要包括开窗技术、分支技术、平行支架技术(包括顺行的“烟囱”技术和逆行的“潜望镜”技术)等,这些技术都有各自的优点和缺点。与开窗技术重建内脏动脉的方案类似,主动脉弓部的开窗技术也是通过支架型血管的“窗口”保留弓上分支血管。开窗技术分“预开窗技术”和“原位开窗技术”两种。其中原位开窗技术存在极大技术挑战而在重建内脏动脉方面很少应用。本文仅对主动脉弓部开窗技术进行技术方案与临床证据评价。     

复合技术治疗主动脉弓部病变的单中心临床经验

目的 总结复合技术治疗主动脉弓部病变的经验.方法 回顾性分析江门市中心医院2013年1月至2020年10月采用复合技术治疗的35例主动脉弓部病变患者资料,其中Stanford B型主动脉夹层29例,Stanford A型主动脉夹层1例,胸主动脉瘤4例,穿透性溃疡1例.观察患者的技术成功率、术后并发症情况和随访结果.结果...     

Comparison of commercially available versus customized branched-fenestrated devices in the treatment of complex aortic aneurysms

Objective

To evaluate and compare the early outcomes of patients treated for complex aortic aneurysms using a commercially available Zenith fenestrated endograft (ZFEN) or an advanced customized fenestrated-branched endovascular repair, which includes custom-made device or off-the-shelf p-branch devices available for use in a physician-sponsored investigational device exemption (PSIDE).

Combined fenestrated-branched endovascular repair of the aortic arch and the thoracoabdominal aorta

ObjectiveThe aim of our study was to evaluate patients who underwent extensive endovascular aortic stent graft coverage (from the aortic arch to abdominal aorta) in terms of early and midterm clinical outcomes.MethodsA retrospective multicenter study was undertaken. All patients were treated with extensive endovascular aortic stent graft coverage with fenestrated and branched endografts at three experienced endovascular centers.ResultsBetween 2012 and 2017, there were 33 patients (22 male [67%]) treated with a combination of fenestrated-branched stent grafts in the aortic arch and the thoracoabdominal aorta. Most of the patients (20/33 [61%]) had fenestrated-branched endovascular aneurysm repair (fb-EVAR) of the thoracoabdominal aorta as a second-stage procedure after thoracic arch (fb-Arch) repair, 10 had fb-Arch repair as the first procedure, and three patients had a single-stage procedure. The mean age was 67 ± 13 years, and the mean interval between procedures was 13 ± 12 months. For fb-Arch repair, 20 fenestrated and 13 branched devices were used; for fb-EVAR, 23 fenestrated, 5 branched, and 5 composite devices were used. The use of spinal drainage was more common in fb-EVAR (20/33 [61%]). Technical success was 100%. Mean hospital stay was 15 ± 13 days for fb-Arch repair and 12 ± 9 days for fb-EVAR. Two patients died in the hospital after fb-EVAR, resulting in a 30-day mortality of 6% (2/33). No deaths occurred during the fb-Arch repair component or in the single-stage cases. Four patients developed spinal cord injury (12%), 1 had permanent paraplegia (3%), and 2 patients had a neurologic event (1 stroke [3%] and 1 transient ischemic attack [3%]). Six patients (18%) died during a mean follow-up of 23 ± 17 months. The survival at 12 months after the second procedure was 72%, and the freedom from any reintervention was 82%. The 12-month freedom from reintervention was 87% for fb-Arch repair and 81% for fb-EVAR.ConclusionsExtensive endovascular coverage of the aorta for aortic disease seems to be a feasible procedure in experienced centers, with acceptable perioperative morbidity and mortality. Spinal cord ischemia appears acceptable despite extensive aortic coverage.     

升主动脉和弓部动脉瘤的外科治疗

目的：总结升主动脉和弓部动脉瘤手术治疗经验，以期进一步提高手术疗效。方法：自2000年7月至2002年5月应用深低温停循环（DHCA）和上腔静脉逆行脑灌注（RCP）技术手术治疗升主动脉和弓部动脉瘤20例，其中急症手术5例。施行全弓置换术2例，全弓置换和象鼻手术3例，半弓置换术15例。同期行Bentall手术8例，升主动脉置换术或同时行主动脉瓣置换术12例，冠状动脉旁路移植术1例。结果：术后早期死亡1例，短时间浅昏迷1例，呼吸功能不全2例，肾功能不全2例，无晚期死亡。结论：DHCA和RCP技术是手术治疗升主动脉和弓部瘤的安全、有效方法，急性A型夹层动脉瘤的手术方式取决于内膜破裂口的位置；正确掌握DHCA和RCP技术，手术方式和手术技术、围术期处理是提高手术疗效的关键因素。     

国人升主动脉及主动脉弓的CT解剖研究

目的 通过CT血管造影(computed tomographic arteriography,CTA)方式回顾性研究中国人群升主及弓部血管的直径、长度特点;方法选择2006年9月至2007年9月接受胸主动脉CT血管造影的患者388例,使用GE公司AW4.2工作站测量升主、弓部、弓上分支的直径及长度数据,运用统计学软件进行分析.结果 冠脉开口以上至左锁骨下动脉以远的主动脉直径D1-D6分别为(34±5)mm;(34±5)mm;(33±4)mm;(30±4)mm;(28±3)mm;(26±3)mm.头臂干两处直径d1,d2分别为(13±2)mm;(13±2)mm.左颈总动脉两处直径d3,d4分别为(8.7±1.5)mm;(7.9±1.0)mm.左锁骨下动脉两处直径d5,d6分别为(10.7±1.7)mm;(9.3±1.3)mm.冠脉开口处至头臂干动脉开口近端的主动脉管腔长度L1为(5.4±1.2)cm;头臂干开口近端与左颈总动脉开口近端之间的主动脉管腔距离L2为(1.3±0.4)cm;头臂干起始处至右锁骨下动脉开口处长度11为(4.0±0.8)cm;左锁骨下动脉起始处至椎动脉开口处管腔长度I2为(3.8±0.8)cm;头臂干与左颈总动脉管壁之间距离I3为(0.39±0.23)cm;左颈总与左锁骨下动脉之间管肇距离I4为(0.7±0.5)cm.结论 得到中国人群升主及弓部血管直径和长度的数据,可为腔内修复升主动脉及主动脉弓的各类研究提供数据支持.     

Quantification of aortic shagginess as a predictive factor of perioperative stroke and long-term prognosis after endovascular treatment of aortic arch disease

Objective

Thoracic endovascular aortic repair (TEVAR) with supra-aortic debranching has recently been introduced as a treatment option for aortic arch disease. Although less invasive than open repair, TEVAR is associated with a risk of perioperative embolic stroke due to dislodgment of atherosclerotic plaque debris, especially in individuals with atheromatous degeneration of the aortic lumen. It is difficult to determine atheroma vulnerability, and there is no current method for predicting the risk of atheroembolism. This study aimed to evaluate the usefulness of our method of quantifying the shagginess of the aorta in predicting the short- and long-term outcomes of TEVAR involving the aortic arch.

腔内隔绝术联合开窗技术治疗累及主动脉弓部的Stanford B型夹层动脉瘤的临床研究

目的 总结腔内隔绝术联合开窗技术治疗累及主动脉弓部的Stanford B型夹层动脉瘤的可行性和手术效果.方法 采用腔内隔绝术联合开窗技术治疗10例累及主动脉弓部的Stanford B型夹层动脉瘤.腔内隔绝术联合开窗技术封堵夹层破口,保留主动脉弓全部分支8例,保留头臂干及颈总动脉2例.手术均在局部麻醉下完成,覆膜支架开窗在术中进行.结果 患者术中造影无内漏,术后无死亡,2例左锁骨下动脉封堵的患者未出现神经系统并发症.随访中,开窗支架通畅,无移位,保留的主动脉弓分支动脉通畅,降主动脉真腔扩大,假腔血栓化并缩小.结论 对于累及主动脉弓部的Stanford B型夹层动脉瘤,腔内隔绝术联合开窗技术治疗是安全有效的治疗方法.     

Surgical treatment for cervical aortic arch with aneurysm formation

Cervical aortic arch is an unusual malformation. Cervical aortic arch with aneurysm formation is very rare. We report a case of cervical aortic arch associated with a saccular aneurysm in a 59-year-old Japanese man. The aneurysm protruded caudally and was located between the left common carotid and left subclavian arteries. Cardiopulmonary bypass and deep hypothermic circulatory arrest was applied as adjunct methods. A Dacron graft was sutured just distal to the left common carotid artery, with the patient in the Trendelenburg position. The proximal site was left open while oxygen-saturated venous blood was supplied in a retrograde manner to perfuse the lower body during occlusion of the descending aorta. Distal anastomosis to the descending aorta was performed during rewarming. The left subclavian artery was reconstructed by using a branch of the graft. This procedure is simple and useful for distal arch operations, especially in patients with Haughton D type aneurysms.     

Surgical treatment for cervical aortic arch with aneurysm formation

Cervical aortic arch is an unusual malformation. Cervical aortic arch with aneurysm formation is very rare. We report a case of cervical aortic arch associated with a saccular aneurysm in a 59-year-old Japanese man. The aneurysm protruded caudally and was located between the left common carotid and left subclavian arteries. Cardiopulmonary bypass and deep hypothermic circulatory arrest was applied as adjunct methods. A Dacron graft was sutured just distal to the left common carotid artery, with the patient in the Trendelenburg position. The proximal site was left open while oxygen-saturated venous blood was supplied in a retrograde manner to perfuse the lower body during occlusion of the descending aorta. Distal anastomosis to the descending aorta was performed during rewarming. The left subclavian artery was reconstructed by using a branch of the graft. This procedure is simple and useful for distal arch operations, especially in patients with Haughton D type aneurysms.     

主动脉弓部瘤及降主动脉瘤的手术治疗

目的总结主动脉弓部瘤及降主动脉瘤的外科治疗经验.方法13例主动脉弓部瘤及降主动脉瘤病人中男8例,女5例.年龄(62.6±8.3)岁.动脉瘤的最大直径为45～68?mm,平均(58.1±7.3)?mm.体外循环方式有完全体外循环、部分体外循环、选择性脑灌注(SCP)、深低温停循环(HCA)及逆行性脑灌注(RCP).6例弓部动脉瘤及3例急性StanfordA型夹层动脉瘤在HCA和SCP下行全弓部置换术;1例StanfordB型夹层动脉瘤在HCA和RCP下行血管置换;3例真性降主动脉瘤中,2例在部分体外循环下,1例在HCA下行血管置换,其中2例行肋间动脉重建.采用的外科吻合技术有开放吻合和阻断瘤体两侧进行吻合两种.结果本组无手术死亡及脊髓损伤.发生2例脑梗塞,无肾功能不全者.结论主动脉弓部瘤及降主动脉瘤手术时,体外循环方式的选择和适当的外科吻合技术是手术成功的两个最重要因素.