急性Stanford B型主动脉夹层行腔内隔绝术后的主动脉重塑CSCD

目的 探讨急性Stanford B型主动脉夹层行胸主动脉腔内修复（thoracic endovascular aor-tic repair,TEVAR）术后的主动脉重塑过程及形态学变化.方法 回顾性分析2015年9月至2016年8月诊断为急性Stanford B型主动脉夹层且行TEVAR手术的51例患者临床资料,利用CTA图像测量原发破口水平、气管分叉水平、腹腔干动脉水平及左肾动脉下缘水平真腔、假腔直径,并计算术后真、假腔直径变化率.结果 近端破口水平,术后真腔扩大及假腔缩小在术后1个月和1年最为明显（P〈0.05）,在术后3个月及术后6个月较为稳定,真、假腔均无明显变化（P〉0.05）.气管分叉水平,真腔持续扩大而假腔持续缩小.在腹腔干动脉及左肾动脉下缘水平,真腔直径呈缓慢增大趋势,而假腔直径变化不明显.结论 急性Stanford B型主动脉夹层行TEVAR术后,胸主动脉段重塑较佳,真腔得到明显恢复,假腔明显减小,假腔血栓形成并吸收率高,而对于支架血管未能覆盖的降主动脉远端重塑作用则较差.     

Debakey Ⅲb型主动脉夹层腔内修复术后腹主动脉重塑的影响因素分析

背景与目的 胸主动脉腔内修复术（TEVAR）是复杂型主动脉夹层的首选治疗方法,近年来已得到广泛应用。TEVAR通常只封闭原发破口,而对夹层远端破口采取旷置处理,但在长期随访中发现旷置远端破口可导致一系列并发症,包括支架远端瘤样扩张、灌注不良导致内脏缺血及覆膜支架远端新发夹层等。此外,近期研究发现TEVAR术后支架覆盖段的胸主动脉重塑效果较好,但对于支架未覆盖的腹主动脉段重塑效果却不尽如人意,甚至出现主动脉扩张或形成夹层动脉瘤,需要再次干预。鉴于TEVAR术后腹主动脉重塑不良与患者预后密切相关,本研究探讨急性期、亚急性期Debakey Ⅲb型主动脉夹层患者TEVAR术后腹主动脉重塑情况及潜在的影响因素,为临床提供参考。方法 回顾性收集2017年5月—2023年5月南昌大学第二附属医院血管外科行TEVAR的Debakey Ⅲb型主动脉夹层患者术前、术后1年的临床信息及影像学资料,根据患者腹主动脉最大直径平面的动脉直径和真、假腔变化将患者分为未重塑组和重塑组,分析TEVAR术后腹主动脉重塑的影响因素。结果 根据纳入与排除标准,最终入选105例患者,其中未重塑组44例,重塑组61例。单因素分析结果显示,两组患者在性别、手术距发病时间、既往史等方面差异均无统计学意义（均P>0.05）;未重塑组与重塑组在中位年龄（62.50岁 vs. 55.00岁）、平均远端破口数量（2.98个 vs. 2.26个）、累及左肾动脉比例（38.64% vs. 19.67%）方面差异有统计学意义（均P<0.05）。多因素Logistic回归分析结果显示,远端破口数量是影响TEVAR术后腹主动脉重塑的独立危险因素（OR=0.589,95% CI=0.406~0.855,P=0.005）。结论 TEVAR术后部分患者腹主动脉重塑不良,远端破口数量是影响腹主动脉重塑的主要因素。对于远端破口较多者,应密切随访观察患者的主动脉重塑情况,必要时再次手术干预。     

腔内修复术治疗多破口Stanford B型胸主动脉夹层的临床研究

目的 分析多破口Stanford B型胸主动脉夹层的临床特征,探讨胸主动脉腔内修复术处理该病的临床方式.方法 回顾性分析2011年2月-2015年5月因多破口(≥2个破口)Stanford B型胸主动脉夹层在广州军区武汉总医院心胸外科接收TEVAR治疗患者的病例资料,除近心端第一破口外,使用外科方式处理远端夹层破口为处理组,否则为非处理组.比较两组术后6个月内胸背疼痛发病率、远端夹层进展情况、假腔变化情况、远端破口获益情况.结果 检索出符合条件的病例67例,所有腔内修复术均获成功,无严重并发症发生病例,术后6个月内无死亡病例.处理组7例,非处理组60例.TEVAR后两组胸背疼痛发病率、远端夹层进展发病率差异无统计学意义(P＞0.05),处理组夹层假腔较非处理组明显变小(差异有统计学意义,P＜0.05),非处理组19例患者通过夹层远端破口的血流供应腹腔内脏动脉.结论 TEVAR是治疗多破口Stanford B型胸主动脉夹层有效的手术方式,远端破口应根据Stanford B型胸主动脉夹层特点进行个性化处理或尽量不处理.     

Stanford B型主动脉夹层腔内隔绝术后主动脉重塑的特点及影响因素

目的：分析StanfordB型主动脉夹层腔内隔绝术（EVGE）后主动脉重塑影响因素并探讨亚急性期行此术式后主动脉重塑的特点。方法：对44例Stanford B型主动脉夹层患者行EVGE治疗,术后采用CT扫描进行随访。根据支架段假腔是否消失分为2组。测量术前CT扫描图像中支架近、中、远段水平假腔径线及总径线,分析性别、高血压、手术时机、支架类型等对主动脉重塑的影响。将亚急性期患者主动脉分为A1、A2、A3段,观察3段主动脉中点所在平面真、假腔及瘤体直径的变化情况。结果：术前CT扫描各径线比较,假腔消失组均低于假腔末消失组;亚急性期行EVGE与急性期及慢性期比较,假腔消失组病例数高于假腔未消失组;夹层累及腹主动脉较未累及者,假腔消失组病例数低于假腔未消失组;术后6个月内A1、A2段瘤体及真假腔重塑变化较明显（真腔增大、假腔变小）,而A3段在术后重塑变化不显著（真腔稍增大、假腔稍减小）。尤其亚急性期行EVGE后连续CT观察：真腔逐渐增大,假腔逐渐减小,6个月内趋于闭合。结论：术前假腔直径、长度以及支架置入时期的不同是影响术后主动脉重塑重要因素。亚急性期行EVGE有利于主动脉重塑。     

Stanford B型主动脉夹层远端破口的处理

胸主动脉腔内修复(Thoracic endovascular aneurysm repair,TEVAR)降低了Stanford B型主动脉夹层患者围手术期病死率,已成为一线治疗方案,但术后远端破口的问题,往往制约了患者远期生存率[1].尽管TEVAR一期封堵了主动脉第一破口,但IRAD注册研究TEVAR术后主动脉扩张发病率为62.7％[2].TEVAR最初目的是防止夹层破裂和内脏及肢体缺血,临床终点由TEVAR后主动脉重塑所决定,因为远端破口直接影响主动脉重塑和破裂事件的发生,所以远端破口是TEVAR术后需要关注的问题[3].本文旨在探讨Stanford B型主动脉夹层远端破口的处理方法,以远端破口处理的必要性、远端破口的整体解决方案、远端破口的局部解决方案3个方向为论点,结合本中心研究和既往临床资料分别论述.     

胸主动脉腔内修复术联合限制性裸支架治疗B型主动脉夹层对术后主动脉重塑的影响

目的:探讨胸主动脉腔内修复术(TEVAR)联合限制性裸支架(RBS)治疗胸主动脉夹层对术后主动脉重塑的影响。方法:回顾性分析2012年8月—2014年8月收治的20例B型主动脉夹层患者资料,其中11例行单纯TEVAR术(TEVAR组)与9例行TEVAR联合RBS(TEVAR+RBS组)。根据术前及术后随访期间行主动脉全长CTA数据,比较两组术后主动脉重塑相关指标。结果:两组手术技术成功率均为100%,术后无截瘫、脑卒中、主动脉破裂等并发症发生。TEVAR+RBS组中RBS与覆膜支架平均重叠了36.5 mm。与TEVAR组比较,TEVAR+RBS组术后整体真腔体积扩大率明显降低(34.9%vs.64.9%,P=0.011);支架远端面积扩大率(43.5%vs.107.3%,P=0.006)、支架远端最长径扩大率(-12.2%vs.18.5%,P=0.002)均明显降低;TEVAR组与TEVAR+RBS组术后整体假腔体积缩小率(74.8%vs.65.3%,P=0.328)、假腔内血栓化比率均无统计学差异(47.3%vs.56.8%,P=0.271)。结论:与单纯TEVAR术比较,TEVAR+RBS对胸主动脉夹层术后主动脉重塑整体改善的程度并没有优势,但可有效降低TEVAR术后支架远端真腔面积(或最长径)过度扩大,因而可能降低支架远端再发破口的发生。     

B型主动脉夹层腔内修复术后远端裂口处理临床研究

目的探讨主动脉夹层腔内修复术(TEVAR)后远端裂口的处理策略,评价在亚急性期隔绝胸主动脉段裂口、栓塞假腔内逆向血流通道、选择性封堵远端裂口对主动脉重塑的影响。方法从2015年6月至2018年8月新疆维吾尔自治区人民医院共对43例TEVAR后仍存在远端裂口的B型主动脉夹层(Type B aortic dissection,TBAD)病人进行了处理,所有病人均进行胸主动脉段假腔完全处理,针对内脏动脉区以上裂口采用胸主动脉主体支架或短段支架血管(cuff)腔内隔绝,经远端裂口的逆向血流通道采用弹簧圈或先心封堵器进行封堵,有11例行肾动脉覆膜支架置入。8例病人胸主动脉段假腔完全血栓化后出现腹主动脉段假腔直径明显增大或症状明显,再次行腔内修复术(EVAR)。回顾性对比分析处理前后主动脉形态变化。结果随访1年,43例病人远端裂口处理后的主动脉最大径显著低于处理前[(27.36±4.92)mm vs.(32.03±6.35)mm,t=5.899,P0.001];主动脉假腔未血栓化范围,处理后明显小于处理前,且有6例主动脉假腔完全血栓化。结论在亚急性期隔绝胸主动脉段裂口、栓塞假腔内逆向血流通道、选择性封堵远端裂口对于TEVAR后远端裂口的处理安全有效。     

Talos远端打孔型胸主动脉覆膜支架治疗Stanford B型主动脉夹层首例报告（附视频）

背景与目的 主动脉腔内修复术（TEVAR）已成为B型主动脉夹层的一线治疗方式,如何能够最大程度覆盖主动脉夹层破口,促进主动脉重塑,而又不增加截瘫风险成为临床关注的难点。本文主要介绍新型Talos远端打孔型胸主动脉覆膜支架（以下简称“Talos支架”）在中南大学湘雅医院成功完成上市后国内首例支架置入术情况并进行相关分析。方法 报道Talos支架上市后国内首例置入病例的临床资料,并分析Talos支架的优缺点及进行相关文献回顾。结果 72岁男性Stanford B型主动脉夹层患者,因主动脉夹层累及范围广泛,需使用支架长度较长,经本人及家属同意后采用新上市的Talos支架行TEVAR。术中支架轻松到达病变部位,同时定位精准。患者完成支架置入后主动脉破口隔绝完全,假腔完全血栓化,而远端打孔段肋间动脉完整保留,同时无主动脉相关不良事件的发生。结论 Talos支架性能优良,长段的支架主体能够最大程度完成主动脉夹层的破口修复,促进主动脉重塑;同时远端的打孔设计能够在修复夹层破口的同时,保留肋间动脉,预防脊髓缺血所致截瘫。     

Stanford B型主动脉夹层远端破口的初步临床探讨

目的 探索性提出Stanford B型主动脉夹层远端破口的腔内修复原则.方法 新疆维吾尔自治区人民医院血管外科2013年1月-2015年1月收治的101例Stanford B型主动脉夹层患者,按照不同的处理原则将患者分为两组:(1)序贯处理组57例:采取由近至远的原则腔内修复主动脉破口(如不处理内脏动脉处破口,亦不处理其远端破口);(2)非序贯处理组44例:不按照由近至远的原则腔内修复主动脉破口(不处理累及内脏动脉破口,其余远端破口行腔内修复).分别对两组患者术后腹腔干处主动脉径直径增长率、不适主诉发病率、假腔血栓化发病率进行统计分析.结果 两组患者术后腹腔干处主动脉直径增长率有明显差异(P＜0.05),序贯组低于非序贯组;不适主诉发病率及假腔血栓化比例均可见明显差异(P＜0.05),序贯组优于非序贯组.结论 经过初步临床探讨,我们得出在处理Stanford B型主动脉夹层远端破口时,序贯处理优于非序贯处理.     

真腔覆膜支架点状植入联合假腔内栓塞技术治疗腔内修复术后主动脉夹层动脉瘤

目的 ：回顾性评价真腔覆膜支架点状植入联合假腔内栓塞技术（spot stenting combined with false lumen endovascular occlusive repair,SS-FLEVOR）治疗腔内修复术后主动脉夹层动脉瘤的中期结果 。方法 ：收集2016年10月至2020年10月间采用SS-FLEVOR治疗胸主动脉腔内修复（thoracic endovascular aortic repair, TEVAR）术后主动脉夹层动脉瘤病人围术期及随访资料。分析病人手术前后胸主动脉、腹主动脉真腔最大径、假腔血栓化及内脏动脉分支支架通畅情况。结果：TEVAR术后远端瘤样扩张病人17例,平均年龄（54.5±14.5）岁,女3例。SS-FLEVOR手术均成功,平均手术时间（151.4±37.9） min。平均随访（24.9±20.7）个月。随访期间内脏动脉分支支架均通畅。胸主动脉和腹主动脉假腔均血栓化10例,胸主动脉假腔血栓化3例,胸主动脉和腹主动脉假腔仍存在部分血流4例。因假腔内血流逐渐减少且瘤体未增大,未予以二次干预。胸主动脉和腹主动脉真腔最大径均较术前增大。术前胸...     

亚急性Stanford B型主动脉夹层腔内隔绝术后瘤体重构分析

目的:探讨亚急性主动脉夹层腔内隔绝术后瘤体重构的特点。方法:回顾性分析我科1998年9月至2005年10月43例亚急性主动脉夹层腔内隔绝术后随访影像学资料。将主动脉分为S1、S2、S3三段,设定每段主动脉中点所在平面为观察横断面,分别测量每次随访CT各观察横断面真、假腔及瘤体直径,观察其变化情况。结果:术后12个月内S1、S2瘤体及真假腔重构变化较明显,真腔直径逐渐增大、假腔血栓化吸收、瘤体逐渐减小,24个月后变化趋于稳定,而S3段在术后重构变化不显著。结论:亚急性主动脉夹层腔内隔绝术安全有效,术后瘤体重构满意。病人在度过急性期后应尽早行腔内隔绝术,使得瘤体得到较好重构,尽量恢复至发病前状态。     

Preoperative thoracic false lumen branches relate to aortic remodeling after thoracic endovascular aortic repair for DeBakey IIIb aortic dissection

Objective

This study evaluated the association between thoracic false lumen branches (TFLBs; dissected thoracic branches fed by a false lumen) and distal thoracic aortic enlargement (DTAE) after thoracic endovascular aortic repair (TEVAR) for DeBakey IIIb aortic dissection.

急性Stanford B型主动脉夹层腔内修复术的指征和治疗时机选择

目的 探讨急性Stanford B型主动脉夹层腔内修复术的指征和治疗时机的选择.方法 对2004年2月至2008年6月收治的Stanford B型主动脉夹层464例进行分析.男性391例,女性73例;年龄26～88岁,平均56.6岁.分析导致急性主动脉夹层破裂的危险因素并评价急性组(n=298)和慢性组(n=166)的腔内治疗效果.结果 夹层破裂组中反复或持续性胸背痛和胸腔渗出的发生率(83.3%和94.4%)高于非破裂组(10.4%和14.1%,P＜0.01).破裂组降主动脉平均最大径(49.4 mm)大于非破裂组(35.1 mm,P＜0.01).合并内脏和下肢动脉缺血的病例在腔内修复术后症状体征和相关指标都得剑明显改善.急性组近端假腔消失率51.7%高于慢性组的19.5%,而远端假腔开放率59.2%低于慢性组的79.3%(P＜0.01).24例壁间血肿或假腔完全血栓形成病例中有4例出现夹层复发.结论 近端假腔持续开放的急性夹层应行腔内修复术,而壁间血肿或假腔完全血栓化的急性病例可暂予密切随访.对于有反复或持续性胸背痛、胸腔渗出和降主动脉直径＞4.5 cm等破裂先兆的病例或短时间内无法好转的主动脉分支血管缺血者,应立即行腔内修复术.     

Severe stenosis of the true lumen in the abdominal aorta after an ascending aorta reconstruction for an acute type a dissection: report of a case

We encountered a case of severe symptomatic stenosis of the abdominal aorta after a surgical repair of an ascending aortic dissection. A 75-year-old woman underwent a reconstruction of the ascending aorta to treat a Stanford type A acute aortic dissection and cardiac tamponade. Eight hours postoperatively, the patient was anuric. An abdominal computed tomography scan revealed severe stenosis of the true lumen of the suprarenal abdominal aorta due to a dilatation of the false lumen. The patient's ischemic symptoms progressed to include a weakening femoral pulse and, as a result, an emergency right axillofemoral artery bypass was performed. We hypothesize that the stenosis of the true lumen of the abdominal aorta was secondary to the mechanical obstruction due to a false lumen, which already existed because of the thoracic dissection, and its size increased postoperatively as a consequence of uncontrolled postoperative hypertension. Received: July 23, 2001 / Accepted: January 8, 2002     

B ���������в�ǻ���޸�����Զ���ѿڴ����ٴ��о�

??Management of distal reentry in type B dissection and evaluation??A report of 43 cases FANG Qing-bo??CI Hong-bo??GE Xiao-hu. Department of Vascular Surgery,People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830000??China
Corresponding author??GE Xiao-hu??E-mail??xj_gexiaohu@163.com
Abstract Objective To discuss the management of distal reentry in type B dissection??evaluate the influence of isolating the distal reentry in thoracic aorta and embolization of the reverse flow channel in the false lumen and selective closure of distal reentry. Methods From June 2015 to August 2018??43 patients with TBAD ??type B aortic dissection?? with distal reentry after TEVAR admitted in People's Hospital of Xinjiang Uygur Autonomous Region were collected.All patients underwent complete treatment of the thoracic aorta segment of the false lumen??TEVAR or short cuff were applied to managing the reentry above the visceral artery.The reverse flow channel from the distal reentry was blocked by coil or closure device.Renal artery stent graft placement was performed in 11 cases??8 cases of thoracic aortic false lumen thrombosis after TEVAR??but the diameter of the abdominal aorta increased significantly??they were performed EVAR. The morphological changes of aorta were compared. Results The time of follow-up was 1 year. The maximal diameter of aorta after distal reentry treatment in 43 patients was significantly lower than preoperative diameter [??27.36±4.92??mm vs.??32.03±6.35??mm??t=5.899??P??0.001]. The range of unthrombosed false lumen significantly shrank after operation. There were 6 cases of complete aortic thrombosis. Conclusion Occlusion of distal reentry in thoracic aorta during subacute phase, blocking the reverse blood flow channel and selective closure of distal reentry are safe and effective.     

Early and mid-term results of endovascular stent grafting for aortic aneurysms]

Early and mid-term clinical results of 28 cases of endovascular stent grafting for descending thoracic aortic aneurysms and 11 cases of abdominal aortic aneurysms are reported. Early clinical results: Among 28 patients (7 true thoracic aortic aneurysms, 3 pseudothoracic aortic aneurysms and 8 acute, 4 subacute, and 6 chronic aortic dissections), two patients (7.1%) with ruptured acute aortic dissection or ruptured infected pseudoaneurysm died in the perioperative period. Two of the remaining 26 patients experienced minor complications. Aneurysmal sacs or false lumens at the descending thoracic aorta were completely thrombosed in the 26 patients. One patient (9.1%) with a ruptured abdominal aneurysm died, and one of the remaining 10 patients had renal and peripheral emboli and peripheral vascular trauma. Inadvertent covering of the renal arteries occurred in another patient. Unless one patient had persistent endoleak, aneurysmal sacs in the 10 surviving patients were thrombosed. Mid-term clinical results: One aortic dissection at a different section of the descending aorta occurred 6 months after stent grafting for aortic dissection, and one patient died of pneumonia 3 months after stent grafting for an abdominal aortic aneurysm. CT scanning 6 months after stent grafting revealed a decrease in maximal aneurysmal size in 3 of 9 patients with true or pseudothoracic aneurysms and in 2 of 5 patients with abdominal aortic aneurysms. Five of 9 patients with stent grafting for acute or subacute dissection showed elimination of the false lumen in the descending thoracic aorta in a CT scan 6 months after grafting. One patient with a true thoracic aneurysm and one patient with an abdominal aortic aneurysm showed an increase in aneurysmal size in a CT scan 2 years and one year after treatment, respectively.     

Transluminal placement of endovascular stent-grafts for the treatment of type A aortic dissection with an entry tear in the descending thoracic aorta

PURPOSE: The current therapy for type A aortic dissection is ascending aortic replacement. Operative mortality and morbidity rates have been markedly improved because of recent advances in surgical techniques and anesthesiology. However, type A aortic dissection with an entry tear in the descending thoracic aorta is still a surgical challenge because of the need for extensive aortic replacement. METHODS: Ten patients with type A aortic dissection were treated with endovascular stent-grafts. The false lumen of the ascending aorta was patent in five patients, and it was thrombosed in the other five patients. The entry tears were located in the descending thoracic aorta in all cases. Seven patients had acute dissection, and three patients had subacute dissection. Four patients had pericardial effusion. Stent-grafts were fabricated from expanded polytetrafluoroethylene and Z-stents. RESULTS: Entry closure was achieved in all patients. Complete thrombosis of the false lumen of the ascending aorta was observed after stent-grafting in all patients. A second stent-graft was required in two patients to obtain complete thrombosis of the false lumen of the descending thoracic aorta. No procedure-related complications were observed, with the exception of a minor stroke in one patient. During a mean follow-up period of 20 months, no aortic rupture or aneurysm formation was noted in either the ascending or descending thoracic aorta, and all patients were alive and doing well. The abdominal aortic aneurysm enlarged after stent-grafting in one patient, and this was treated by closing the fenestrations of the abdominal aorta with stent-grafts. CONCLUSION: Stent-graft repair of aortic dissection with an entry tear in the descending thoracic aorta is a safe and effective method and may be an alternative to surgical graft replacement in highly selected patients.     

Value of intravascular ultrasound for endovascular stent-graft placement in aortic dissection and aneurysm

BACKGROUND: Endovascular stent-graft placement is a new concept for the treatment of aortic dissection and aneurysm. Intravascular ultrasound (IVUS) with established diagnostic features may be instrumental in guiding endovascular procedures. METHODS: We performed IVUS and digital angiography before, during, and after implantation of 47 stent grafts in 40 patients with Stanford type B dissection (26 patients, 28 stent grafts), thoracic aneurysm (9 patients, 11 stent grafts), and abdominal aneurysm (5 patients, 8 stent grafts). RESULTS: IVUS could clearly identify the aortic anatomy and differentiate between true and false lumen in all cases of dissection. In four patients with type B dissection extending from the thoracic to the abdominal aorta the true lumen was exclusively identified by IVUS, and thus, essential for safe execution of the procedure. In another patient stent-graft placement in the aorta was optimized by covering a second entry detected by IVUS, but undetected by angiography. The site of stent implantation, the true and false lumen, as well as entry and reentry were always identified in both thoracic and abdominal aorta. In comparison with angiography, IVUS information led to additional balloon molding due to incomplete stent apposition in seven cases. CONCLUSIONS: As an adjunctive imaging modality IVUS is likely to improve stent-graft placement in aortic type B dissection, especially in patients with abdominal extension.