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.     

亚急性期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:探讨亚急性期Stanford B型主动脉夹层胸主动脉腔内修复术(TEVAR)后的血管重塑特点及影响因素。方法:回顾性分析2008年1月—2016年6月于安徽省立医院血管外科行TEVAR的50例亚急性期Stanford B型主动脉夹层患者术前及术后临床及影像学资料,分析术后3、6、12个月主动脉各平面段真假腔直径及假腔血栓化情况及术后主动脉重塑的影响因素。结果:TEVAR手术技术成功率为100%。术后8例失访。其余42例患者的影像学资料分析结果显示,TEVAR术后各时间点胸主动脉段真腔直径较术前明显扩大、假腔直径较术前明显缩小(均P0.05),而腹主动脉段真腔和假腔变化与术前均无统计学差异(均P0.05);胸主动脉段术后假腔血栓化比率高于腹主动脉。多因素分析显示,假腔内存在分支血管灌注(OR=27.45,P0.05)、存在多破口(OR=19.02,P0.05)是TEVAR术后主动脉重塑不良的独立危险因素。结论:亚急性期Stanford B型主动脉夹层行TEVAR后胸主动脉段重塑优于腹主动脉段;假腔内存在分支血管灌注、存在多破口是TEVAR术后主动脉重塑不良的独立危险因素。     

Endovascular treatment of type B thoracic aortic dissections

PURPOSE: To evaluate the initial experience of endovascular repair of aortic dissections from a single center. MATERIALS AND METHODS: From June 1999 to March 2002, endovascular stent grafting was performed in 20 high-risk patients (16 to 80 years). Eighteen patients had a type B dissection (14 acute and 4 chronic). Two patients had chronic type A dissection. Preoperative work-up included CT and MRI to evaluate the extent of the dissection, the relation to the left subclavian artery, the size of false and true lumen, and branch complications. RESULTS: Stent-graft deployment was technically successful in all cases. None was converted to open repair. Three patients died within 30 days, i.e., a 15% mortality rate. Four patients (20%) had a perioperative stroke. Paraplegia was observed in one case. No migration of the stent grafts or endoleaks was observed during the mean follow-up period of 13 months. In all but two patient thrombosis of the false lumen was noted. CONCLUSIONS: Endovascular treatment of thoracic dissections is feasible. Early results are encouraging. While endovascular repair with stent-grafts is progressing rapidly as a viable strategy for aortic dissections in selected patients careful investigations must continue to focus on its safety. Randomized controlled trials are urgently needed.     

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.     

Coil embolization of persistent false lumen after stent graft repair of type B aortic dissection

Patent false lumen after endovascular stent graft treatment of type B aortic dissection is a predictor for late death and retreatment. Between June 2008 and March 2010, five men with patent false lumen, due to a type B dissection previously treated with thoracic stent graft, underwent endovascular coiling treatment. Within a 30-day period, there were no deaths or major complications. The follow-up duration ranged from 1 to 22 months (mean 10.6 ± 8.5). Endovascular coiling of patent false lumen after endovascular stent graft treatment for type B aortic dissection avoided the risk of rupture or death due to secondary aneurysm formation.     

Retrograde aortic dissection after a stent graft repair of a type B dissection: how to improve the endovascular technique

To date, endovascular repair of thoracic dissections is a reality, associated with acceptable morbidity and mortality. We present the case of a 72-year-old woman presenting a retrograde aortic dissection at the postoperative day 12, after an endovascular repair for a 60-mm thoracic dissecting aneurysm. Two years earlier, she had presented an uncomplicated thoracoabdominal type B aortic dissection between the isthmic aorta and the iliac bifurcation. Despite an acceptable blood pressure control, a 62-mm thoracic dissecting aneurysm was observed on the 24-month CT-scan. Due to a chronic obstructive pulmonary disease, we chose the endovascular approach to exclude the thoracic entry tear leading to the complete false lumen thrombosis around the endoprosthesis. However, the inferior part of the false lumen remained patent due to a second abdominal entry tear. The initial outcome was uneventful but the patient presented a sudden death syndrome twelve days after the endovascular repair. During the autopsy, we discovered an intrapericardial rupture of a retrograde dissection, starting at the level of the proximal bare spring of the endoprosthesis. We discuss some important technical details to improve the safety, and to reduce the risk of immediate or delayed complications.     

血管旁路移植术联合腔内隔绝术治疗主动脉扩张疾病的临床研究

目的总结采用血管旁路移植术联合腔内隔绝术(endovascular aortic repair,EVAR)治疗主动脉扩张疾病的临床经验。方法 2008年1月-2011年8月,采用血管旁路移植术联合EVAR治疗12例主动脉扩张疾病患者。其中男11例,女1例;年龄47～81岁,平均65.9岁。均经主动脉血管造影(computed tomography angiography,CTA)确诊,其中Stanford A型夹层1例,Stanford B型夹层5例,主动脉弓部动脉瘤4例,腹主动脉瘤2例。8例患者先行颈部血管旁路移植术,再行EVAR;4例患者先行EVAR,再行股动脉血管旁路移植术。结果术后肺部感染3例,肾功能不全2例,脑梗死1例,血红蛋白和血小板降低7例,腹股沟切口愈合不良1例。11例患者获随访3～42个月,平均18.6个月。1例行胸、腹主动脉EVAR患者,术后6个月复查发现移植物远端有新的动脉瘤形成,再次行EVAR,3个月后复查恢复良好。其余患者术后3、6及12个月复查,主动脉CTA均提示假腔明显缩小以及假腔内血栓形成,未发现内漏,支架无迟发变形或移位,人工血管吻合口通畅。结论血管旁路移植术联合EVAR扩大了腔内修复术的适应证,既提供了足够的锚定区,又保证了重要脏器血供,简化了手术操作过程,降低了腔内治疗难度。     

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.     

Remodeling of the thoracic aorta after stent grafting of type B dissection: a Swedish multicenter study

AIM: Endovascular repair of complicated type B dissections has evolved as a promising alternative to open repair. Previous studies have indicated that continued false lumen flow is a predictor of continued aortic dilatation and risk of rupture during follow-up. This multicenter study was conducted to analyze the postoperative changes of the false lumen after endografting of complicated type B dissections. METHODS: All patients treated with endovascular stent grafts for thoracic type B dissections at 5 major Vascular Centers in Sweden were identified through local databases. Review of charts and all available pre- and postoperative CT scans were performed to identify demographics, indications for repair as well as postoperative changes of the aorta and false lumen. RESULTS: A total of 129 patients treated for type B dissections between 1994 and December 2005 were identified. Median radiological follow-up was 14 months. Fourteen patients died perioperatively leaving 115 patients available for analysis. Seventy-four of these had CT imaging of sufficient quality for morphological analysis. The vast majority of acute patients were treated for rupture or end-organ ischemia whereas most chronic patients were treated for asymptomatic aneurysms. In 80% of patients, the false lumen thrombosed along the stent graft but it remained perfused distal to the stent graft fixation in 50% of patients. Only 5% of patients presented with aortic enlargement of the stent grafted area when adequate proximal sealing was achieved. The distal, uncovered aorta displayed expansion in 16% of patients. CONCLUSIONS: The stent grafted thoracic aorta after type B dissection appears to be stabilized by covering the primary entry site with a stent graft in the majority of both acute and chronic dissections. The uncovered portion of the aorta distal to the stent graft, however, remains at risk of continuous dilatation. Stent grafting for complicated type B thoracic dissections seems to be a treatment option with reasonable morbidity and mortality even though the incidence of severe complications is still significant.     

B型主动脉夹层98例报告

目的探讨B型主动脉夹层的治疗效果,急、慢性主动脉夹层的治疗措施。方法 2001年7月～2011年6月98例B型主动脉夹层(胸主动脉夹层96例,腹主动脉夹层2例;急性主动脉夹层89例,慢性9例)行胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)83例,外科手术修复1例,保守治疗10例,术前夹层动脉瘤突然破裂死亡4例。采用直型带膜支架修复80例,分支带膜支架修复3例。杂交手术7例,先行右腋动脉-左腋动脉人工血管旁路移植5例,行左颈动脉-左锁骨下动脉人工血管旁路移植2例。保守治疗的10例中,4例经1周治疗痊愈。9例慢性主动脉夹层发现夹层不断扩大,采取腔内修复治疗。结果 83例腔内修复手术围手术期死亡2例,病死率2.4%(2/83),死亡原因:1例术后1周因心包填塞(尸检结果),1例为不明原因于术后第2天死亡,考虑为其他位置再次破裂所致;余81例术后恢复良好,无脑卒中发生。腔内手术发生Ⅰ型内漏14例(16.9%);81例出院时夹层内血栓形成69例,12例夹层中仍可见部分血流。保守治疗的10例,6例显示夹层内血栓形成,其余变化不大。84例随访2～121个月,平均36.5月,随访率91.3%(84/92),其中TEVAR随访75例,保守治疗随访8例,外科手术随访1例:1例腔内修复术后3个月胸降主动脉再次破裂死亡,2例Ⅰ型内漏存在,夹层不断扩大,再次放置带膜支架后消失,其余病例情况良好。结论急性B型主动脉夹层的治疗要积极,TEVAR为首选,可以取得比较好的疗效;慢性B型主动脉夹层应注意随访,必要时采用TEVAR治疗。     

Placement of a branched stent graft into the false lumen of a chronic type B aortic dissection

The treatment of chronic type B aortic dissections remains challenging and controversial. Currently most centers advocate open or endovascular intervention for patients with evidence of malperfusion, rupture or impending rupture, continued pain, or aneurysm formation. Regardless of the type of intervention, the incidence of complications or death remains high, even when undertaken in an elective setting. The standard endovascular treatment usually involves placement of a stent graft into the true lumen of the dissection in an effort to exclude the false lumen. This case report describes the placement of a branched stent graft into the false lumen of a patient with chronic type B dissection to encourage exclusion and thrombosis of the true lumen whilst maintaining flow to all visceral vessels.     

Endovascular surgery for failed open aortic aneurysm repair.

OBJECTIVE: Determine the usefulness of endovascular surgery for repair of aortic lesions late after open surgical repair. PATIENTS AND METHODS: A retrospective analysis of our databank (Patient Analysis and Tracking System, Dendrite, UK) for 2000-2002 showed 286 descending thoracic and/or abdominal aortic aneurysms: 60/286 (21%) descending thoracic, and 255/286 abdominal (89%). Endovascular surgery was planned in 98 patients (17/60 (28%) for thoracic lesions, and 81/255 (32%) for abdominal lesions). 13/98 patients (13%) underwent endovascular surgery late after failed open aortic repair: 4/13 at the level of distal aortic arch (3/4 for false aneurysms post-coarctation repair), 4/13 at the level of the descending thoracic aorta (3/4 for false aneurysms proximal to the previous graft), and 5/13 at the level of the infrarenal abdominal aorta (4/5 for false aneurysms proximal to the previous graft). Endovascular surgery included per procedural target site identification (previous graft) with intravascular ultrasound (IVUS) under fluoroscopic control (no angiographies), controlled hypotension (partial inflow occlusion with a right atrial balloon introduced through a femoral vein) for unloading of covered endoprostheses in the thoracic aorta, as well as in situ introducer sheath dilatation in case of complex access to the aorta. RESULTS: There were no hospital deaths and no parapareses or paraplegias in this small series of patients who underwent endovascular surgery for aneurismal lesions occurring late after open repair. An endoleak type I was documented in 2/13 patients (15%) requiring a proximal extension in 1 patient. For the second patient with a minor endoleak, a control examination is planned at 6 months of follow-up. CONCLUSION: Endovascular surgery is an elegant approach for repair of recurring aortic lesions late after open aortic surgery. IVUS is a precious instrument for per procedural identification of the previous implants. However, long-term follow-up is mandatory after endovascular surgery.     

Endograft repair of acute aortic dissection. Promises and challenges

Acute dissection is a uniquely complex, relatively common, and frequently lethal aortic catastrophe. Historically, surgical treatment has been reserved for cases with complications including rupture; the results have been less than optimal because of excessive morbidity and mortality. This is the main reason why conservative management emerged as the standard of care for management of acute type B aortic dissection (TBAD). While more patients would appear to survive with a conservative treatment strategy, the outcome in terms of 30-day mortality (20%) and occurrence of late complications - such as enlarging aneurysms of the thoracic false lumen (30-40%) - leaves (again) much to be desired. Stent-graft endovascular repair has emerged as a very promising, less invasive treatment option. These devices, when used appropriately, can achieve the important therapeutic goals of entry-site coverage, depressurization of the false lumen, and expansion of the compressed true lumen - overcoming ischemic (malperfusion) manifestations. The early results of stent-graft repair of TBAD are encouraging, and even exciting, but much more work needs to be done in various critical areas surrounding this condition. Thoracic endograft technology has lagged behind its abdominal counterpart. The design of acute dissection-specific devices is imperative, reflecting the significant differences between TBAD and degenerative thoracic aortic aneurysm disease. Needs for this and other important developments notwithstanding, it is generally acknowledged that stent-graft intervention does represent an important advance in the treatment of patients with TBAD. Well-designed, controlled clinical trials will be necessary to elucidate the relative value of several endovascular thoracic strategies.     

Preoperative thoracic false lumen branches are predictors of aortic enlargement after stent grafting for DeBakey IIIb aortic dissection

Objective

The study objective was to assess the effect of preoperative thoracic false lumen branches on thoracic aortic enlargement along the stent graft after thoracic endovascular aortic repair for DeBakey IIIb aortic dissection.

Serious complications following endovascular thoracic aortic stent-graft repair for type B dissection.

OBJECTIVE: To describe our experience with endovascular stent-graft repairs in type B aortic dissection focusing on serious secondary complications resulting in immediate or late conversion to open repair. METHODS: From November 1997 to May 2007, 28 patients underwent a thoracic endovascular stent-graft procedure for acute symptomatic type B dissection at our institution. Indication for endovascular repair at our department is a complicated course of type B dissection, including thoracic aortic rupture, suspicion of impending rupture, visceral and/or peripheral ischemia, uncontrollable hypertension, and severe therapy-resistant pain. Median follow-up time was 48.3 months (range 2-97 months). RESULTS: Secondary complications with indication for a secondary intervention occurred in 5/28 patients, resulting in additional procedures in 4 patients. One patient declined any further therapy. Conversion to an open procedure was performed in four patients, one due to type I endoleak followed by retrograde type A dissection, and three due to retrograde type A dissection. One of these patients had an additional stent-graft procedure performed due to a type III endoleak 20 months post stent grafting. Retrograde type A dissection occurred 39 months later, finally leading to conversion to an open procedure. Open surgery was performed in four patients after 3, 26, 29, and 1170 days post stent-graft placement and was successful in three patients. The fourth patient died 3 months post-surgically due to multi-organ failure. The procedure-related mortality rate following secondary complications was (1/5) 20%. CONCLUSIONS: Endovascular stent-graft repair of the thoracic aorta is an alternative to surgical repair, however not without significant morbidity and mortality. Potentially lethal complications, acute or delayed, may occur.     

Endovascular repair of a ruptured chronic type B aortic dissection

Aneurysm formation is a common sequel of chronic type B aortic dissection. Ruptured false lumen aneurysms have traditionally been treated with open repair. These procedures are associated with high morbidity and mortality rates. We report the first successful endovascular repair of a ruptured chronic type B aortic dissection in a patient who had been turned down for elective surgery. The endovascular management of chronic dissection with rupture is difficult and may necessitate stenting of both entry and reentry points to induce false channel thrombosis. The long-term efficacy of this technique is unknown.     

Utility of Intraoperative Transesophageal Echocardiography during Endovascular Stent-graft Repair of Acute Thoracic Aortic Dissection

This study was undertaken to evaluate the utility and efficacy of intraoperative transesophageal echocardiography (TEE) in the endovascular management of patients with acute type B aortic dissection. Twelve consecutive patients with acute type B aortic dissection underwent elective endoluminal stent-graft repair in the operating room under angiographic and TEE guidance. The follow-up protocol included spiral CT scanning before discharge from the hospital to assess thrombosis exclusion of the aortic false lumen, perfusion of branch vessels, and the absence of perigraft leak. No complications related to the use of TEE were encountered. TEE clearly demonstated the presence and extent of the dissection flap in all patients. After the procedure a persistent perigraft leak or residual flow into the false lumen was diagnosed by TEE in 6 patients, whereas intraoperative angiography visualized only 3 cases. Postoperative CT scan confirmed these findings. One patient died 2 months later by aortic rupture secondary to a persistent perigraft leak not treated (8.3% mortality). No postoperative paraplegia or visceral ischaemia were registered, although an asymptomatic occlusion of left subclavian artery was observed. TEE monitoring detects perigraft leakage, identifies the entry tear, and accurately demonstrates sealing of the false lumen. TEE is essential in our practice as an adjuvant to fluoroscopy to achieve optimal results during endovascular stent-graft repair of acute thoracic aortic dissection.     

Stanford B型主动脉夹层的腔内治疗

目的 探讨腔内胸主动脉修复术治疗Stanford B型夹层的临床价值.方法 回顾性分析2006年1月至2011年4月126例行腔内胸主动脉修复术的B型主动脉夹层患者的临床资料,其中男86例,女40例;年龄32～82岁,平均(56±8)岁.在数字减影血管造影(digital subtraction angiography,DSA)监控下,切开股动脉,将带膜支架置于胸主动脉内膜破口处,封堵破口.术后影像学随访观察有无内漏、移位和支架塌陷等术后并发症.结果 126例手术成功,释放支架157枚.所有患者原发胸主动脉夹层破口完全封闭,真腔血流恢复,受损脏器功能恢复正常.术后82例患者获得随访,随访率65％,随访时间3～63个月,平均随访时间(26±8)个月.复查显示无内漏、移位等并发症,围手术期死亡2例,随访死亡1例,12例出现支架尾部破口,再次行腔内隔绝,1例术后出现逆行性A型夹层.结论 腔内胸主动脉修复术是治疗Stanford B型夹层具有技术可靠,安全性高,术后恢复快等优点.     

降主动脉扩张病变腔内修复的初步探讨

目的探讨降主动脉扩张性疾病腔内修复术的有效性和安全性。方法 2009年5月～2011年12月,对20例降主动脉扩张性疾病行腔内修复手术。术前全部应用CTA确诊,其中Stanford B型夹层15例,假性动脉瘤4例,降主动脉减速伤1例。均在全麻下行股动脉切开作为覆膜支架置放入路。结果全组均一次支架释放成功,无手术死亡。修复后造影显示降主动脉夹层破口或假性动脉瘤均被即刻封闭,真腔均较术前扩大。2例主动脉腹腔分支段破口遗留假腔,假腔直径均<10 mm,未给予处理。14例术后6个月行CTA检查,无支架移位、破裂、断裂、内漏发生,第一破口所致假腔均无活动血流。结论腔内修复治疗降主动脉扩张性疾病安全,有效。     

Outcomes of emergency in situ laser fenestration-assisted thoracic endovascular aortic repair in patients with acute Stanford type A aortic dissection unfit for open surgery

ObjectiveThis study investigated the outcomes of emergency in situ laser fenestration (ISLF)-assisted thoracic endovascular aortic repair (TEVAR) for patients with acute Stanford type A aortic dissection unfit for open surgery.MethodsTwenty patients with acute Stanford type A aortic dissection who were found to be unfit for open surgery, underwent emergency ISLF-assisted TEVAR in our center between March 2016 and December 2018. Anatomic criteria for endovascular repair: coronary artery and aortic valve was not involved, proximal landing zone diameter of 45 mm or less, and proximal landing zone length of 20 mm or greater. Their clinical outcomes were reviewed retrospectively.ResultsTwenty patients achieved a procedural success of 100.0%. The 30-day mortality was 10%; two patients died, one of severe pneumonia and the other from cerebral hemorrhage after the operation. Rate of stroke at 30 days was 5%. The average follow-up time was 16 months (range, 3-26 months). One death owing to heart failure occurred at 23 months postoperatively. Kaplan-Meier curve analysis revealed that the 24-month survival rate was 77.1%. Two patients had type Ia endoleaks and one had a type II endoleak. There was no stent graft migration or fenestration-related endoleak and all patients had a thrombosed false lumen in the covered section of the stent grafts. No reintervention, myocardial infarction, transient ischemic attacks, cerebral infarction, or other complications occurred during the follow-up period.ConclusionsEmergency ISLF-assisted TEVAR is a safe and effective alternative method for treating acute Stanford type A aortic dissection unfit for open surgery.