胸降主动脉瘤伴主动脉右弓右降手术的护理配合

目的探讨临床少见的右位主动脉弓、右位降主动脉、胸降主动脉瘤外科手术中的护理配合,以提高手术配合质量,减少手术相关并发症的发生。方法针对8例行右弓、右降胸降主动脉瘤手术的病例进行术前准备、麻醉配合、体位管理和皮肤保护、术中配合、术后交接等护理配合。结果8例患者于术后4～7h清醒,无左上肢缺血、无皮肤压伤感染等护理问题。结论术前心理护理、麻醉配合、正确的体位摆放以及充分显露术野和娴熟的手术配合是确保手术顺利进行的关键因素之一。     

Penetrating Atherosclerotic Ulcerative Disease of the Aorta: Do Emergency Physicians Need to Worry?

Background

In recent years, different aortic pathologies have been grouped together and described in terms of a spectrum of disease referred to as Acute Aortic Syndrome (AAS). Overlapping of these conditions has traditionally introduced discrepancy to the understanding of the pathophysiology and definitive care. Penetrating atherosclerotic ulcer (PAU), an ulceration of an atherosclerotic plaque, has been increasingly recognized as the individual cause of the acute aortic pathology.

Objective

The natural evolution and complications of PAU are described, as well as the current diagnostic strategies, definitive management options, and initial care in the emergency department.

Discussion

The natural history of PAU is variable but is generally considered to be an AAS with a high incidence of complications. The clinical differentiation of symptomatic PAU from other causes of AAS is very challenging. Computed tomography imaging has provided additional accuracy with the use of the retrospective electrocardiographic gating technique. Despite traditional surgical therapies for aortic pathology, later studies have demonstrated the success of non-operative management, such as endoluminal grafting.

Conclusion

The relative rarity of this disease, the difficulties in its detection, and the lack of precise guidelines about its management may result in diagnostic delays. Asymptomatic patients with well-controlled blood pressure are safely managed as outpatients in close consultation with vascular surgery.     

Acute aortic syndromes: aortic dissections,penetrating aortic ulcers and intramural aortic hematomas

Acute aortic syndromes, including dissections, intramural hematomas and penetrating aortic ulcers, are a catastrophic clinical entity that are relatively uncommon. A high index of clinical suspicion along with proper imaging modalities are critical in making a prompt and accurate diagnosis for immediate management and to improve survival of the patient.     

Seasonal variation in the occurrence of nontraumatic rupture of thoracic aorta

Research has identified circadian and seasonal patterns for several acute cardiovascular diseases. In order to investigate the possible existence of a seasonal variation in the onset of acute nontraumatic ruptures of thoracic aorta, this study considered all patients referred to the emergency department of St Anna Hospital of Ferrara, Italy, from January 1985 to December 1996. In the considered period, 85 patients (52 males, 33 females) of nontraumatic ruptures of thoracic aorta were observed. Cosinor analysis and partial Fourier series with up to 4 harmonics were applied to monthly data, and the best-fitting curves for circannual rhythmicity were calculated. A higher winter occurrence with a significant peak in January was found for the total population and the male subgroup. Although the underlying factors are not fully known, such patterns strictly resemble that of arterial blood pressure. Emergency doctors can put to practical use the recognition of a clearly identified chronorisk for aortic rupture, increasing alertness, and providing the most effective antihypertensive protection at the specific vulnerable periods.     

胸主动脉瘤破裂入左肺1例报告及文献分析

目的 对胸主动脉瘤破裂入左肺进行回顾性分析，旨在提高对胸主动脉瘤破裂入左肺的早期诊断和治疗的有效性。方法 结合1例报告，总结自1990年1月至2005年3月文献报道的胸主动脉瘤破裂入左肺16例病例。根据其有无感染、首发症状、胸主动脉瘤部位、侵入肺叶、手术方法及治疗效果进行分析。结果 胸主动脉瘤侵入左肺叶多数病程长，多合并肺部细菌和／或特异性感染，咯血是最常见的首发症状；来源于主动脉弓的瘤多侵入左肺上叶。手术多以全弓或次全弓切除及人工血管置换和左肺上叶切除术为主，而降主动脉瘤多侵入左肺下叶，手术以主动脉瘤切除及主动脉修补或血管置换术和左肺下叶切除为主；若无不可控制的大出血，预后较好。结论 胸主动脉瘤切除及人工血管置换术加侵入相应肺叶的切除术是治疗胸主动脉瘤侵入左肺的有效方法。     

A surgical treatment for frank rupture of acute type a small intramural hematoma

A 71‐year‐old woman was admitted to the hospital due to cardiac tamponade. Computed tomography revealed that the diameter and wall thickness of the ascending aorta were 36 and 9 mm, respectively. An emergent ascending aortic replacement was performed uneventfully. The pathological findings indicated frank rupture of intramural hematoma.     

二维斑点追踪成像评价胸主动脉腔内修复术后升主动脉纵向应变

目的 观察胸主动脉腔内修复术(TEVAR)后升主动脉纵向应变(LS)变化。方法 回顾性分析82例以TEVAR作为一线治疗的胸主动脉疾病患者,根据术前升主动脉收缩末期内径(AoS)≥35 mm或<35 mm分为A组(n=37)及B组(n=45),以20名健康人作为对照组。比较组间基本资料差异,测量A、B组术前、术后及对照组AoS和舒张末期内径(AoD),计算升主动脉应变(Aortic Strain)及动脉硬化指数β。以二维斑点追踪成像(2D-STE)获取升主动脉前、后壁LS(LS-AW/PW),将其均值记为平均LS(LS_mean)。采用偏相关分析评价各指标间相关性。结果 A组收缩压(SBP)、脉压(PP)均高于对照组(P均<0.05);B组PP高于对照组(P<0.05);A组PP及吸烟史比例均高于B组(P均<0.05)。3组间AoD、AoS、Aortic Strain及β差异均有统计学意义(P均<0.05)。A组及B组LS-AW、LS_mean均较对照组降低(P均<0.05);A组LS-PW较对照组降低(P&l...     

心脏瓣膜病胸主动脉CT重建特征及其临床意义

目的  观察心脏瓣膜病胸主动脉CT重建特征及其临床意义。 方法  选取2018年10月~2021年12月北碚区中医医院放射科收治的300例患者作为研究对象,将95例心脏瓣膜病患者纳入病例组,205例非心脏瓣膜病变的普通患者纳入对照组,均行CT增强扫描和三维重建,比较两组的临床一般资料和CT测量值(包括胸主动脉长度、主动脉峡部直径和膈肌层面主动脉直径),采用Logistic分析患者胸主动脉长度的影响因素。 结果  病例组患者的胸主动脉长度、主动脉峡部直径和膈肌层面主动脉直径均高于对照组,差异有统计学意义(P < 0.05),心脏瓣膜病变患者主要CT特征为主动脉扩张,瓣膜增厚; 不同年龄、性别、高血压和主动脉壁斑块、心脏瓣膜病的患者胸主动脉长度比较,差异有统计学意义(P < 0.05);年龄(OR=2.121)、主动脉壁斑块(OR=2.234)、心脏瓣膜病(OR=1.964)是影响患者胸主动脉长度的因素,差异有统计学意义(P < 0.05)。 结论  心脏瓣膜病患者胸主动脉增长、主动脉峡部及膈肌层面增长增宽,同时胸主动脉长度受年龄、主动脉壁斑块和心脏瓣膜病的影响,了解其形态特征,对于主动脉手术治疗具有一定的指导意义。     

原发性肝癌多层螺旋CT灌注成像临床研究

目的:探讨原发性肝癌多层螺旋CT灌注成像的价值。方法:采用PHILIPS16层螺旋CT对23例原发性肝癌及13例无肝脏疾病患者进行肝脏灌注扫描,并用其ExtendedBrillianceTM工作站灌注软件分别测量肝动脉灌注量、肝门静脉灌注量、总肝灌注量及肝动脉灌注指数等,以评价原发性肝癌的血流动力学改变及其规律性。结果:原发性肝癌组肝动脉灌注量、肝门静脉灌注量、总肝灌注量和肝动脉灌注指数分别为0·45±0·26ml·min-1·ml-1、0·31±0·22ml·min-1·ml-1、0·76±0·34ml·min-1·ml-1和0·61±0·21;对照组分别为0·19±0·06ml·min-1·ml-1、0·66±0·20ml·min-1·ml-1、0·86±0·20ml·min-1·ml-1和0·23±0·08。与对照组比较,原发性肝癌的组肝动脉灌注量和肝动脉灌注指数显著增高,肝门静脉灌注量显著降低,总肝灌注量稍降低,但差异无统计学意义。结论:原发性肝癌与正常肝脏CT血流灌注参数肝动脉灌注量、肝门静脉灌注量和肝动脉灌注指数存在显著差异;CT灌注成像可用于评价原发性肝癌血流灌注情况。     

Review article: Accuracy of emergency physician performed point-of-care ultrasound of the thoracic aorta: A systematic review and narrative synthesis of the literature

Point-of-care ultrasound (POCUS) is becoming ubiquitous in emergency medicine. POCUS for abdominal aortic aneurysm is well established in practice. The thoracic aorta can also be assessed by POCUS for dissection and aneurysm and transthoracic echocardiography is endorsed by international guidelines as an initial test for thoracic aortic pathologies. A systematic search of Ovid Medline, PubMed, EMBASE, SCOPUS and Web of Science from January 2000 to August 2022 identified four studies evaluating diagnostic accuracy of emergency physician POCUS for thoracic aortic dissection (TAD) and five studies for thoracic aortic aneurysm (TAA). Study designs were heterogeneous including differing diagnostic criteria for aortic pathology. Convenience recruitment was frequent in prospective studies. Sensitivity and specificity ranges for studies of TAD were 41–91% and 94–100%, respectively when an intimal flap was seen. Sensitivity and specificity ranges for studies of thoracic aorta dilation >40 mm were 50–100% and 93–100%, respectively; for >45 mm ranges were 64–65% and 95–99%. Literature review identified that POCUS is specific for TAD and TAA. POCUS reduces the time to diagnosis of thoracic aortic pathology; however, it remains insensitive and cannot be recommended as a stand-alone rule-out test. We suggest that detection of thoracic aorta dilation >40 mm by POCUS at any site increases the suspicion of serious aortic pathology. Studies incorporating algorithmic use of POCUS, Aortic Dissection Detection Risk Score and D-dimer as decision tools are promising and may improve current ED practices. Further research is warranted in this rapidly evolving field.     

胸主动脉瘤样扩张的超声特征及病因分析

目的：通过马凡综合征及动脉硬化性动脉瘤患者超声资料的详细分析，为临床鉴别诊断及手术机选择提供有价值的依据。方法：应用超声心动图对68例马凡综合征、105例动脉硬化性动脉瘤患者的心脏结构，功能进行评价。特别注意测量主动脉瓣环，主动脉窦部，升主动脉，主动脉弓部及胸降主动脉。结果：（1）马凡综合征胸主动脉扩张部位，扩张程度与动脉硬化动脉瘤不同。（2）马凡综合征患者主动脉关闭不全及左心功能不全程度较动脉硬化性动脉瘤患者为重。（3）马凡综合征患者易发生DebakeyⅠ、Ⅱ型夹层动脉瘤，动脉硬化患者易发生Debakey Ⅰ、Ⅲ型，特别是Ⅲ型夹层动脉瘤。（4）发生夹层动脉瘤时，动脉硬化组胸主动脉最大扩张程度较马凡综合征组为轻。结论：超声心动图能鉴别马凡综合征与动脉硬化性动脉瘤，为患者手术时机选择提供有价值的依据。     

胸主动脉瘤的外科治疗

目的:总结7例胸主动脉瘤病人的外科治疗经验.方法:7例病人中胸降主动脉瘤2例,主动脉根部瘤(马凡综合征)2例,夹层动脉瘤3例,均为Ⅱ型夹层动脉瘤,其中1例合并冠心痛,前降支单支病变.胸降主动脉瘤在低温体外循环下行人工血管置换术.升主动脉瘤和Ⅱ型夹层动脉瘤在低温体外循环下行Bentall手术,其中1例采用带管道无支架生物瓣,同时行冠脉搭桥手术.结果:6例存活,1例死于低心排综合征.结论:在胸主动脉瘤的外科治疗中,Bentall手术是治疗升主动脉瘤较好的手术方法.外科手术技术是手术成功的重要因素.体外循环管理,良好的心肌保护和血液保护是保证手术成功的重要手段.带管道无支架生物瓣对老年人及抗凝有禁忌或主动脉根部较小者更适宜,对合并冠心病的患者宜同期行冠脉搭桥术.     

Current challenges in endovascular therapy for thoracic aneurysms

Surgical treatment of thoracic aortic aneurysms can be associated with high mortality and complication rates, resulting in prolonged hospital stay. Endovascular techniques for treating thoracic aortic disease have been rapidly embraced, showing limited mortality and major adverse events. Its wide availability and relative ease of application has changed and extended management options for thoracic aortic disease, including inpatients deemed unsuitable for open surgery. Rapid technical evolution has allowed it to be applied to even hostile anatomy and complex cases. However, as it is still a young technology, many unknowns remain, including long-term outcomes with respect to conservative treatment and open surgical repair.     

Cocaine-associated dissection of the thoracic aorta

Patients present to emergency departments with a variety of complications related to cocaine abuse. Emergency physicians must be aware of the life- and limb-threatening complications to avoid undue mortality and morbidity. We present the case of a patient with aortic dissection who developed the acute onset of abdominal pain 5 minutes after subcutaneous cocaine use. Four previous reports of cocaine-associated aortic dissection are reported in the literature. These cases and other reports of intra-abdominal vascular injuries related to cocaine use are reviewed. Cocaine's mechanism of action as it relates to aortic dissection and some of the pharmacologic agents available for treatment are discussed.     

腔内修复术中一期覆盖左锁骨下动脉的术后护理

目的探讨胸主动脉瘤及夹层腔内修复术中左锁骨下动脉一期覆盖后的护理要点。方法对40例因近端锚定区过短,腔内修复术中一期完全覆盖左锁骨下动脉患者的术后护理进行总结与分析。结果40例患者一期完全覆盖左锁骨下动脉后,早期窃血综合征发生率为20%(8/40),左肱动脉平均收缩压(62.6±24.2)mmHg,住院期间未出现严重脑及上肢缺血并发症。结论腔内修复术中,一期覆盖左锁骨下动脉是可行的;术后对于上肢血压的监测、上肢血运状况以及窃血综合征的观察是护理的关键。     

腔内修复术中一期覆盖左锁骨下动脉的术后护理

目的探讨胸主动脉瘤及夹层腔内修复术中左锁骨下动脉一期覆盖后的护理要点。方法对40例因近端锚定区过短，腔内修复术中一期完全覆盖左锁骨下动脉患者的术后护理进行总结与分析。结果40例患者一期完全覆盖左锁骨下动脉后，早期窃血综合征发生率为20％（8／40），左肱动脉平均收缩压（62．6±24．2）mmHg，住院期间未出现严重脑及上肢缺血并发症。结论腔内修复术中，一期覆盖左锁骨下动脉是可行的；术后对于上肢血压的监测、上肢血运状况以及窃血综合征的观察是护理的关键。     

Revolution CT行冠状动脉联合胸腹主动脉成像

Objective: To investigate the value of Revolution CT for CT angiography (CTA) of coronary artery combined with thoracoabdominal aorta. Methods: Totally 120 patients with suspected coronary artery and/or aortic diseases underwent CTA of coronary artery combined with thoracic and abdominal aorta (group A), coronary artery alone (group B) as well as thoracic and abdominal aorta (group C) using Revolution CT, respectively(each n=40). The effective radiation dose (ED) was recorded, and CT value, signal noise ratio (SNR) and contrast noise ratio (CNR) were compared between group A and group B, also between group A and group C. Results: There was no statistical difference of CT value of target branches of coronary artery between group A and group B (all P>0.05), nor of SNR and CNR of other branches (all P>0.05), while significant differences of SNR and CNR were found of left circumflex artery (t=2.84, 2.61, both P<0.05). There were significant differences of CT value of common iliac artery bifurcation between group A and group C (t=3.63, P<0.05), also of SNR and CNR of aorta at diaphragm level between group A and group C (t=-2.92, -2.76, both P<0.05), but no of CT value, SNR nor CNR of other vascular branches (all P>0.05). There was no significant difference of ED between group A and group B during coronary artery CTA ([3.00±0.39] mSv vs [3.03±0.42 ]mSv, t=-0.91, P>0.05), while ED of patients in group A ([4.60±1.09] mSv) was lower than that in group C ([10.88±1.15] mSv) during CTA of thoracic and abdominal aorta (t=-17.79, P<0.05). Conclusion: CTA of coronary artery combined with thoracoabdominal aorta using Revolution CT might obtain satisfactory imaging quality and significantly reduce ED. Copyright © 2021 by the Press of Chinese Journal of Medical Imaging and Technology.     

Unexpected thrombus migration obstructing the right coronary ostium after thoracic aorta graft replacement

Unexpected and reversible causes of ventricular dysfunction requiring a prompt second surgical procedure to restore the cardiac function should always be sought before the initiation of positive inotropic support. We report a case of obstruction of the right coronary ostium by an organized thrombus that had migrated retrogradely from the false lumen of a dissected aortic aneurysm. The resultant ventricular dysfunction hindered separation from cardiopulmonary bypass. Prompt recognition was done by transesophageal echocardiography and a second surgical procedure was immediately performed to remove the thrombus before irreversible ventricular dysfunction occurred. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound 42 :318–320, 2014     

A fatal masquerade in pneumonia: Ruptured thoracic aortic aneurysm

We described an 87‐year‐old man who presented with fever and hemoptysis. Nosocomial pneumonia was initially suspected. However, the patient had worsening hemoptysis despite defervescence. Chest computed tomography disclosed ruptured thoracic aortic aneurysm. Emergent surgery was then commenced for adequate treatment.