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.     

Stanford B型主动脉夹层远端破口处理原则的对比研究

目的 探讨Stanford B型主动脉夹层远端破口的处理原则.方法 按照不同的处理原则将Stanford B型主动脉夹层合并远端破口的患者分为两组：原则处理组：采取由近至远的原则,腔内修复远端破口,如不处理内脏动脉处破口,则也不处理其远侧破口;非原则处理组：不处理累及内脏动脉的破口,其余远端破口行腔内修复.分别对其术后不适主诉（胸背部、腰背部疼痛）发生情况、术后支架远端再破口发生情况及假腔变化情况进行分析.结果 共纳入符合标准的患者53例,其中原则处理组37例,非原则处理组16例,两组术后不适主诉发生情况及术后支架远端再破口发生情况差异无明显统计学意义（P＞0.05）,两组术后假腔变化情况差异有统计学意义（P＜0.05）.结论 原则处理组的患者预后优于非原则处理组,对于Stanford B型主动脉夹层远端多破口应按照由近至远的顺序行腔内修复,如不处理内脏动脉处破口,则也应不处理其远侧破口.     

Gore C-TAG分段释放联合潜望镜技术处理B型主动脉夹层远端破口

目的 探讨胸主动脉覆膜支架分段释放技术联合"潜望镜"技术在Stanford B型主动脉夹层腔内修复术后远端破口处理中的临床应用价值.方法 回顾性分析2019～2020年5例Stanford B型主动脉夹层腔内修复术后胸主动脉远端假腔扩张患者的临床资料.结果 5例患者均为男性.主动脉CTA影像资料显示内脏区主动脉存在夹层...     

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.     

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。     

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.     

Stanford B型主动脉夹层远端破口的腔内治疗策略

目前,胸主动脉腔内修复术是复杂型Stanford B型主动脉夹层的首选治疗方法。但该手术并未封闭夹层远端破口,假腔血流可持续存在,导致主动脉无法重塑甚至发生夹层进展。尤其是慢性Stanford B型主动脉夹层患者,内膜瓣已发生增厚和纤维化,主动脉重塑更加困难。研究结果显示,远端破口的存在可增加患者发生远期主动脉事件的可...     

体外开窗EVAR技术治疗远端主动脉夹层动脉瘤3例病例报告

自1999年Dake等首次报道应用腔内修复术（thoracic endovascular aortic repair,TEVAR）封堵主动脉夹层的近端破口治疗B型主动脉夹层（type B aortic dissection,TBAD）以来,大部分病例真腔血供改善、假腔逐渐血栓化、远端主动脉重新塑形,但是仍有部分病例支架远端主动脉假腔持续增大形成夹层动脉瘤,影响真腔供血甚至破裂。     

胸主动脉腔内修复术后腹段假腔重塑影响因素分析

目的:探讨胸主动脉腔内修复术（TEVAR）后中远期腹段假腔重塑的影响因素。方法:回顾性分析2009年11月至2019年11月在解放军总医院第一医学中心血管外科确诊为Stanford B型主动脉夹层（B型夹层）并接受TEVAR治疗的患者资料。纳入术后腹主动脉段有残余裂口而胸段无裂口、随访1年以上的急性或亚急性长段夹层病例...     

主动脉夹层TEVAR术后远端破口的临床分型及手术时机的选择

目的 探讨主动脉夹层TEVAR术后远端破口的治疗方法.方法 对新疆维吾尔自治区人民医院血管外科2006年1月-2012年4月168例行TEVAR的Stamford B型主动脉夹层患者的病例资料进行同顾性分析,根据远端破口位置的不同将其分为4型:Ⅰ型:破口位于支架尾部;Ⅱ型:破口位于胸腹主动脉,距离内脏动脉较近或累及内脏动脉;Ⅲ型:破口位于肾下腹主动脉,破口未累及内脏动脉;Ⅳ型:破口位于髂动脉.据此分型标准,对主动脉夹层TEVAR术后发生远端破口的82例患者制定相应的治疗策略并决定手术时机.结果 有82例患者支架远端仍有破口,临床分型为Ⅰ型:12例出现支架尾部破口,均行支架远端破口腔内隔绝术;Ⅱ型:47例破口位于腹主动脉并累计内脏动脉,经随访,其中4例在随访中发现假腔持续扩大或伴有症状,行“杂交”手术,即先行内脏动脉重建(髂动脉-双肾动脉,髂动脉-肠系膜上动脉,髂动脉-腹腔干人工血管搭桥术),二期行胸腹主动脉腔内隔绝术.43例患者随访发现假腔无扩大,目前继续随访.Ⅲ型:13例破口位于肾下腹主动脉,均行腔内隔绝术.Ⅳ型:10例破口位于髂动脉,均行腔内隔绝术.术后围手术期无死亡.82例患者获得随访,随访时间10 ～36个月,平均随访时间(25.6±8.4)个月,在随访过程中未发现并发症.结论 对于TEVAR术后远端破口,应根据个体情况,结合临床分型选择适宜的手术时机和手术方式,从而达到满意的治疗效果.     

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.     

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.

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??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.     

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.     

主动脉夹层动脉瘤腔内隔绝术中真腔进入困难的处理

目的探讨腔内隔绝术治疗Stanford B型胸主动脉夹层动脉瘤术中真腔进入困难的处理方法。方法对1998年9月至2004年2月间施行的Stanford B型胸主动脉夹层动脉瘤进行回顾性研究。手术均在DSA监视下完成。其中28例出现导丝进入真腔困难,4例出现导丝误入假腔再入真腔。术中使用的进入真腔的方法有：导管沿途造影法,夹层裂口多角度造影法,左肱动脉穿刺近端漂流法,真腔导入动脉选择法,导丝上下贯通法。结果导管沿途造影法应用于32例患者,夹层裂口多角度造影法应用于12例患者,左肱动脉穿刺近端漂流法应用于10例患者,真腔导入动脉选择法应用于28例患者,导丝上下贯通法应用于2例患者。32例患者均成功导入真腔,支架型人造血管成功隔绝夹层裂口。结论导丝进入真腔困难及误入假腔,会导致手术失败及支架型人造血管误放假腔的灾难性后果。利用多种血管腔内技术可以解决这一问题。     

Stanford B型主动脉夹层腔内修复术后再干预的危险因素研究

目的 探究Stanford B型主动脉夹层TEVAR术后再干预情况及相关危险因素.方法 回顾性分析2014年1月至2018年1月新疆医科大学第二附属医院初次行TEVAR的Stanford B型主动脉夹层患者93例,对再干预组和无需再干预的对照组进行比较,分析影响患者TEVAR术后再干预的危险因素.结果 22例患者(23...     

Risk factors for distal stent graft-induced new entry tear after endovascular repair of thoracic aortic dissection

ObjectiveA review of the literature was conducted for incidence, outcomes, and risk factors for distal stent graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) of aortic dissection.MethodsThe review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsSeven articles reporting on 1415 patients with thoracic aortic dissection undergoing TEVAR without supplemental distal bare stenting were included. In this cohort, 86 patients were treated for a residual type A aortic dissection and 1329 for a complicated type B aortic dissection. Distal SINE occurred in 112 patients (7.9%). The mean time to identification of distal SINE was 19 ± 7 months. The incidence of distal SINE after TEVAR for type B aortic dissection differed on the basis of whether it was a chronic or acute dissection repair and was, respectively, 12.9% (43/331) and 4.3% (12/273). Successful secondary interventions were performed in 54% of the patients. All the studies analyzing the relationship between distal stent graft oversizing and incidence of distal SINE reported a significantly higher rate of SINE with oversizing.ConclusionsThe successful management of complicated descending thoracic aortic dissections by TEVAR is well established. Whereas distal SINE is relatively frequent, if it does occur, the complication can generally be treated with additional TEVAR without a poor outcome. The main determinant of SINE seems to be excessive distal oversizing.     

覆膜支架主动脉腔内修复术在Stanford B型主动脉夹层中的应用

目的观察覆膜支架主动脉腔内修复术（TEVAR）对Stanford B型主动脉夹层和降主动脉瘤的治疗效果。方法回顾性分析华西医院2013年3～6月采用TEVAR治疗Stanford B型主动脉夹层和降主动脉瘤患者20例的临床资料,其中男19例,女1例;年龄41～76（58．3±10．2）岁,分析其疗效。结果20例患者中,治愈18例,自动出院1例,术后死亡1例。随访满3个月者16例,随访率88．9％。全部随访患者支架范同内真腔管径有所恢复,假腔或瘤腔内血栓形成。结论TEVAR为Stanford B型主动脉瘤提供了一个新的选择,特别是为高龄和合并严重疾病的患者提供了新的治疗手段,优势明显,值得临床应用。