胸主动脉夹层的外科治疗

目的总结胸主动脉夹层(AD)的外科治疗经验。方法1993年至2003年4月手术治疗A型AD40例，B型20例，其中急性夹层16例。A型采用中度低温体外循环13例，深低温停循环(DHCA)和上腔静脉逆灌(RCP)27例；行升主动脉置换24例，升主动脉和半弓置换11例，升主动脉、全弓和象鼻手术5例；同期行Bentall手术18例，主动脉瓣置换8例，冠状动脉旁路移植术1例。B型采用左心转流7例，股一股转流2例，DHCA 11例；行近端降主动脉置换14例，全胸降主动脉置换或伴肋间动脉移植6例。结果全组术后死亡率10％(急性夹层18．8％，慢性夹层6．8％)，近3年降至4．4％。术后并发呼吸功能不全8例，二次开胸止血3例，延迟性心包压塞和腹腔内出血各2例，声音嘶哑3例。结论正确掌握手术指征、手术技巧和术中脑保护是手术治疗AD的关键。A型夹层的手术范围应依据内膜破裂口位置决定。     

“烟囱”技术在胸主动脉夹层动脉瘤腔内治疗中的应用

目的 探讨“烟囱”技术在胸主动脉夹层动脉瘤的腔内治疗中的适应证、技术要点及并发症的预防.方法 回顾性分析2010年～2012年我科采用“烟囱”技术治疗4例胸主动脉夹层动脉瘤患者的临床资料,其中破口累及左锁骨下动脉3例,累及左颈总动脉1例.结果 4例患者支架均释放准确,“烟囱”支架通畅.1例患者释放支架后即刻造影提示少量Ⅰ型内漏,术后CT血管造影复查未见明确内漏;1例术后第2天出现精神差、嗜睡,左侧肢体肌力较对侧减退,给予抗凝活血药物治疗1周后左侧肢体肌力恢复.随访6～12个月,均未出现支架闭塞或严重狭窄.结论 “烟囱”技术通过完全腔内方法重修分支血管,实现了微创腔内治疗.     

Implications of secondary aortic intervention after thoracic endovascular aortic repair for acute and chronic type B dissection

BackgroundThoracic endovascular aortic repair (TEVAR) has become a mainstay of therapy for acute and chronic type B aortic dissection (TBAD). Dynamic aortic morphologic changes, untreated dissected aorta, and persistent false lumen perfusion have significant consequences for reintervention after TEVAR for TBAD. However, few reports contrast differences in secondary aortic intervention (SAI) after TEVAR for TBAD or describe their influence on mortality. This analysis examined incidence, timing, and types of SAI after TEVAR for acute and chronic TBAD and determined their impact on survival.MethodsAll TEVAR procedures for acute and chronic TBAD (2005-2016) were retrospectively reviewed. Patients with staged (<30 days) or concomitant ascending aortic arch repair or replacement were excluded. Acuity was defined by symptom onset (0-30 days, acute; >30 days, chronic). SAI procedures were grouped into open (intended treatment zone or remote aortic site), major endovascular (TEVAR extension or endograft implanted at noncontiguous site), and minor endovascular (side branch or false lumen embolization) categories. Kaplan-Meier methodology was used to estimate freedom from SAI and survival. Cox proportional hazards were used to identify SAI predictors.ResultsTEVAR for TBAD was performed in 258 patients (acute, 49% [n = 128]; chronic, 51% [n = 130]). Mean follow-up was 17 ± 22 months with an overall SAI rate of 27% (n = 70; acute, 22% [28]; chronic, 32% [42]; odds ratio, 1.7; 95% confidence interval, 0.9-2.9; P = .07]. Median time to SAI was significantly less after acute than after chronic dissection (0.7 [0-12] vs 7 [0-91] months; P < .001); however, freedom from SAI was not different (1-year: acute, 67% ± 4%, vs chronic, 68% ± 5%; 3-year: acute, 65% ± 7%, vs chronic, 52% ± 8%; P = .7). Types of SAI were similar (acute vs chronic: open, 61% vs 55% [P = .6]; major endovascular, 36% vs 38% [P = .8]; minor endovascular, 21% vs 21% [P = 1]). The open conversion rate (either partial or total endograft explantation: acute, 10% [13/128]; chronic, 15% [20/130]; P = .2) and incidence of retrograde dissection (acute, 6% [7/128]; chronic, 4% [5/130]; P = .5) were similar. There was no difference in survival for SAI patients (5-year: acute + SAI, 55% ± 9%, vs acute without SAI, 67% ± 8% [P = .3]; 5-year: chronic + SAI, 72% ± 6%, vs chronic without SAI, 72% ± 7% [P = .7]). Factors associated with SAI included younger age, acute dissection with larger maximal aortic diameter at presentation, Marfan syndrome, and use of arch vessel adjunctive procedures with the index TEVAR. Indication for the index TEVAR (aneurysm, malperfusion, rupture, and pain or hypertension) or remote preoperative history of proximal arch procedure was not predictive of SAI.ConclusionsSAI after TEVAR for TBAD is common. Acute TBAD has a higher proportion of early SAI; however, chronic TBAD appears to have ongoing risk of remediation after the first postoperative year. SAI types are similar between groups, and the occurrence of aorta-related reintervention does not affect survival. Patients' features and anatomy predict need for SAI. These data should be taken into consideration for selection of patients, device design, and surveillance strategies after TEVAR for TBAD.     

Molecular mechanisms of thoracic aortic dissection

Thoracic aortic dissection (TAD) is a highly lethal vascular disease. In many patients with TAD, the aorta progressively dilates and ultimately ruptures. Dissection formation, progression, and rupture cannot be reliably prevented pharmacologically because the molecular mechanisms of aortic wall degeneration are poorly understood. The key histopathologic feature of TAD is medial degeneration, a process characterized by smooth muscle cell depletion and extracellular matrix degradation. These structural changes have a profound impact on the functional properties of the aortic wall and can result from excessive protease-mediated destruction of the extracellular matrix, altered signaling pathways, and altered gene expression. Review of the literature reveals differences in the processes that lead to ascending versus descending and sporadic versus hereditary TAD. These differences add to the complexity of this disease. Although tremendous progress has been made in diagnosing and treating TAD, a better understanding of the molecular, cellular, and genetic mechanisms that cause this disease is necessary to developing more effective preventative and therapeutic treatment strategies.     

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...     

Early aortic growth in acute descending aortic dissection

Open in a separate window OBJECTIVESAcute aortic dissection leads to the destabilization of the aortic wall, followed by an immediate increase in aortic diameter. It remains unclear how the aortic diameter changes during the dissection’s acute and subacute phases. The aim of this study was to evaluate the change in aortic geometry within 30 days after the onset of a descending aortic dissection.METHODSPatients with acute type B and non-A non-B dissection who had at least 2 computed tomography angiography scans obtained within 30 days after the onset of dissection were evaluated. Exclusion criteria were a thrombosed false lumen, connective tissue disorders and endovascular or open aortic repair performed prior to the second computed tomography angiography.RESULTSAmong 190 patients with acute aortic dissection, 42 patients met our inclusion criteria. Their aortic geometry was analysed according to the computed tomography angiography scans obtained between 0–3 (N = 35), 4–7 (N = 9) and 8–30 (N = 12) days after the dissection onset. The highest aortic diameter growth rate was observed in the first quartile of the thoracic aorta and measured 0.66 (0.06; 1.03), 0.29 (−0.01; 0.41) and 0.06 (−0.13; 0.26) mm/day at 0–3, 4–7 and 8–30 days after the dissection, respectively. Proximal entry location (P = 0.037) and entry located at the arch concavity (P = 0.008) were associated with a higher aortic diameter increase.CONCLUSIONSEarly rapid growth occurs during the first week after the descending aortic dissection—most intensely over the first 3 days, and this is associated with the location of the dissection’s entry.     

Sex and gender in thoracic aortic aneurysms and dissection

Disease of the aorta affects more than 40,000 Americans annually, with a portion of these presentations involving the thoracic aorta. Studies have revealed gender differences in the presentation, management, and outcome of patients with aortic disease. However, most of this work focuses on the abdominal aorta; the data are then extrapolated to the thorax. It is currently established that women with abdominal aortic disease have worse outcomes, are less likely to undergo surgical treatment, and have higher morbidity and mortality. Similar results are seen in the management of women with thoracic aortic dissection. Herein we review the issue of sex and gender differences in thoracic aortic disease.     

Long-term outcomes after ascending aortic replacement and aortic root replacement for type A aortic dissection

 Open in a separate windowOBJECTIVESWe investigated whether the selective use of supracoronary ascending aorta replacement achieves late outcomes comparable to those of aortic root replacement for acute Stanford type A aortic dissection (TAAD).METHODSPatients who underwent surgery for acute type A aortic dissection from 2005 to 2018 at the Helsinki University Hospital, Finland, were included in this analysis. Late mortality was evaluated with the Kaplan–Meier method and proximal aortic reoperation, i.e. operation on the aortic root or aortic valve, with the competing risk method.RESULTSOut of 309 patients, 216 underwent supracoronary ascending aortic replacement and 93 had aortic root replacement. At 10 years, mortality was 33.8% after aortic root replacement and 35.2% after ascending aortic replacement (P = 0.806, adjusted hazard ratio 1.25, 95% confidence interval, 0.77–2.02), and the cumulative incidence of proximal aortic reoperation was 6.0% in the aortic root replacement group and 6.2% in the ascending aortic replacement group (P = 0.65; adjusted subdistributional hazard ratio 0.53, 95% confidence interval 0.15–1.89). Among 71 propensity score matched pairs, 10-year survival was 34.4% after aortic root replacement and 36.2% after ascending aortic replacement surgery (P = 0.70). Cumulative incidence of proximal aortic reoperation was 7.0% after aortic root replacement and 13.0% after ascending aortic replacement surgery (P = 0.22). Among 102 patients with complete imaging data [mean follow-up, 4.7 (3.2) years], the estimated growth rate of the aortic root diameter was 0.22 mm/year, that of its area 7.19 mm²/year and that of its perimeter 0.43 mm/year.CONCLUSIONSWhen stringent selection criteria were used to determine the extent of proximal aortic reconstruction, aortic root replacement and ascending aortic replacement for type A aortic dissection achieved comparable clinical outcomes.     

胸主动脉瘤及主动脉夹层外科治疗进展

胸主动脉瘤及主动脉夹层病情凶险，死亡率和病残率均很高。近几年在保留和不保留主动脉瓣的主动脉根重建术治疗升主动脉瘤，弓部主动脉瘤切除与脑保护，胸主动脉瘤或胸腹主动脉瘤切除与脊髓保护，以及主动脉腔内支架移植术等方面取得了较大的进展。手术死亡率已从31．4％下降至3．3％－4．8％。胸主动脉瘤，特别是主动脉夹层系一全身性主动脉病变，近年来手术疗效有所改善，但远期复发率和再手术率仍较高。主动脉内支架移植与外科手术结合应用，对复杂的伴有降主动脉病变的A型主动脉夹层治疗，可能是一种安全而有效的方法。     

Thirty-day outcomes from the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair for type B dissection project

Objective

The purpose of the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair (TEVAR) for dissection project is to assess the effectiveness of TEVAR for type B dissection by evaluation in a prospective quality improvement registry. Here we describe the project cohort and 30-day outcomes of TEVAR for both acute dissection (AD) and chronic dissection (CD) patients and focus specifically on outcomes of uncomplicated AD patients based on timing of treatment.

Matrix metalloproteinase levels in chronic thoracic aortic dissection

Background

Imbalance between matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs (TIMPs) can lead to aortic wall failure. We hypothesized that patients with aneurysms resulting from chronic descending thoracic aortic dissection have elevated tissue and plasma levels of specific MMPs and decreased tissue levels of TIMPs.

Materials and methods

Aortic tissue was obtained from 25 patients who required surgical repair of descending thoracic aortic aneurysm due to chronic aortic dissection and from 17 organ-donor controls without aortic disease. Tissue levels of MMP-1, -2, -3, -9, -12, and -13 and TIMP-1 and -2 were measured by colorimetric activity assay or enzyme-linked immunosorbent assay and confirmed by Western blot and immunohistochemistry. Blood obtained from the 25 patients and 15 controls without aortic diseases was used to compare plasma levels of MMP-3, -9, and -12.

Results

Total MMP-1, total MMP-9, and active MMP-9 levels were higher and total MMP-2 levels were lower in dissection tissue than in control tissue. Additionally, the MMP-9 to TIMP-1 and active to total MMP-2 ratios were higher and the MMP-2 to TIMP-2 ratio was lower in dissection tissue. Furthermore, patients had higher plasma active to total MMP-9 ratios than the controls. Age and hypertension were associated with increased MMP levels.

Conclusions

Increased levels of several MMPs and increased MMP to TIMP ratios in aortic tissue from patients suggest an environment that favors proteolysis, which may promote progressive extracellular matrix destruction and medial degeneration after aortic dissection. An elevated active to total MMP-9 ratio in plasma may be a biomarker for end-stage aneurysm development in patients with chronic thoracic aortic disease.     

基质金属蛋白酶9在胸主动脉瘤和胸主动脉夹层中的表达

目的 观察基质金属蛋白酶(MMP)-9在DebakeyI型胸主动脉夹层(TAD)和胸主动脉瘤(TAA)中的表达,探讨其在TAD和TAA中的作用.方法 苏木素-伊红(HE)染色、铁苏木素染色、TUNEL染色、免疫组织化学染色分别观察11例TAD和10例TAA的病理特征、弹力纤维断裂、管壁细胞凋亡、MMP-9在动脉管壁中的表达和定位,并分析MMP-9表达与各项临床参数的关系.结果 MMP-9在TAD和TAA中高表达(P<0.05),主要位于中外膜平滑肌细胞和炎性细胞,MMP-9表达与主动脉直径显著相关(P<0.05).结论 MMP-9在TAD和TAA中高表达,中外膜平滑肌细胞和炎性细胞是其主要表达细胞;MMP-9可能通过弹力板层的破坏来影响管壁重构过程.     

Retrograde type A dissection after thoracic endovascular aortic repair for type B aortic dissection

Background

The purpose of this study was to evaluate clinical, anatomic, and procedural characteristics of patients who developed retrograde type A dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD).

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目的 研究适合升主动脉夹层的支架型血管，探讨支架型血管放置的合理途径和方法；观察支架型血管放置后模型动物的病理生理变化及评估临床腔内治疗升主动脉夹层的可行性。方法 以国产镍钛记忆合金和人造血管为材料制作支架型血管系统，以犬制作升主动脉夹层动物模型，通过输送器在透视下将支架型血管经主动脉弓的头臂分支动脉释放在模型犬升主动脉适当的集团内，使支架型血管覆盖犬升主动脉夹层模型的内膜撕裂处，使夹层内口封闭，再经髂股动脉在降主动脉起始段放置合适的裸支架一枚，用来纠正或预防夹层在远处的产生和蔓延。结果 7例实验动物升主动脉夹层模型均相当于DeBakeyⅡ型；7实验动物中有5例经右锁骨下动脉，1例经头臂干动脉（预先行右颈总动脉、主动脉弓人造血管临时性转流），1例经左锁骨下动脉途径送入输送系统；支架型血管均准确迅速地旋转在升主动脉内，覆盖夹层内破口位置，即刻造影显示，无明确的主动脉瓣关闭不全影象，术后观察7例实验动物，2例由于失血过多等原因术后未能复苏外，另5例均于术后24h内复苏，3天内恢复正常饮食，观察期间内，神态、视听反射正常，四肢动脉搏动正常。术后第一周内尸检观察5只实验动物显示升主动脉内支架型血管完好，有1只支架型血管向远端移位约1cm，夹层内破口被支架型血管完好封闭。结论 此实验设计制作的国产支架型血管系统及选择的输送途径合理、可行；并主动脉夹层动物模型的制作有待进一步完善；选择合适的升主动脉夹层病例进行腔内修复治疗的临床应用应是安全、可行的，交给升主动脉夹层的临床治疗带来新的选择和希望。     

Endovascular repair of a ruptured thoracic aortic dissection with a right sided aortic arch: A case report

BackgroundEmergency treatment of complex aortic pathology is challenging in the setting of a right-sided aortic arch. We report the successful treatment of a ruptured thoracic aortic aneurysm (TAA) in the setting of a Stanford type B aortic dissection (TBAD) and right-sided aortic arch.Presentation of caseThe patient is a 66-year-old male with chronic kidney disease (CKD) admitted with right sided chest pain and hypotension. Computed tomography angiography (CTA) revealed a 5 cm ruptured TAA in the setting of a TBAD and right-sided aortic arch. The TBAD began just distal to the right common carotid artery and involved the origin of the left subclavian artery (SCA). Using a totally percutaneous approach, a conformable Gore^® TAG^® thoracic endoprosthesis was placed in proximal descending thoracic aorta covering the left SCA. Aside from progression of his pre-existing CKD, the patient had an uneventful recovery. CTA one-month post-procedure revealed a type IB endoleak with degeneration of the distal descending thoracic aorta. To exclude the endoleak, the repair was extended distally using a Medtronic Valiant^® thoracic stent graft. The left subclavian artery was subsequently coil embolized to treat an additional retrograde endoleak. The patient has done well with no further evidence of endoleak or aneurysm expansion.ConclusionRight-sided aortic arch presents challenges in the emergency setting. CTA and post-processing reconstructions are very helpful. While the endoleaks prompted additional interventions, the end result was excellent. This case displays the importance of careful attention to detail and follow-up in these complicated patients.     

Outcomes of Liu’s aortic root repair and valve preservation in patients with type A dissection and aortic regurgitation

 Open in a separate windowOBJECTIVESTo evaluate short- and medium-term outcomes following Liu’s aortic root repair and valve preservation in patients with acute type A aortic dissection complicated by moderate-to-severe aortic regurgitation (AR). METHODSFrom October 2011 to July 2018, a total of 324 consecutive patients underwent emergency surgery for acute type A aortic dissection. There were 122 patients (38%) with moderate-to-severe AR, of whom 82 (67%) underwent Liu’s aortic root repair and valve preservation. Aortic computed tomography angiography and echocardiography were performed at discharge, 6 and 12 months postoperatively, and annually thereafter. We focused on assessing the survival and aortic root and valve durability in the 82 patients.RESULTSThe 30-day, 1-year, 3-year and 6-year survival estimates were 94%, 90%, 85% and 81%, respectively. At a median follow-up of 36.5 (interquartile range 24.9–50.9) months, all patients were free from reoperation. No residual false lumens in the aortic root, recurrent aortic root dissections or aortic root pseudoaneurysms were observed during the follow-up period. Only 1 patient (1%) presented with moderate AR at 6 months, which remained asymptomatic with no significant changes over a 3-year period. The remaining patients showed satisfactory valve function with an AR grade of mild (27%) or trace or none (72%). In the competing risk analysis, the incidence of recurrence of AR was 2% at 8 years.CONCLUSIONSLiu’s aortic root repair and valve preservation is a safe and effective operative strategy that achieves favourable short- and medium-term outcomes for acute type A aortic dissection with moderate-to-severe AR.     

Endovascular plugs to occlude proximal entries in chronic aortic dissection

Open in a separate window OBJECTIVESPatients with expanding chronic aortic dissection and patent proximal entries are sometimes poor candidates for open surgery or TEVAR. Occlusion of proximal entries with endovascular plugs has previously been suggested in selected patients, but clinical results over time are unknown. This study analyses aortic remodelling and clinical outcome after proximal entry occlusion.METHODSBetween 2007 and 2016, 14 patients, with expanding chronic aortic dissection, considered poor candidates for standard treatment, were treated with endovascular plugs in proximal entries located in the arch (n = 6) or descending aorta (n = 8). The Amplatzer™ Vascular Plug II was used for entries ≤4 mm and the Amplatzer™ Septal Occluder or Amplatzer™ Muscular VSD Occluder for entries 5–16 mm. Patients were followed for 0.5–13 years (median 7.3) with clinical visits and computed tomography. Diameters and cross-sectional areas along the aorta were measured.RESULTSOcclusion of proximal entries was achieved in 10/14 patients (71%), including 4 patients with an adjunctive reintervention needed for complete seal in the segment. Unchanged or reduced maximum thoracic aortic diameter was observed in all 10 patients with successful occlusion. In 4 patients, proximal occlusion was not achieved and early conversion to FET (n = 1), FET/TEVAR (n = 2) or TEVAR (n = 1) was performed. Two aorta-related deaths occurred during follow-up, both after early conversion.CONCLUSIONSEndovascular occlusion of proximal dissection entries of expanding chronic aortic dissections can induce favourable aortic remodelling and may be considered in selected patients with expanding chronic aortic dissection who are poor candidates for open surgery or stent graft repair.     

主动脉壁间血肿、穿透性粥样硬化性主动脉溃疡和主动脉夹层:影像学表现和发病机制进展

主动脉壁间血肿（AIH）、穿透性粥样硬化性主动脉溃疡（PAU）和主动脉夹层（AD）有相似的易患因素和临床表现,临床有时不易鉴别,但三者影像学表现和发病机制不同。本文对AIH、PAU和AD的影像学表现和发病机制进展进行综述。     

骨桥蛋白在主动脉夹层中的上调表达及其意义

目的 应用Real time聚合酶链反应(PCR)、免疫组织化学技术观察OPN在夹层血管标本和正常对照标本中的表达是否存在差异.方法 选取急性期的主动脉夹层标本(AD)标本12例,正常胸主动脉12例.抽提标本总RNA,以GAPDH基因为参照,采用Real time PCR比较AD组和对照组OPN基因在RNA水平的差异;采用免疫组织化学方法 显示OPN蛋白在两组标本中的表达,两组各个标本在低倍视野下随机选择3个部位进行阳性细胞计数,比较两组OPN在蛋白质水平表达的差异.结果　AD组OPN基因的表达水平是正常组的5.56倍(P＜0.01),AD组OPN蛋白的表达水平是对照组的3.03倍(P＜0.01).结论　AD组标本OPN在基因和蛋白质水平均发生上调表达;OPN的上调表达可能与AD的形成密切相关.

Abstract：

Objective To identify the differential expression of osteopontin (OPN) between the aorta specimens from the aortic dissection (AD) and the normal controls. Methods Twelve descending aorta specimens from patients with acute Stanford B dissection were taken during surgical operation, and 12 normal descending aorta specimens were taken from multi-organ donors. The GAPDH gene was used as control, and mRNA and protein expression of OPN was detected by using real-time polymerase chain reaction (PCR) and immunohistochemisty, respectively. Three low-powered fields of each specimen in beth groups were randomly chosen to count the cells positive for OPN protein. Results The expression levels of OPN in AD group was 5. 56 folds as those in the control group (P ＜0. 0l ). The protein expression levels of OPN was 3. 03 folds as those in the control group ( P ＜ 0. 01 ). Conclusion The gene and protein expression levels of OPN were down-regulated in AD group as compared with normal controls. OPN is one of the markers to identify smooth muscle cells as synthetic phenotype. The up-regulation of OPN may contribute to the development of AD.