主动脉疾病腔内治疗的进展与前景

1990年阿根廷医生Parodi的首次成功的经股动脉植入腔内移植物治愈一例腹主动脉瘤 ,在此后 10余年中 ,腔内技术的发展使主动脉疾病的治疗模式发生了巨大的改变 ,例如腹主动脉瘤的治疗 ,在发达国家的多数血管外科中心利用腔内移植物进行的腔内隔绝术已经替代了一半以上的开腹手术 ,在主动脉夹层和胸主动脉瘤的治疗中 ,腔内技术的使用也日益普及。1　腹主动脉瘤腔内隔绝术1.1　移植物的分类腹主动脉瘤的腔内隔绝术按照使用移植物的结构可分为以下三型 :直管型、分叉型、腹主 单支髂动脉型 (见图 1) ,其中直管型由于适应证较为狭窄和继发内漏…     

一站式杂交手术治疗复杂胸腹主动脉疾病

目的 总结应用Hybrid技术,腹主动脉去分支化联合降主动脉腹主动脉腔内修复术治疗复杂胸腹主动脉疾病的经验及效果.方法 2016年10月～2020年10月我院收治胸腹主动脉病变病人10例,其中胸腹主动脉瘤1例,胸腹主动脉夹层9例.根据主动脉疾病累及范围,先行相应累及部位的内脏动脉旁路手术,再一期或二期行主动脉腔内覆膜支...     

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。     

复杂主动脉夹层及胸主动脉瘤的腔内治疗

目的总结复杂主动脉夹层(AD)及胸主动脉瘤(TAA)腔内隔绝术的治疗经验。方法共76例行腔内治疗的复杂AD及TAA病例,其中行单纯腔内隔绝术52例,结合烟囱技术的腔内隔绝术6例;结合支架近端开槽的腔内隔绝术5例;颈部杂交手术13例。结果围手术期死亡2例,其中1例患者术后4小时死于心跳骤停,1例杂交手术患者术后死于脑血管意外。51例得到随访,随访时间3个月至9年,平均18个月,1例TAA杂交手术患者人工血管全段闭塞,但患者无任何神经系统症状。2例患者分别在术后3个月及1年出现支架远端破口再行腔内隔绝术。1例AD患者术后6个月时出现支架近端新破口。在随访期死于肺癌和冠心病各1例。结论结合覆盖左锁骨下动脉、烟囱技术、开槽技术及颈部血管搭桥的腔内隔绝术,可提高复杂AD及TAA的疗效,降低并发症。     

复杂主动脉疾病的腔内修复治疗及其并发症防治

主动脉夹层和主动脉瘤严重地威胁着人们生命安全,治疗上较为复杂,风险大,一旦破裂,病死率高。1991年,Parodi首先应用血管腔内支架人造血管（stentgraft,SG）技术治疗腹主动脉瘤获得成功;1992年,Mitchell利用SG成功治疗降主动脉瘤;1994年Dake将该技术应用于主动脉夹层,取得较为满意的效果。近十年来,应用SG治疗主动脉病变在技术上有了飞速发展,我国学者也在主动脉腔内修复（endovascular aortic repair,EVAR）领域作了较多探索,尤其在主动脉夹层EVAR治疗方面已进入了国际先进行列。国内一些血管外科中心还进行了自制SG的研究工作,并应用于临床取得初步成功。     

胸主动脉瘤和主动脉夹层的腔内治疗

本文综述了近年来应用支架型人工血管治疗胸主动脉瘤和主动脉夹层的主要进展，认为该术式是手术等传统治疗方法的有效替代之一，但还存在一些亟待解决的问题。     

3D打印辅助腔内治疗复杂主动脉疾病的临床疗效

目的 探讨3D打印辅助腔内治疗复杂主动脉疾病的可行性。方法 纳入中山市中医院血管介入科2019年12月至2021年10月收治的5例复杂主动脉疾病患者。术前行CT血管造影（CTA）后进行主动脉三维重建,在3D打印机打印成1∶1主动脉模型,并辅助手术方案制定及进行手术模拟。结果 1例肾上型腹主动脉穿透性溃疡,1例近肾型腹主动脉假性动脉瘤,2例累及弓上分支的胸主动脉瘤,1例累及弓上分支的主动脉夹层,所有患者在术前完成主动脉病变段3D模型打印,根据结果辅助制定手术方案,手术技术成功率为100%,无内漏、支架移位或闭塞、内脏动脉丢失等严重并发症出现。结论 3D打印辅助腔内治疗能使复杂主动脉疾病腔内治疗直观化、精准化,具有良好的可行性。     

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.     

胸主动脉瘤和主动脉夹层动脉瘤外科治疗不同术式的评价

胸主动脉瘤 ,尤其是马凡氏主动脉根部瘤伴主动脉瓣关闭不全和主动脉夹层动脉瘤 ,起病凶险 ,死亡率高达 70 %～ 90 % ,外科治疗是当前唯一有效的治疗技术 ,但也存在一些问题 ,至今仍是对心血管外科医师的一项挑战。经过近半个世纪的努力 ,对不同部位的病变已创造了许多手术治疗方法和术式。本文将作者以往 2 0年( 1 982年 5月～ 2 0 0 2年 6月 )的临床资料进行回顾性研究 ,对过去所采用的各种基本方法和手术术式 ,从手术效果、手术的风险性、术后的并发症和中远期结果及患者生存质量等方面 ,对不同的手术方法进行评价 ,为今后优选手术提供参…     

Recent advances in the surgical treatment of aortic disease in Japan

The annual survey by the Japanese Association for Thoracic Surgery in 2010 found that the nationwide hospital mortality rate after surgery was 11.1% in 3,628 patients with acute type A aortic dissection, 18.9% in 158 patients with acute type B dissection, 6.0% in 866 patients with chronic type A dissection, 6.6% in 724 chronic type B dissection, 4.3% in 6,348 patients with nondissection thoracic aortic aneurysm, and 24.8% in 715 ruptured thoracic aneurysms. For abdominal aortic aneurysms, the hospital mortality rate after elective surgery was 2.3% and 15.3% in ruptured aneurysms among 7,906 patients nationwide. These results are superior to the results of aortic surgery in Western countries.     

腔内血管外科时代|主动脉疾病的治疗进展

腔内血管外科时代的到来,实现了主动脉疾病手术治疗的微创化。用最小的创伤治疗高危、复杂的主动脉疾病,是未来主动脉外科的发展方向之一。随着腔内血管外科器械的进步和腔内技术的飞速发展,过去诸多血管外科腔内治疗禁忌的疾患成为腔内治疗的适应证,未来20年将是腔内微创治疗的时代。     

Hybrid treatment of aortic arch disease

Introduction

The management of thoracic aortic disease involving the ascending aorta, aortic arch and descending thoracic aorta are technically challenging and is an area in constant development and innovation.

Objective

To analyze early and midterm results of hybrid treatment of arch aortic disease.

Methods

Retrospective study of procedures performed from January 2010 to December 2012. The end points were the technical success, therapeutic success, morbidity and mortality, neurologic outcomes, the rate of endoleaks and reinterventions.

Results

A total of 95 patients treated for thoracic aortic diseases in this period, 18 underwent hybrid treatment and entered in this study. The average ages were 62.3 years. The male was present in 66.7%. The technical and therapeutic success was 94.5% e 83.3%. The perioperative mortality rate of 11.1%. There is any death during one-year follow- up. The reoperation rates were 16.6% due 2 cases of endoleak Ia and one case of endoleak II. There is any occlusion of anatomic or extra anatomic bypass during follow up.

Conclusion

In our study, the hybrid treatment of aortic arch disease proved to be a feasible alternative of conventional surgery. The therapeutic success rates and re- interventions obtained demonstrate the necessity of thorough clinical follow-up of these patients in a long time.     

Recent advances in thoracic aortic surgery

Surgical treatment for thoracic aortic diseases has been challenging for cardiovascular surgeons. Advances in diagnostic modalities such as multidetector row computed tomography, magnetic resonance imaging, and transesophageal and epiaortic echocardiography provide precise information to determine the surgical strategy. The pathologic entity of acute aortic dissection has been clearly defined, although the terminology for penetrating aortic ulcer, intramural hematoma, and thrombosed aortic dissection remains controversial. The term "acute aortic syndrome" has been advocated for emergent treatment. Therapeutic advances in total aortic arch replacement have been remarkable, particularly in the field of brain protection. Selective antegrade cerebral perfusion and retrograde cerebral perfusion have been developed since the 1990s and refined mainly by Japanese surgeons. Endovascular aortic repair with stent grafting is the most recent emerging technology that encourages a more aggressive strategy for the treatment of high-risk patients with thoracic aortic pathology.     

Recent advances in molecular pathogenesis and polycystic kidney disease treatment

Polycystic kidney diseases (PKD) are common genetic disorders characterized by formation and progressive enlargement of cysts kidney, liver and other organs, leading to end stage renal disease. Regardless of the genetic defect underlying PKD, cystic epithelia seem to display common abnormalities: increased proliferation and apoptosis, loss of cellular differentiation and polarity, hypersecretion. The localization of multiples proteins, whose function are disrupted in PKD, in the primary cilium or at basal body at the base of the cilium highlight this neglected organelle as a common trigger of cystic diseases. Significant progresses have been made over the last few years towards a greater understanding of the molecular pathogenesis of cysts formation, particularly in the signaling pathways involved in cytogenesis: cAMP, mTOR, Wnt, Ras/MAPK. These advances have already brought several potential therapies targeting several key pathways of cystogenesis.     

Recent advances in thoraco-abdominal aortic aneurysm repair

Thoraco-abdominal aortic aneurysm repair remains a formidable challenge to vascular surgeons. The traditional repair of thoraco-laparotomy with aortic cross-clamping is associated with a high morbidity and mortality despite significant advances in perioperative critical care, anaesthetic and surgical techniques.The advent of the endovascular revolution has shown a marked paradigm in the approach to all aneurysm repairs. As a logical progression from the open repair, the St Mary's visceral hybrid repair combines traditional open techniques (retrograde visceral and renal revascularisation via mid-line laparotomy) with endovascular stent grafting, thereby avoiding the need for thoracotomy and aortic cross-clamping. In specialist centres, the results have been encouraging and easily comparable to the open repair. The technique has been used in several centres around the world and represents a robust, transferrable method of repairing thoraco-abdominal aortic aneurysms.Stent-grafting technologies have reached a point of sophistication that wholly endovascular methods of repairing thoraco-abdominal aortic aneurysms are being performed in several centres around the world. Although these stent grafts have to be customised to the individual patient and are only suitable for certain types of aneurysmal anatomies, they represent the future of thoraco-abdominal aortic aneurysm repair.We review the history of thoraco-abdominal aortic aneurysm repair, the exciting advances in their treatment and discuss our approach to the management of thoraco-abdominal aortic aneurysms in the 21st century.     

Technical advances in total aortic arch replacement

BACKGROUND: We compared the effects of using hypothermic circulatory arrest (HCA) alone, HCA combined with selective cerebral perfusion (SCP), and use of SCP with a trifurcated graft (T) on outcome after aortic arch repair. METHODS: One hundred fifty patients, median age 66 years (range, 27 to 85), underwent total arch replacement between 1988 and 2002; 75 were female. We retrospectively compared the results of three patient groups roughly comparable with regard to preoperative risk factors: 45 patients using HCA beginning in 1988; 67 patients using HCA/SCP beginning in 1994; and 38 patients utilizing a trifurcated arch graft in conjunction with SCP through the axillary artery (HCA/SCP/T) since 2000. The groups were well matched with regard to median age (66, 68, and 66 years), urgency (emergent 11%, 13%, 5%; urgent 24%, 9%, 18%; and elective 64%, 78%, 76%), and several other known risk factors (p = not significant). RESULTS: An adverse outcome-hospital death or permanent stroke-occurred in 14%: in 16% with HCA, in 16% with HCA/SCP, and in 8% with HCA/SCP/T. Transient neurologic dysfunction among patients surviving without stroke was lower with HCA/SCP/T (11%) than with HCA (33%) or HCA/SCP (17%). Mean duration of HCA was 52 +/- 16 minutes with HCA alone versus 45 +/- 10 minutes with HCA/SCP and 31 +/- 7 minutes with HCA/SCP/T (p < 0.0001 for groups HCA and HCA/SCP combined versus HCA/SCP/T). Mean duration of SCP was 57 +/- 25 minutes with HCA/SCP versus 62 +/- 24 minutes with HCA/SCP/T (p = not significant). Comparison of the groups of patients who had comparable preoperative risk factors for adverse outcome showed a trend toward lower adverse outcome and transient neurologic dysfunction rates using HCA/SCP/T; a significant reduction in respiratory (p < 0.001), infectious (p = 0.015) and cardiac (p = 0.005) complications in HCA/SCP/T compared with the earlier groups; and significantly shorter durations of intensive care (p < 0.0001) and hospitalization (p = 0.004). CONCLUSIONS: Our results suggest that HCA/SCP is superior to HCA alone for preventing cerebral injury during operations on the aortic arch. By further reducing embolic risk as well as duration of HCA, HCA/SCP/T with axillary artery cannulation may be the optimal technique for averting adverse outcomes, reducing complications, and shortening hospital stay after aortic arch repair.