急性Stanford B型主动脉夹层腔内修复治疗的疗效评价

目的:评价腔内修复术（TEVAR）治疗急性Stanford B型主动脉夹层的中、远期疗效。方法: 2001年12月～2009年6月,对急性Stanford B型主动脉夹层进行血管腔内支架植入治疗患者288（男237,女51）例,年龄21～79（平均51.2）岁。局部或全身麻醉,在 X线透视下将支架型人工血管经股动脉放置在主动脉夹层第1裂口位置,实现腔内修复。应用多排CT等技术进行38个月（6～102月）的随访,观察假腔血栓形成情况、有无内漏、血流动力学变化、移植物位置及形态、内脏动脉供血等情况,评估该方法的安全性及有效性。结果: 全组患者无移植物错放、移位、瘤体破裂、中转手术和截瘫等并发症。围术期死亡6例,分别为:腹腔脏器缺血/再灌注损伤2例、升主动脉逆行夹层1例、夹层破裂1例、心肌梗死1例及死亡原因不明1例。住院期间并发症发生率25.3%,包括术后即刻内漏、发热、肾功能不全、切口感染、肺炎、神经系统并发症、心功能不全、左肱动脉假性动脉瘤、截肢等。随访中共有7例死亡(2.4%),4例患者行二次TEVAR术后治愈。Kaplan-Meier生存曲线显示5年累积生存率达96%。结论: TEVAR术是治疗急性Stanford B型主动脉夹层的一种有效方法,中期疗效满意,患者远期生存状况良好。     

急性主动脉夹层并下肢动脉严重缺血患者的治疗分析

目的探讨急性主动脉夹层合并下肢动脉严重缺血患者的治疗效果及安全性。方法收入2013年10月至2015年1月沈阳军区总医院收治的急性主动脉夹层合并下肢动脉严重缺血患者8例,均为男性,年龄(43.6±8.4)岁,分析其治疗策略及疗效。结果 1例Stanford A型主动脉夹层患者合并主动脉瓣关闭不全,行主动脉瓣置换+人工支架象鼻手术;6例Stanford B型主动脉夹层患者行胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR);1例Stanford B型主动脉夹层患者于术前急性肾功能衰竭死亡。Stanford A型主动脉夹层患者于外科术后第4天因多脏器功能衰竭死亡;1例Stanford B型主动脉夹层于TEVAR后次日因急性肾衰竭死亡;余5例顺利出院。术后随访时间(11±5)个月。随访期间3例均病情平稳,血压控制良好,患侧下肢疼痛及麻木感消失,术后恢复良好,无截瘫等事件发生。1例右下肢活动仍受限,1例虽病情相对平稳,但活动后仍存在下肢疼痛症状,于术后6个月植入微创腹主动脉覆膜支架1枚,右髂总动脉至髂外动脉植入金属裸支架1枚。术后患者病情平稳,活动后下肢疼痛症状消失,术后3个月复查主动脉增强计算机断层扫描(CT),主动脉夹层愈合良好,双髂动脉及下肢动脉血流通畅,肾动脉可见一小破口。结论急性主动脉夹层合并下肢动脉严重缺血患者病情危重,围术期病死率高,需加强围术期管理,TEVAR后远期疗效良好。     

胸主动脉病变腔内修复术合并“烟囱”支架置入术后内漏情况分析

目的:探讨Standford B型主动脉病变在近端锚定区不足时,置入覆膜支架行胸主动脉腔内修复术(TEVAR)合并"烟囱"支架处理受累的左颈总动脉或左锁骨下动脉时,术中发生内漏的情况及其与病变位置之间的关系、手术疗效及预后。方法:回顾性分析2011-09至2015-07我院收治的Standford B型主动脉病变在近端锚定区不足的患者32例,采用置入覆膜支架行TEVAR合并"烟囱"支架治疗,观察术后即刻左颈总动脉或左锁骨下动脉显影、神经系统并发症及左上肢严重缺血症状、内漏情况,并术后随访3~46个月神经系统并发症及左上肢严重缺血症状、内漏情况。结果:32例患者TEVAR合并"烟囱"支架均成功。术后即刻左颈总动脉或左锁骨下动脉均显影良好,患者均未出现神经系统并发症及左上肢严重缺血症状,主动脉弓发生内漏7例,其中病变位于主动脉弓大弯侧6例,病变位于主动脉弓小弯侧1例。术后随访3~46个月,主动脉覆膜支架形态良好,"烟囱"支架内血流通畅,7例发生内漏患者中5例内漏逐渐减小、消失,2例持续存在。结论:Standford B型胸主动脉病变在近端锚定区不足时,"烟囱"支架可延长锚定区并保持左颈总动脉或左锁骨下动脉通畅,更为安全地拓展了胸主动脉病变腔内治疗的适应证,达到微创、安全、有效的目的,但当破口位于主动脉弓大弯侧时,"烟囱"支架可能增加内漏发生几率。     

不同类型胸主动脉夹层腔内隔绝术疗效观察

目的进一步探讨腔内隔绝术治疗胸主动脉夹层的适应症选择和疗效.方法2002年8月至2004年11月我院住院的4例(年龄48～82岁;男3例,女1例)胸主动脉夹层患者行腔内隔绝术,并进行临床分析和随访,评价其临床效果.结果在全麻下4例均成功在胸主动脉夹层的血管腔内释放覆膜支架,其中为Standford A型及StandfordB型各2例,共使用Talent覆膜血管支架4个,术中造影证实Standford B型夹层裂口完全封闭,无术中严重并发症及死亡发生,Standford A型1例术后证实内漏存在,术后3天死亡,1例在支架释放后出现左冠脉急性闭塞致死亡.结论应用覆膜血管内支架行腔内隔绝术(EVGE)是治疗Standford B型胸主动脉夹层安全有效的方法.Standford A型夹层行EVGE术仍有待进一步对技术及器械进行改良.     

主动脉夹层合并下肢灌注不良临床治疗分析

目的：探讨主动脉夹层合并下肢灌注不良的治疗经验。方法：南京军区南京总医院2010年1月～2015年5月收治伴有下肢灌注不良的主动脉夹层患者13例,回顾分析其治疗方法及近中期随访结果。结果：所有患者均接受手术,7例B型夹层患者行胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR),其中4例植入裸支架。6例支架释放后造影见原发破口隔绝,真腔扩张,受累髂动脉显影良好。1例术后右下肢缺血坏死行截肢术,后因多器官功能衰竭死亡。6例A型夹层患者,2例术前评估下肢缺血症状明显,急诊行内膜开窗恢复髂动脉血流,二期行杂交手术。其余4例一期行升主动脉、主动脉弓置换 降主动脉覆膜支架植入术,术后造影见下肢动脉恢复真腔供血。术后患者存活12例,下肢缺血症状明显缓解。所有患者均获随访,患者无胸背部剧痛及下肢缺血表现,髂动脉显影良好。结论：主动脉夹层合并下肢灌注不良应尽早干预,主动脉腔内修复术可消除原发破口,恢复真腔血流,改善大部分患者的缺血症状。     

合并迷走右锁骨下动脉的B型主动脉夹层的治疗体验

目的:总结术中支架人工血管植入术或胸主动脉腔内修复术治疗合并迷走右锁骨下动脉的B型主动脉夹层的初步经验。方法:2010年8月至2017年8月,我中心共收治合并迷走右锁骨下动脉的B型主动脉夹层17例,其中术中支架人工血管植入术7例,胸主动脉腔内修复术10例。结果:术中支架组和腔内修复组均无患者围术期死亡。术中支架组有1例患者术后7d发生胸骨哆开行清创术。腔内修复组无围术期并发症。术中支架组随访13~85个月,平均(54.86±27.01)个月,腔内修复组随访(12~89)个月,平均(51.10±24.71)个月。随访期间两组无死亡病例。结论:合并迷走右锁骨下动脉的B型主动脉夹层应根据不同的解剖特点和合并病变,选择术中支架人工血管植入术或胸主动脉腔内修复术。     

胸主动脉腔内修复术在复杂型与非复杂型B型主动脉夹层患者中应用的效果对比

目的:对比胸主动脉腔内修复术(TEVAR)在复杂与非复杂型B型主动脉夹层患者中应用的效果。方法:收集自2013年1月至2015年3月,在北京安贞医院就诊并行TEVAR术治疗的B型主动脉夹层患者资料用于分析。结果:共有226例患者符合入选标准,中位随访时间25个月(6～38个月),其中非复杂型B型夹层患者197例;围术期死亡1例,随访期间死亡4例,3例分别因I型内漏、逆行性A型夹层、支架远端新发破口再次行手术治疗;术后3年生存率为98.1%。复杂型B型夹层患者29例;围术期死亡2例,随访期间死亡1例,1例因支架远端新发破口再次行手术治疗;术后3年生存率为96.3%。结论:TEVAR术能够使复杂型B型夹层患者获得与非复杂型患者相似的3年生存率,但在复杂型B型主动脉夹层患者中围术期并发证发生率较高。     

两段式覆膜支架治疗B型主动脉夹层的研究

目的:探讨两段式覆膜支架腔内修复术(TEVAR)治疗Stanford B型主动脉夹层(TBAD)的疗效。方法:分析2013年3月至2015年3月间,在本中心采用两段式覆膜支架TEVAR术治疗的61例TBAD患者的临床影像及术后随访资料。适应证:1胸降主动脉段主动脉弯曲变形;2胸降主动脉存在多发破口;3主动脉远端锚定区真腔因假腔挤压而过细。结果:应用两段式覆膜支架TEVAR术治疗的TBAD共61例。术后平均随访(23.6±7.4)个月,围手术期死亡1例(1.6%),支架远端新发破口1例(1.6%),支架远端贴壁不良3例(4.9%),支架段假腔完全血栓化率91.8%(55/61),其中支架段假腔完全消失率41.8%(23/55),主动脉完全重塑率7.3%(4/55)。结论:采用两段式覆膜支架腔内修复术治疗Stanford B型主动脉夹层实现了主动脉夹层腔内治疗远端锚定区的精确选择,近中期疗效安全满意,中、远期疗效尚需远期随访。     

胸主动脉腔内修复术治疗Stanford B型主动脉夹层

目的 总结胸主动脉腔内修复术（thoracic endovascular aortic repair,TEVAR）治疗Stanford B型主动脉夹层的临床经验.方法 回顾性分析134例Stanford B型主动脉夹层患者的临床资料,分析并发症发生的原因及随访近、远期效果.结果 术前死亡4例,未手术1例,施行TEVAR 129例,手术操作均成功,部分封堵左锁骨下动脉27例（20.9％）,完全封闭左锁骨下动脉12例（9.3％）;Ⅰ型内漏13例（10.1％）,夹层逆剥为Stanford A型1例,低氧血症23例（17.8％）,肾功能衰竭需血液滤过9例（7.1％）,术后精神症状37例（28.7％）,脑梗死3例.随访2个月～5年,随访110例,随访率85.7％,1例术后1年和1.5年出现支架远端夹层,两次手术植入覆膜支架,部分封闭了腹腔干动脉,1例术后2个月时因肠梗阻在外院行手术治疗,1例术后4年时支架远端发生夹层破裂死亡,1例术后3个月突然死亡.Ⅰ型内漏消失11例,持续存在2例.结论 急诊TEVAR治疗Stanford B型主动脉夹层安全、可靠,近期效果良好,加强并发症的防治,可进一步改善临床效果.     

Stanford B型主动脉夹层局麻下支架植入32例治疗体会

目的 总结Stanford B型主动脉夹层局麻下支架植入的治疗经验。方法 回顾性分析2017-05～2019-05该院实施的32例B型主动脉夹层局麻下行胸主动脉覆膜支架腔内修复术(thoracic endovascular aortic repair,TEVAR)的病历资料,总结治疗经验。结果 32例均顺利完成手术。术中1例出现少量Ⅰ型内漏。无死亡病例,无重大心脑血管意外发生。随访6. 4～10. 5个月,1例术后6个月复查时发现远端支架膨出,再次植入支架1枚后治愈。结论 主动脉夹层经过术前的精心准备、评估、测量,可局麻下实行Stanford B型主动脉夹层的TEVAR治疗。通过改良腹股沟横切口或经皮穿刺代替纵切口,以及围手术期精心护理,可显著减少术中、术后并发症的发生。     

主动脉腔内修复术对B型主动脉夹层患者肾动脉血流及肾脏功能的影响

目的探讨主动脉腔内修复术对于B型主动脉夹层患者主动脉腔内修复术前、术后肾动脉血流及肾脏功能的影响。方法选择B型主动脉夹层患者110例,根据男性肾动脉受累类型不同分为ⅠA组(单侧或双侧肾动脉均为动力型缺血)10例、ⅠB组(单侧肾动脉为静力型缺血)36例、ⅠC组(双侧肾动脉为静力型缺血)8例;根据男性肾动脉受累数目分为双侧肾动脉未受累(未受累组)20例、单侧肾动脉受累(单侧受累组)38例、双侧肾动脉受累(双侧受累组)34例;根据女性肾动脉受累数目分为双侧肾动脉未受累(未受累组)8例、单侧肾动脉受累(单侧受累组)7例、双侧肾动脉受累(双侧受累组)3例。术前及术后观察双侧肾动脉的缺血情况及肾功能检查指标。并将各项指标进行对比。结果 220支肾动脉中动力型缺血共42支(19.1%);静力型缺血共80支(36.4%),主动脉腔内修复术后肾动脉动力型缺血全部得到显著改善,静力型缺血者可得到不同程度改善。随着肾动脉受累数量的增加,男性或者女性患者的肾功能受累情况呈进行性加重,且术后较术前呈下降趋势。结论对于B型主动脉夹层患者,主动脉腔内修复术能够开大主动脉真腔,提升肾动脉灌注,改善患者肾功能情况。     

急性期Standford B型主动脉夹层腔内修复术后早、中期随访结果

目的 评价急性期StanfordB型胸主动脉夹层(TAD)腔内修复术后早、中期手术效果.方法 2009年11月至2012年6月完成80例急性期Stanford B型胸主动脉夹层腔内修复术,手术在发病72 h内完成.手术前行胸腹主动脉夹层强化CT检查,在DSA手术室全麻下切开股动脉进行支架置入术,出院前进行CTA检查,手术后半年至一年内复查CTA.结果 14例患者手术后失去随访.5例术后造影提示有Ⅰ型内漏,4例1年内复查消失或造影剂溢出量明显减少,1例手术后仍有明显Ⅰ型内漏,1年后接受再次支架手术成功.其余支架安装后造影显示破口封闭,无内漏.住院期间死亡2例,1例为高龄患者降主动脉破裂,1例为夹层逆行撕裂至升主动脉后破裂.住院期间发生严重低氧血症8例,急性肾功能不全6例,均经治疗后恢复.结论 急性期Stanford B型胸主动脉夹层进行腔内修复术,术后早期并发症发生率高,中期效果理想.     

Aortic stenting on a type B aortic dissection with visceral and limb ischemia.

Aortic dissection complicated with limb and visceral ischemia is a clinical dilemma since surgical intervention carries high risk of morbidity and mortality. The management is further complicated when renal perfusion is impaired and thus associated with severe renovascular hypertension. As catheterization techniques advanced over the past decade, percutaneous endovascular intervention provides a less invasive alternative for management of such cases. We report a case of chronic Stanford type B aortic dissection complicated with visceral and limb ischemia presenting with marked renovascular hypertension, which was successfully treated with percutaneous endovascular aortic stenting.     

“杂交”手术治疗弓部主动脉夹层的疗效评价

目的:评价人工血管旁路移植术结合腔内隔绝术的“杂交”手术用于主动脉弓部夹层动脉瘤的治疗效果。方法:对12例破口位于主动脉弓部的主动脉夹层动脉瘤患者进行了人工血管旁路移植术+腔内隔绝术的“杂交”手术治疗。评价该方法围手术期死亡率、并发症以及术后桥血管通畅率,进行了6~48(28±11)个月的随访观察。结果:全组1例死亡,原因为等待二期腔内手术期间发生动脉瘤破裂。1例患者因并发医源性升主动脉夹层而改行全主动脉弓置换+支架植入术,随访中1例患者出现90%人工血管狭窄,1例患者出现轻度I型内漏,经18月观察无明显变化,其余患者生存良好,未出现截瘫及其他严重并发症。结论:本文所指的“杂交”手术治疗主动脉弓部夹层动脉瘤具有良好效果。     

Palliative stent graft placement combined with subsequent open surgery for retrograde ascending dissection intra-thoracic endovascular aortic repair

Thoracic endovascular aortic repair (TEVAR) is an effective strategy for type B dissection. Retrograde ascending dissection (RAD) intra-TEVAR is a rare complication on clinic. In this case, a 48-year-old Chinese man with Stanford type B aortic dissection suffered acute RAD during the TEVAR. And palliative stent grafts placement was performed in a local hospital, which earned the time for transfer and subsequent total arch replacement surgery in Zhongshan Hospital Fudan University. This report suggests that the palliative strategy may be an option for RAD in some specific situation.     

Dissection aortique étendue aux artères rénales : intérêt de la volumétrie rénale après angioplastie

ObjectiveType A or B aortic dissection can extend to renal arteries, causing a renal ischemia which treatment is usually endovascular. The aim of our study is to show the interest of the renal volumetry in the follow-up of these patients.Patients and methodsTwenty-two patients (16 men, mean age 63.4 ± 11.8 years, BMI 25.2 ± 3.4 kg/m²) with a type A or B aortic dissection spread to one or to both renal arteries and followed at Grenoble university hospital were consecutively included. All patients underwent renal angiography with aorto-renal pressure gradients measurements and follow-up by renal volumetry (scanner Siemens^®). A renal ischemia was defined by a decrease of 20% or more of the volumetry.ResultsSixteen patients (73%) were hypertensive before the aortic dissection among which ten (62%) were treated. Eight patients (36%) have a significant renal pressure gradient among which five (62%) underwent renal endovascular therapy. The renal volumetry of these five patients remained unchanged while six of 17 patients (36%) without angioplasty have a decreasing volumetry.ConclusionRenal volumetry appeared an effective and attractive option for the follow-up of the patients with aortic dissection spread to the renal arteries. These results should be taken into account to put the indication of an endovascular treatment.     

孤立性腹腔干与肠系膜上动脉夹层二例并文献复习

目的 探讨孤立性腹腔干及肠系膜上动脉(SMA)夹层的诊断及治疗方法.方法 收集中山大学附属第三医院收治的2例孤立性腹腔干并SMA夹层的临床资料,并结合文献报道的119例病例,对孤立性内脏动脉夹层(IDVA)的诊断及治疗方法进行分析总结.结果 119例IDVA中69例存在相关症状,全部病例均由增强CT或MRI检查确诊.发现IDVA后,采取外科治疗8例,支架置入术5例,保守治疗106例,均取得满意疗效.本组2例患者亦由CT检查发现,并经血管造影证实,1例行降压、抗凝治疗,1例行支架置入术,随访中均无不适.结论 腹腔增强CT或MRI检查是诊断IDVA的主要方法.大部分IDVA可选择保守治疗,但需密切CT随访病变情况;对于动脉破裂、管腔阻塞及保守治疗中夹层进展者,需行腔内介入治疗或外科手术治疗.

Abstract：

Objective To investigate the diagnosis and treatment of isolated celiac artery (CA) dissection and superior mesenteric artery (SMA) dissection.MethodsIntegrating clinical data of 119 cases with isolated dissection of the visceral arteries ( IDVA ) reported in literature and 2 patients with spontaneous isolated dissections of both CA and SMA treated in the Third Affiliated Hospital of Sun Yat-sen University,the diagnosis and treatment of IDVA were analyzed retrospectively.Results Among 119 cases reported in the literature,69 cases were symptomatic.All of the cases were diagnosed by contrast-enhanced abdominal CT or MRI.After IDVA was discovered,surgical treatment and endovascular stent placement was performed in 8 and 5 patients respectively,although the remaining 106 patients were managed conservatively with good results.In our 2 cases,the diagnosis of CA and SMA dissection was established by contrastenhanced CT and confirmed by conventional angiograghy.One patient was treated with anticoagulation and antihypertension,and the other patient was treated with endovascular stenting.Both of the patients didn't have discomfort during the follow-up period of 12 and 3 months respectively.ConclusionsContrastenhanced abdominal CT is the main tool for detection of IDVA.Most of the patients with IDVA can be managed conservatively,but close surveillance with imaging studies is necessary for early recognition of dissection progression.Patients with persistent or relapsed symptoms,and dissection progression,should undergo surgical or endovascular treatment.     

Ulcer-like projections into the dilated false lumen after stent-graft placement for aortic dissection: A case report

Rationale:Acute type A aortic dissection and chronic type B aortic dissection (TBAD) occurs simultaneously in rare cases. Although the development of ulcer-like projection (ULP) is associated with an increase in adverse aorta-related events, the false-lumen enlargement caused by the ULP progression is uncommon.Patient concerns:A 72-year-old female with chronic TBAD was admitted to our unit with back and chest pain. Computed tomography revealed acute type A aortic dissection and a hematoma caused by rupturing of the descending aorta due to chronic TBAD. After endovascular intervention, the false lumen thrombosed and shrunk.Diagnosis:After 9 months, a developing ULP, which projected into a dilating false lumen, was found. An impending ruptured descending aortic aneurysm was confirmed.Interventions:Emergency Total arch replacement and thoracic endovascular aortic repair (TEVAR) was performed.Outcomes:The procedure was successful. One year later, regular follow-up showed that the false lumen had completely shrunk.Lessons:ULP can arise and cause progressive dilation of false lumen after TEVAR. Careful and regular computed tomography examinations are required for early diagnosis of false lumen becoming thrombosed after TEVAR. Close follow-up and timely intervention, including TEVAR, should be considered in cases of aortic enlargement due to a newly developed ULP.