同期杂交手术治疗复杂Stanford B型主动脉夹层

目的回顾性分析同期杂交手术治疗复杂Stanford B型主动脉夹层的手术方法及疗效,探讨基层医院施行该手术的可行性。方法2010年12月至2013年3月襄阳市中心医院胸心外科对7例复杂Stanford B型急性主动脉夹层患者施行同期杂交手术治疗。男2例、女5例,年龄45～64（50．0±8.3）岁。术前主动脉CT血管造影（CTA）示主动脉夹层破口距左锁骨下动脉开口〈15mm 4例,累及左锁骨下动脉开口3例,其中1例合并胸主动脉壁多部位钙化,冠状动脉CTA示前降支近中段狭窄约70％。采用气管内插管静脉复合麻醉,手术室先期行颈部切口完成主动脉弓分支旁路手术,术毕转送导管室行股动脉切口完成主动脉腔内修复术,冠状动脉粥样硬化性心脏病患者同期完成前降支支架植入术。结果所有患者均成功完成手术,并植入覆膜支架。1例术后发生少量Ⅰ型内漏。围术期无死亡和严重并发症发生。术中CTA证实主动脉夹层真腔血流恢复正常,旁路血管血流通畅,支架植入定位准确,支架无明显移位。随访7例,随访时间3～24（12．0±3．6）个月,所有患者均生存,恢复正常生活。6例术后3个月及术后1年或2年复查主动脉增强CT示支架无移位和内漏,支架内及人工血管旁路血流通畅;1例少量Ⅰ型内漏患者术后3个月复查假腔内仍有造影剂显示,但部分血栓形成,假腔程度及范围较术前变小,真腔明显增大,术后6个月复查内漏消失。所有患者未见脑部和肢体缺血征象。结论复杂Stanford B型主动脉夹层采用同期杂交手术治疗安全、有效,扩大了介入覆膜支架腔内治疗的适应证,在基层医院值得推广应用。     

钝性外伤后胸主动脉扩张性病变的临床分析

目的 总结钝性外伤后胸主动脉扩张性病变诊疗经验.方法 回顾性分析12例钝性外伤后胸主动脉扩张性病变的临床资料,其中主动脉夹层(Stanford B型)8例以及降主动脉假性动脉瘤4例.术前螺旋CT血管造影及术中数字血管减影造影对病变进行评估,待严重合并症稳定后行腔内支架型人工血管植入术.术后3、6、12个月以及其后每年随访CTA明确治疗效果.结果 11例行腔内支架型人工血管植入术,另1例未及手术死亡.所有手术患者均获技术成功,完全或部分遮蔽左锁骨下动脉6例,支架释放后即刻造影发现内漏3例,2例球囊扩张后内漏消失,1例仅给予随访.共9例获随访(B型主动脉夹层6例、降主动脉假性动脉瘤3例),均正常生存,未出现左上肢缺血症状及神经系统阳性体征,CTA检查示近远端主动脉无新发夹层或动脉瘤,无内漏、截瘫以及支架移位等并发症.结论 钝性外伤后胸主动脉损伤多位于主动脉峡部,待重要脏器合并症稳定后行腔内支架型人工血管治疗有效可行,安全性高.     

肾下主动脉夹层的腔内治疗

目的：探讨肾下主动脉夹层腔内修复治疗的效果与特点。方法：回顾性分析本科2004年1月至2010年11月期间15例以腔内修复为主治疗的肾下主动脉夹层。术前均通过MRA或CTA明确诊断。手术在DSA室进行,采用以腔内修复为主的方法进行治疗。病人术后1个月、3个月、6个月,以后每年于门诊进行随访。记录手术时间、出血量、总住院日数、随访时间和随访事件。结果：2例病人接受直管型移植物（支架型人工血管）植入;9例病人接受分叉型移植物植入;1例病人接受AUI型移植物植入、对侧髂动脉结扎加股-股人工血管旁路术;1例病人接受2枚直管型移植物植入、对侧髂动脉结扎加股-股人工血管旁路术;2例病人接受AUI型移植物植入,对侧髂动脉封堵器栓塞,加股-股人工血管旁路术。手术时间为（178±96）min,术中失血（152±103）mL,总住院时间为（11±5）d;随访时间（42±26）个月。1例病人6个月随访时发现存在少量内漏,随访24个月时假腔略有增大,但内漏消失;1例病人36个月时出现支架近端轻度移位,瘤腔未见扩大,未给予特殊处理;1例病人48个月时CTA检查发现股-股人工血管吻合口中度狭窄;2例病人随访半年后失访;其余10例病人随访结果满意。结论：腔内修复能有效治疗肾下主动脉夹层,具有简洁、微创的特点。远期疗效有待进一步观察。     

Stanford B型主动脉夹层的腔内治疗（附134例报告）

目的探讨腔内胸主动脉修复术治疗Stanford B型夹层的临床价值。方法对我院2006年1月～2011年8月134例行腔内胸主动脉修复术的B型主动脉夹层患者的治疗情况进行回顾性分析。男93例,女41例。年龄32～82岁,（56.4±8.3）岁。全麻,数字减影动脉造影（digital subtraction angiography,DSA）监控下,切开股动脉,将带膜支架置于胸主动脉内膜破口处封堵破口。结合术前影像学、术后门诊影像学随访资料,观察夹层病变演化过程,观察有无内漏、移位和人工血管内支架塌陷等术后并发症。结果 134例原发胸主动脉夹层破口均完全封闭,真腔血流恢复,原受损脏器功能恢复正常。释放支架165枚。围手术期死亡2例,随访死亡1例。90例获得随访,随访时间3～63个月,（25.6±8.4）月,主动脉CT血管成像（CT angiography,CTA）复查显示无内漏、移位等并发症。12例支架尾部破口,再次行腔内隔绝,1例术后逆行性A型夹层。结论腔内胸主动脉修复术治疗Stanford B型夹层具有技术可靠、安全性高、术后恢复快等优点,临床应用前景良好。     

CUFF预开窗技术治疗胸主动脉腔内修复术后近端内漏

目的探讨胸主动脉腔内修复手术中即时造影提示覆膜支架近端出现Ⅰ型内漏,通过追加植入体外预开窗的支架延长段(CUFF)以延长锚定区,并消除Ⅰ型内漏的手术方式的安全性、有效性及其技术要点。方法 2016～2017年阜外医院血管外科中心实施胸主动脉腔内修复手术623例,其中6例患者在第1枚覆膜支架植入后,采取了追加植入1枚体外预开窗CUFF的方法处理了近端Ⅰ型内漏并保留了弓部分支动脉。6例患者平均年龄63.3(54～76)岁,男4例、女2例,其中Stanford B型主动脉夹层2例,胸主动脉假性动脉瘤1例,主动脉穿通性溃疡3例,全部接受经股动脉途径的胸主动脉腔内修复术治疗。结果本组手术成功率100.0%,预开窗技术分支动脉保留成功率100.0%,预开窗平均时间10.3(6～17)min。5例保留了左锁骨下动脉,1例同时保留了左颈总动脉和左锁骨下动脉,后者经开窗向左颈总动脉植入覆膜支架1枚。本组锁骨下动脉均未植入支架。Ⅰ型内漏消除率83.3%(5/6),1例患者术后仍有微少量内漏,未予进一步处理。所有患者均获得门诊或电话随访,随访时间10.3(3～25)个月,即时造影残留微少量内漏患者于术后3个月随访时内漏完全消失,所有患者生活质量改善,无死亡患者。结论对于腔内修复治疗术中出现近端Ⅰ型内漏的主动脉弓降部疾病患者,采取追加植入体外预开窗CUFF的方法,可在延长近端锚定区的同时成功保留弓上分支动脉。     

腔内修复术治疗主动脉夹层的体会（附15例报道）

目的总结腔内修复术治疗主动脉夹层的经验。方法选择2011年7月至2013年1月期间我院住院的胸主动脉夹层患者15例,术前均采用CTA评估,全部行腔内修复术。结果15例患者采用腔内修复手术全部成功,手术时间95～165min,（120＋26）min;失血量30～160mL,（68±34）mL。10例采用经股动脉入路,5例采用经股动脉及肱动脉入路。13例单一破口者各植入支架1枚,手术全部成功。15例患者未发生截瘫,无一椎基底动脉缺血症状,无下肢缺血改变,无伤口感染及腹股沟区淋巴瘘。2例存在Ⅱ型内漏,未经处理自行闭合。随访胸腹主动脉CTA扫描显示覆膜支架均未移位,未发现植入支架后并发近端夹层者。结论腔内修复术治疗主动脉夹层是一种有效的治疗方法,具有安全性高、术后并发症少、治疗效果好等优点。     

腔内修复术治疗Stanford B型胸主动脉夹层临床分析

目的 探讨腔内修复术治疗胸主动脉夹层的方法和疗效.方法 回顾性分析78例StanfordB型胸主动脉夹层的临床资料.术前均采用CT血管造影(CTA)或磁共振血管造影(MRA)对患者进行评估;在数字减影血管造影( DSA)的监控下经股动脉将带膜支架型人工血管置入胸主动脉内膜破口处,封闭夹层近端第一破口;术后即行DSA.于术后1,3,6个月及1年以后每隔1年行CTA随访,随访患者生存状况、内漏类型及残余夹层真假腔内径.结果 腔内修复后,术中造影发现Ⅰ型内漏6例,其中2例内漏在cuff植入后消失;2例近端内漏行球囊扩张后内漏消失;2例漏血少,假腔显影浅淡,未予处理;术后3个月发现1例内漏仍持续存在,但假腔直径未见增大.Ⅱ型内漏2例,因漏血少,未予处理.术后6个月发现其中自行封闭1例;另1例内漏仍存在,但假腔直径未见增大.78例患者中,术中封闭左锁骨下动脉者15例.其中2例出现左上肢窃血综合征,并伴有乏力症状;2例2年后出现脑梗死;1例6个月后出现Stanford A型夹层而行升主动脉置换术.其余患者无心、肺、肾功能衰竭及截瘫等严重并发症.结论 近期随访结果表明,腔内修复术治疗Stanford B型胸主动脉夹层安全、有效;内漏是该手术的主要并发症.     

腔内修复治疗肾下腹主动脉夹层六例经验

目的 探讨肾下腹主动脉夹层腔内治疗的可行性、方法选择和疗效。方法 回顾性分析2000年1月至2006年10月以腔内修复为主的6例肾下腹主动脉夹层患者的临床资料，患者术前均通过螺旋CT或者DSA检查明确诊断。3例采用分叉弄人工血管内支架进行腔内修复；2例植入腹主-单侧髂动脉型人工血管内支架、对侧髂动脉植入封堵器、股股人工血管旁路术；1例植入2枚直管型人工血管内支架，对侧髂动脉结扎、股股人工血管旁路术。患者术后1、3、6个月、1年及以后间隔1年于门诊行彩色B超、X线或者螺旋CT进行随访。结果 所有患者夹层得到完全修复，围手术期4例患者出现一过性发热，无血象异常。术后患者随访6～36个月，5例患者结果满意，1例患者于6个月随访时瘤腔内残留少量血流信号，瘤腔基本血栓化。结论 肾下腹主动脉火层采用以腔内修复为主的方法 安全可行、短期和中期疗效可靠。     

血管腔内治疗主动脉夹层和夹层动脉瘤

目的 探讨血管腔内治疗主动脉夹层和夹层动脉瘤的技术方法和疗效。方法 对20例主动脉夹层和夹层动脉瘤患者的临床资料进行分析。Stanford A型2例,其中1例内膜撕裂口位于升主动脉。Stanford B型18例。5例在不同部位有2个以上撕裂口。全组均以带膜支架型人工血管腔内植入行隔绝术。其中1例加作腹主动脉开窗和人工血管置换术,1例先行升主动脉．左锁骨下动脉和左颈总动脉Y形人工血管旁路术,再行腔内隔绝术。结果 无一例患者术中死亡,术后3d 1例Stanford B型患者死于心肌梗死,其余19例健康存活,生存率95％。术后随访1—20个月,各例主动脉夹层和动脉瘤均消失,无内漏,各器官灌注良好。结论 血管腔内植入带膜支架型人工血管是治疗主动脉夹层和夹层动脉瘤的简便、安全而有效的方法。手术死亡率低,手术成功率和生存率高。     

穿透性主动脉溃疡的外科治疗

目的 总结经开放手术或腔内修复穿透性主动脉溃疡(PAU)的外科治疗经验.方法 回顾性分析10例PAU患者的临床资料,其中6例病灶位于降主动脉,4例位于腹主动脉;并发主动脉瘤1例、间壁血肿2例、溃疡破溃2例及夹层6例.结果 4例采用开放手术治疗,1例术后出现右胸腔积液,但经处理后基本痊愈;6例采用腔内治疗,1例腔内治疗后发生轻微的内漏,1个月后该内漏自发消失.10例患者获得随访,平均随访时间为(17.8±11.53)个月,1例在随访12个月后失访.开放手术者无一例发生与血管手术相关的并发症;腔内治疗患者无一例发生支架移位.结论 PAU经正确选择外科治疗方案并进行处理后的效果是理想、安全的,而且其短期及中期效果是稳定的.     

Endovascular repair of symptomatic penetrating atherosclerotic ulcer of the thoracic aorta.

BACKGROUND: In this study we evaluate published and personal experience of Endovascular Repair (EVAR) of penetrating atherosclerotic ulcers (PAU). PATIENTS AND METHOD: In 12 patients (mean 74 years, 58-87 years) PAU was diagnosed with computer tomography (CT). Symptomatic ulcers were treated by vascular surgeons using stentgrafts via a femoral access route. Patients were followed up clinically and with CT for an average of 849 days (186-1968 days). RESULTS: 11 patients had severe acute thoracic pain, one patient presented with hemoptysis. CT showed well outlined ulcer, intramural hematoma, and contrast enhancement of the aortic wall (n=12), pseudoaneurysm (n=11), intimal calcification adjoining the ulcer (n=10), pleural (n=9) and mediastinal fluid (n=4). Mean duration of surgery was 68min (32-120min). Primary technical success was achieved in all patients. There was no perioperative complications except one acute hemorrhage from an intercostal artery and one iliac dissection. 3 months after stentgraft application owing to a severe stenosis of the right common femoral artery, an iliofemoral bypass was performed in one patient. All patients were free of symptoms after the procedure. There was incomplete sealing of PAU in 2 of 12 patients, but no re-intervention was needed. All patients were alive during follow-up. CONCLUSION: Symptomatic PAU is a potentially fatal lesion. Considering the low morbidity and mortality of EVAR, this option might be first choice.     

Limb graft occlusion following EVAR: clinical pattern, outcomes and predictive factors of occurrence.

INTRODUCTION: We reviewed our experience with limb occlusion after EVAR in order (1) to assess the clinical pattern and treatment options (2) to assess outcomes and (3) to identify predictive factors of occurrence. MATERIALS AND METHOD: Between 1995 and 2005, 460 AAA patients were electively treated with a variety of commercially available stent grafts. There were 369 bifurcated and 91 aortouniiliac grafts (829 limbs). Follow-up included physical examination, plain X-ray, Duplex ultrasonography, and spiral computed tomographic scans at 1, 6, 12 months and annually thereafter. All pertinent data were collected prospectively and analysed retrospectively. The follow-up period ranged from Day 0 to 104 months, with a median follow-up of 23.4 months. RESULTS: 36 limbs in 33 patients (7.2%) occluded between Day 0 and 71 months (average: 9.5 months) after EVAR. Presentation was acute ischemia in 11 cases, rest pain in 9, claudication in ten. Four occlusions remained asymptomatic and two occurred intraoperatively. Treatment was femoro-femoral cross-over graft in 19 cases, axillo-femoral bypass in three, thrombectomy and stent in three, thrombolysis and stent in nine, and conservative in two. One patient (3%) died of multiple organ failure after thrombolysis. There was no amputation. Reocclusions occurred in two patients (6.1%). Multivariate logistic regression showed that kinking (odds ratio [OR] 11.9; confidence interval [CI] 3.39-42.1; p=0.0001), first graft generation (OR 2.87; CI 1.25-6.62; p=0.017) and younger age (OR 1.05; CI 1.00-1.09; p=0.034) were independently related to the occurrence of graft limb occlusion. CONCLUSION: Acute graft limb occlusion is not rare after EVAR. The frequency of limb occlusion has declined with current stent grafts generation. Although surgery and endovascular treatments are efficient and safe, development of a graft limb kink should lead to aggressive pre-emptive treatment to prevent occlusion.     

Initial experience with endovascular aortic aneurysm repair without cardiologists or radiologists--do vascular surgeons really need them?

Endovascular abdominal aortic aneurysm repair (EVAR) has been predominantly accomplished by teams of multidisciplinary interventionalists, frequently under the primary direction of cardiologists and radiologists. The purpose of this paper was to examine the feasibility and safety of an initial experience of EVARs performed by vascular surgeons at a single institution without other interventionalists. The authors reviewed the first 50 EVARs performed solely by vascular surgeons at our hospital, which we believed represented a fair and sizable enough learning curve for this new procedure. The operations were performed in an endovascular operating room and the surgeons had prior endovascular experience. The EVAR protocol included preoperative abdominal computed tomography (CT) scans and aortograms, same-day admissions, epidural anesthesia, transfer to the ward the day of surgery, and discharge the first postoperative day. CT scans were performed on postoperative day 1 and then annually, unless duplex ultrasound (DU) suggested an endoleak. DU was performed 1 week postoperatively, every 3 months for the first year, and then every 6 months thereafter. Of the first 23 patients, 3 required immediate conversion to open repair because of device malfunction (all in a Phase III FDA trial) and 1 underwent conversion 3 weeks after initial graft placement during treatment of a failing endograft limb as diagnosed by duplex ultrasonography. None of the next 27 cases required conversion. In 2 (4%) patients, graft limb occlusions occurred postoperatively and were treated with femorofemoral crossover grafts. There were 5 (10%) endoleaks: 2 were treated endovascularly, 1 closed spontaneously, and 2 were followed. Several advanced adjunctive endovascular procedures were performed concomitantly during EVAR including internal iliac artery coil embolization using aortic crossover catheters in 16% (8/50) of patients, proximal or distal extension cuff placement in 16% (8/50), and graft limb stenting in 50% (25/50). The average length of stay for patients who underwent uncomplicated aortic stent grafts was 1.9 days (range, 1-4 days) compared to 2.3 days for all patients (range 1-13 days). In no case were other interventionalists necessary for intraoperative assistance. These results of EVAR performed solely by vascular surgeons are comparable to reports by multidisciplinary teams and support the premise that vascular surgeons with endovascular skills have the knowledge and capability to begin performing EVAR independently of other specialists.     

胸主动脉夹层腔内治疗相关并发症的处理

目的 回顾血管腔内修复术(EVAR)治疗胸主动脉夹层后相关并发症的治疗经验,探讨并发症发生原因和处理中存在的问题.方法 回顾性分析2002年7月至2008年3月胸主动脉瘤夹层stanford B型EVAR术后相关并发症33例,其中男性21例,女性12例,平均年龄46.3岁.EVAR术后最长6个月,平均12.3 d.并发症包括左颈总动脉闭塞5例,内漏5例,下肢动脉损伤4例,支架血管植入假腔3例,支架远端逆行性夹层3例,继发A型夹层2例,肢体动脉栓塞2例,以及肱动脉假性动脉瘤和脑血管意外、植入物感染等.除保守治疗外,行二期支架植入13例,颈-颈动脉和颈-锁骨下动脉转流7例,髂股动脉修补或移植4例,动脉取栓1例,经腹主动脉假腔开窗2例,转为升主动脉置换1例.结果 随访结果显示,二期支架植入后内漏消失,动脉转流术后中枢神经系统、肢体及肠管缺血明显改善,逆行性夹层消失.1例A型夹层死于急性心包填塞,1例死于脑出血.结论 对于EVAR术后并发症必须及早处理,采用血管腔、内外治疗相结合措施可提高成功率.     

主动脉创伤腔内修复术后的影像学随访

目的 分析主动脉腔内修复术救治的主动脉创伤伤员的影像学随访资料,探讨预防主动脉腔内修复术后出现并发症的措施.方法 回顾性分析2006年1月-2014年9月因主动脉创伤在广州军区武汉总医院心胸外科行主动脉腔内修复术的伤员影像学随访资料,要求术后至少有2次CTA检查,且最后一次检查需离手术至少3个月.结果 检索出符合条件的病例23例,CTA显示主动脉内血管支架无移位、严重内漏,伤员无严重并发症的临床症状.11例伤员出现主动脉血管内支架在病变部位凸出,其中3例明显致使邻近食管管腔狭窄.结论 主动脉腔内修复术是主动脉创伤的一种快速、有效的救治方式,术后的一些特殊类型的并发症应在手术前进行评估.     

胸降主动脉瘤腔内修复41例治疗体会

目的 总结胸降主动脉瘤腔内修复治疗方法和经验.方法 回顾分析2001年1月至2007年7月41例胸降主动脉瘤患者腔内修复诊治经过、结果和并发症,其中4例行辅助性右-左颈总动脉、左颈总动脉-左锁骨下动脉旁路术,二期(1周后)或一期行腔内修复治疗.结果 41例移植物均被放置在预定位置.2例患者(4.9%)围手术期分别因多器官功能衰竭和急性心肌梗死而死亡.18例患者(43.9%)术后即时造影显示近端Ⅰ型内漏;其中4例内漏量大,行球囊扩张后内漏消失.2例(4.9%)患者围手术期出现急性肾功能不全,1例透析时间超过30 d.其余患者围手术期无脑卒中、截瘫、动脉瘤破裂或肢体严重缺血等并发症.26例(63.4%)患者获随访,随访时间为1～60个月[平均(18.6 ±4.2)个月].1例术后4年发生支架型人工血管移位并发Ⅰ型内漏,1例术后2年于支架型人工血管连接处出现Ⅲ型内漏,均再次行腔内修复治疗.2例死于其他疾病.其余患者术后3个月CT证实瘤腔内完全血栓形成,无支架移位和内漏.随访期间动脉瘤最大直径缩小0～22 mm,平均(8.3±4.5)mm,4例辅助性动脉旁路均通畅.结论 腔内修复治疗胸降主动脉瘤技术上可行,具有创伤小、术后恢复快和并发症少等优点.有条件者,特别对不能耐受传统手术的患者应优先考虑腔内修复治疗.     

Stent grafts for thoracic aortic pathology: single-center experience in Western Australia

The purpose of this article is to report a single-center experience in treating thoracic aortic pathology with stent grafts. This is a retrospective review of cases done within a period of 30 months. Between January 2002 and May 2004, 12 patients were treated in our institution with thoracic stent grafts (n = 12) for various clinical conditions. There were seven men and five women. Three patients required emergency treatment (n = 3), two for aortic transection and one for iatrogenic injury during lung biopsy. Others were treated electively (n = 9). All patients were high risk for open surgery. There was one perioperative death, with a patient with multiple trauma succumbing to head injury 4 weeks after stent graft insertion. There was no incidence of paraplegia. Three patients underwent bypass surgery in the neck to achieve an adequate proximal seal zone prior to stent grafting. One patient with an aneurysm of the descending thoracic aorta required an extension limb below the original graft for an increase in sac size, possibly owing to endotension. Renal failure occurred in one patient and resolved without dialysis. One patient died 18 months after her procedure, possibly owing to aneurysm expansion. Stent grafts are a viable alternative to open surgery for thoracic aortic pathology in high-risk individuals. Visceral and spinal cord ischemia is less prevalent with stent grafts compared with open surgery. The short-term results are promising. Long-term follow-up is awaited. Stent grafts might have greater impact in the thoracic aorta than the abdominal aorta for which they were initially developed.     

Endovascular repair of the half aortic arch in pigs with an improved, single-branched stent graft system for the brachiocephalic trunk

The objective of this study was to evaluate the feasibility of endovascular repair of half of the aortic arch in pigs using an improved, integrated, single-branched stent graft for the ascending aorta and brachiocephalic trunk (BCT). We designed an improved stent graft in an integrated fashion and deployed the stent grafts into the ascending aortas and BCT of eight pigs. The feasibility of the stent graft deployments was evaluated three months after the procedures using arteriography, computed tomography angiography (CTA) and animal autopsy. The stent grafts were successfully deployed in eight pigs. All animals survived for at least three months. Arteriography, CTA and animal necropsy revealed good stent fixation in eight cases. Their head CT scans found no evidence of cerebral infarction. In conclusion, endovascular repair of the half aortic arch with the integrated single-branched stent graft system appears to be safe and feasible in pigs.