国人升主动脉及主动脉弓的CT解剖研究

目的 通过CT血管造影(computed tomographic arteriography,CTA)方式回顾性研究中国人群升主及弓部血管的直径、长度特点;方法选择2006年9月至2007年9月接受胸主动脉CT血管造影的患者388例,使用GE公司AW4.2工作站测量升主、弓部、弓上分支的直径及长度数据,运用统计学软件进行分析.结果 冠脉开口以上至左锁骨下动脉以远的主动脉直径D1-D6分别为(34±5)mm;(34±5)mm;(33±4)mm;(30±4)mm;(28±3)mm;(26±3)mm.头臂干两处直径d1,d2分别为(13±2)mm;(13±2)mm.左颈总动脉两处直径d3,d4分别为(8.7±1.5)mm;(7.9±1.0)mm.左锁骨下动脉两处直径d5,d6分别为(10.7±1.7)mm;(9.3±1.3)mm.冠脉开口处至头臂干动脉开口近端的主动脉管腔长度L1为(5.4±1.2)cm;头臂干开口近端与左颈总动脉开口近端之间的主动脉管腔距离L2为(1.3±0.4)cm;头臂干起始处至右锁骨下动脉开口处长度11为(4.0±0.8)cm;左锁骨下动脉起始处至椎动脉开口处管腔长度I2为(3.8±0.8)cm;头臂干与左颈总动脉管壁之间距离I3为(0.39±0.23)cm;左颈总与左锁骨下动脉之间管肇距离I4为(0.7±0.5)cm.结论 得到中国人群升主及弓部血管直径和长度的数据,可为腔内修复升主动脉及主动脉弓的各类研究提供数据支持.     

胸主动脉分支血管的CT研究

目的 利用CT血管造影测量胸主动脉分支血管,为胸主动脉腔内修复技术提供相关的血管解剖指导.方法 收集2008年1月-2012年2月在广州军区武汉总医院进行胸主动脉CT血管造影检查的739例患者资料,测量升主动脉、主动脉弓、弓上分支的直径和长度,并进行统计、分析.结果 主动脉弓分为标准型和变异型,其中标准型最常见,占总例数的91.1％,变异型占8.9％.主动脉弓标准型患者的冠状动脉开口处升主动脉直径为(35.7±4.3) mm,头臂干开口处升主动脉直径为(33.6±4.2) mm,头臂干与左颈总动脉之间的主动脉弓直径为(29.4±5.7) mm,左颈总动脉与左锁骨下动脉之间的主动脉弓直径为(27.6±4.2) mm,左锁骨下动脉开口处降主动脉直径为(25.4±4.5) mm,头臂干在主动脉弓分支处的直径为(12.9±0.9) mm,左颈总动脉在主动脉弓分支处的直径为(8.5±0.7)mm,左锁骨下动脉在主动脉弓分支处的直径为(10.4±1.1) mm,冠状动脉与头臂干之间的管壁长度为(53.3±12.5) mm,头臂干与左颈总动脉之间的管壁长度为(4.7±1.5) mm,左颈总动脉与左锁骨下动脉之间的管壁长度为(7.9±2.6)mm,头臂干起始处至右锁骨下动脉开口处长度为(41.1±8.2)mm,左锁骨下动脉起始处至椎动脉开口处管腔长度为(38.5±5.7) mm,头臂干与左颈总动脉间距的平面与矢状面之间的夹角为(71.2±7.2)°,左颈总动脉与左锁骨下动脉间距的平面与矢状面之间的夹角为(31.1±2.9)°.结论 CT测量所得的胸主动脉数据可以为血管支架的生产提供支持,还能为腔内修复术中支架的定位释放提供指导.     

主动脉弓扩张性疾病的腔内治疗

主动脉弓的近端为无名动脉(头臂干)在主动脉上的起始部前端,远端为左锁骨下动脉起始部以远约2 cm的主动脉峡部(在左锁骨下动脉与肺动脉韧带之间)[1]。自1991年腹主动脉瘤腔内隔绝术成功后,腔内治疗已逐步应用于腹主动脉非分支区(N3区)、胸降主动脉非分支区(N2区)及腹主动脉分支区     

主动脉弓部夹层的腔内治疗

主动脉弓的近端为无名动脉(头臂干)在主动脉上的起始部前端,远端为左锁骨下动脉起始部以远约2cm的主动脉峡部(在左锁骨下动脉与肺动脉韧带之间)[1].无论是DeBakey分型,还是Stanford分型,对于起源于主动脉弓部的夹层,或者由于逆撕影响到主动脉弓部的Stanford B型夹层,都没有给予明确的分型[2-3].但是,这一类夹层确实存在.     

主动脉弓降部病变患者胸主动脉腔内治疗同期左锁骨下动脉血流重建的近中期效果CSCD

目的 探讨胸主动脉腔内治疗主动脉弓降部病变同期行左锁骨下动脉血流重建的预后.方法 2010年1月到2016年8月,55例主动脉弓病变合并椎动脉左侧优势型患者,术前均经主动脉CT诊断,接受覆盖左锁骨下动脉开口的胸主动脉腔内治疗,其中28例同期行左锁骨下动脉重建.研究终点包括术后死亡、再手术、卒中和主动脉相关不良事件.结果 患者均随访,平均（30.0 ±17.5）个月.左侧椎动脉直径为（4.88 ±0.85）mm,右侧椎动脉为（3.00 ±0.75）mm.全组无院内死亡、再次手术和主动脉相关的不良事件.随访期间,2例主动脉覆膜支架仍存在Ⅳ型内漏,3例死亡.结论 主动脉弓降部病变患者于腔内修复同期行左锁骨下动脉重建的治疗效果安全可靠,中期预后良好,仍需长期随访.     

Stanford B型主动脉夹层腔内修复术中左锁骨下动脉处理的研究进展

近年来胸主动脉腔内修复术(TEVAR)在Stanford B型主动脉夹层的治疗中取得了显著的疗效。主动脉弓结构复杂、曲度大、弓上分支血管负责脑部和上肢等重要区域的血供,其中左锁骨下动脉包含椎动脉等重要分支,负责左上肢、后脑部等的血供。为了保证足够的锚定区,当近端裂口距左锁骨下动脉开口距离1.5cm时需对左锁骨下动脉做相应处理,现对Stanford B型主动脉夹层腔内修复术中左锁骨下动脉的处理予以综述。     

Castor分支型覆膜支架预开窗治疗累及升主动脉的非A非B型主动脉夹层1例北大核心CSCD

77岁男性患者,因血尿行泌尿系增强CT提示主动脉夹层,膀胱占位,进一步查胸腹主动脉CTA示近端累及升主动脉的非A非B型主动脉夹层,夹层破口位于左锁骨下动脉开口后壁。利用Castor分支型覆膜支架通过预开窗重建无名动脉和左颈总动脉,联合左锁骨下动脉栓塞成功隔绝夹层破口。     

倒装Gore Excluder对侧喇叭腿支架治疗孤立性髂动脉瘤1例

<正>患者,男性,77岁。因"突发胸背部疼痛1天"于2017年3月8日入住我院心血管内科,入院后行全主动脉CT血管造影(computed tomography angiography,CTA)显示:胸主动脉弓降部小弯侧溃疡;左髂总动脉瘤(瘤体最大直径40 mm,近端髂总动脉瘤颈直径16 mm、长度15 mm,远端髂外动脉直径12 mm)(图1)。于2017年3月14日,气管插管全麻下行胸主动脉溃疡腔内隔绝+左锁骨下动脉烟囱支架植入+左髂内动脉栓塞+左髂动脉腔内隔绝(倒装Gore Excluder对侧喇叭腿支架)术。手     

Castor分支型覆膜支架预开窗治疗累及升主动脉的非A非B型主动脉夹层1例

77岁男性患者, 因血尿行泌尿系增强CT提示主动脉夹层, 膀胱占位, 进一步查胸腹主动脉CTA示近端累及升主动脉的非A非B型主动脉夹层, 夹层破口位于左锁骨下动脉开口后壁。利用Castor分支型覆膜支架通过预开窗重建无名动脉和左颈总动脉, 联合左锁骨下动脉栓塞成功隔绝夹层破口。     

经颈动脉腔内技术重建主动脉弓治疗Stanford A型夹层动脉瘤(附1例报告)

目的探讨血管腔内技术重建主动脉弓治疗升主动脉、主动脉弓病变的可行性。方法2005年,对1例StanfordA型夹层动脉瘤,腔内修复主动脉病变之前做右颈总动脉-左颈总动脉-左锁骨下动脉的旁路术;经右颈总动脉将修改的分叉支架型血管主体放入升主动脉,长臂位于无名动脉。短臂应用延长支架型血管延伸至降主动脉。通过腔内技术重建主动脉弓实现累及升主动脉和主动脉弓主动脉病变的微创治疗。结果腔内修复术后移植物形态良好,血流通畅,病变被隔绝,脑、躯干、四肢循环稳定。无严重并发症。结论该手术方案设计合理、技术可行。可能成为复杂胸主动脉病变新的腔内治疗模式。     

DSA检测主动脉弓形态及分支变异

目的应用DSA技术评估主动脉形态及其分支变异。方法回顾性分析4272例接受主动脉弓及全脑血管DSA患者的DSA资料,评估主动脉弓形态及分支变异的发生率。结果 4272例患者中主动脉弓形态及分支正常3925例(3925/4272,91.88%),主动脉弓形态及分支变异347例(347/4272,8.12%)。变异类型:左颈总动脉(LCCA)与头臂干(BT)共干起自主动脉弓(175/4272,4.10%);左椎动脉(LVA)直接起自于主动脉弓LCCA与LSA之间(97/4272,2.27%);右颈总动脉(RCCA)直接发自主动脉弓伴迷走右锁骨下动脉(RSA)(35/4272,0.82%);RCCA、LCCA、LSA直接起自主动脉弓,迷走RSA起自降主动脉(10/4272,0.23%);RCCA、LSA直接起自主动脉弓,RSA与LCCA共干起自主动脉弓,RVA起自RCCA(4/4272,0.10%);右椎动脉双起源于RSA(4例/4272,0.10%);RVA起自右侧颈内动脉(4/4272,0.10%);弓上自右向左发出RCCA、LCCA、LSA、RSA,迷走RSA,LVA缺如,伴原始三叉动脉(4/4272,0.10%);镜像型右位主动脉弓(13/4272,0.30%);右位主动脉弓,LSA起自弓上Kommecell憩室(1/4272,0.02%)。结论通过DSA评估主动脉弓形态类型及分支的变异情况对介入诊断及治疗和某些胸部手术具有重要指导意义。[关键词]血管造影术,数字减影;主动脉,胸;解剖学变异     

Selective Delayed Management of Blunt Traumatic Left Common Carotid Artery Injury Using Hypothermic Circulatory Arrest

Most traumatic carotid artery aneurysms occur at or close to its bifurcation, and traumatic aneurysm of the intrathoracic carotid arteries are rare. We describe a case of false aneurysm at the origin of the left common carotid artery (LCCA) after blunt trauma. A 53-year-old man suffered a blow from a broken steel plate, which flew from a working concrete crusher over his neck when he looked down the machine. Chest computed tomography revealed aneurysm of the LCCA, and aortic arch arteriography demonstrated a false aneurysm of about 3 × 5 cm at the origin of the LCCA, with loss of arterial continuity and abnormal tortuosity above the aneurysm. An ascending aorta to LCCA bypass graft was placed during the cooling period of cardiopulmonary bypass, and mattress sutures were placed in the normal aorta to close the origin of the LCCA under hypothermic circulatory arrest because of the extreme danger of dissection. The LCCA was transected partially at its origin from the aorta. We speculated that the direct lifting force which caused the carotid artery to move upward might produce a tear at the junction of the LCCA and the aortic arch.     

Ankura主动脉覆膜支架行原位开窗重建弓上分支的应用

背景与目的 胸主动脉腔内修复术（TEVAR）已经成为治疗主动脉弓部病变的首选术式。然而,此术式要求支架近端安全锚定区至少为15 mm,对于锚定区不足者,则通常需重建弓部分支血管以确保手术安全。在目前各种重建技术中,原位开窗技术因其较大程度的保留分支血管以及较低的内漏风险而应用最多。因此,本研究探讨Ankura主动脉覆膜支架进行原位开窗重建弓上分支的可行性及效果。方法 回顾性分析2017年3月—2020年12月中国科学院大学宁波华美医院收治的47例近端锚定区不足的主动脉病变患者的临床资料。其中胸主动脉夹层38例,胸主动脉瘤6例,胸主动脉溃疡3例。根据术前CTA影像资料决定患者的开窗数目、开窗支架规格,术中利用穿刺针对Ankura主动脉覆膜支架进行原位开窗重建弓部分支,术后定期行主动脉CTA复查随访。结果 所有患者均获手术成功,共植入Ankura胸主动脉覆膜支架47枚,Gore Viabahn覆膜支架51枚,Cordis Smart裸支架20枚。4例术中转烟囱支架植入,原位开窗成功率91.5%（43/47）,包括左锁骨下动脉（LSA）开窗29例,左颈总动脉（LCCA）开窗+LSA栓塞1例,LSA开窗+左椎动脉烟囱1例,LSA开窗+左LCCA烟囱9例,LCCA+LSA开窗+无名动脉（IA）烟囱1例,LCCA开窗+IA烟囱+LSA栓塞2例。全组患者手术时间160~300 min,平均（200±20）min,术中开窗时间18~45 min,平均（30±8）min;术后内漏（1型）3例,逆撕2例（1例行升主动脉置换后好转,1例死亡）,脑梗死2例,截瘫0例。平均随访时间（28.4±14.7）个月,期间2例内漏在随访中消失,1例内漏未进一步增大予以观察随访中,未见开窗分支血管闭塞。结论 利用穿刺破膜技术对Ankura主动脉覆膜支架进行原位开窗重建分支血管是一种切实可行且有效的治疗方式,近期效果良好。     

Analysis of origin of the supra-aortic trunks from the aortic arch

Objective

The objective of this study was to describe in the general population the anatomy of the supra-aortic trunks (SATs: brachiocephalic trunk [BCT], left common carotid artery [LCCA], and left subclavian artery [LSA]) arising from the aortic arch in terms of mutual distances from the valvular aortic plane (VAP), ostial diameters, and clock face orientation from the sagittal aortic axis, with an analysis of each distribution.

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??Objective:To discuss the methods of Endovascular aneurysm repair (EVAR) for artic arch aneurysm or dissection. Methods:From Sep.1998 to Feb.2006,63 cases related with the super??arch branches.Three methods were used in the lesions with left subclavain artery (LSA) invasion only,covering the LSA without reconstruction,LSA bypass before EVAR or covering LSA completely and then re??open it by endovascular technique.To the lesions with LSA and left common carotid artery (LCCA) invasion,a traditional bypass of LCCA and LSA was done before EVAR,or covering most of LCCA first,and then reconstructed it through LCCA by endovascular technique.To the lesions with three super??arch branches invasion,a bifurcated stent??graft was planted for reconstructing the artic arch. Results:LSA was treated in 54 cases,LSA and LCCA were treated in 8 cases and all of the super??arch branch arteries were treated in 1 case.All of the auxiliary techniques were enforced successfully.The primary average systolic pressure of left brachial artery was ??62.6±24.2??mmHg in cases without LSA reconstruction.The 30??days endoleak rate was 17.5%. Conclusion:Covering the LSA is safe to the patients with normal contraliteral vertebral and basilar artery.EVAR combined with supplementary techniques can expand the EVAR indications of aortic arch lesions.The long term result still keep in follow up.     

Partial debranching hybrid stent graft for distal aortic arch aneurysms

Purpose

To evaluate the early outcomes of treating distal aortic arch aneurysms (DAAAs) with a partial debranching hybrid stent graft, and to analyze the morphology of distances among the supra-aortic branches.

Methods

We used this stent graft to treat DAAA in 12 patients, by debranching the left common carotid artery (LCCA) and the left subclavian artery (LSA). With computed tomography (CT) data on the collective total 28 thoracic aortic aneurysms, the distances from the LSA to the LCCA and those from the LSA to the brachiocephalic artery (BA) were measured using multiplanar reconstruction (MPR) and centerline of flow (CLF) methods.

Results

All procedures were done in two stages and all stent grafts were deployed in zone-1. The devices used were the TALENT in seven patients and the TAG in five patients. There were no operative deaths, paraplegia, or type-1 or -3 endoleaks. One patient suffered minor cerebral infarction. The distance from the LSA to the BA was longer than that from the LSA to the LCCA by10?mm in the CLF method and by 13?mm in the MPR method.

Conclusions

It was possible to achieve a longer proximal landing zone by debranching two supra-aortic branches, the LCCA and the LSA. The partial debranching hybrid stent graft was less invasive and more effective for DAAAs.     

DeBakey Ⅰ型主动脉夹层动脉瘤的血管腔内治疗

目的探讨血管腔内治疗DeBakeyⅠ型主动脉夹层动脉瘤的方法。方法对7例DeBakeyⅠ型主动脉夹层动脉瘤进行血管腔内治疗。7例均行磁共振血管造影、CT和动脉造影检查确诊。内膜撕裂口均位于升主动脉,距冠状动脉开口2．5-6．0cm,距右头臂干开口0．5-4．0cm。2例通过左颈总动脉置入带膜支架,术前行左锁骨下动脉-左颈总动脉间内转流术以保证左颈总动脉血供。5例通过右股总动脉置入带膜支架,其中2例先行左锁骨下动脉-左颈总动脉-右颈总动脉人工血管旁路术。结果全组均手术成功。3例第1枚支架释放后仍有较多内漏,即再放入第2枚支架,交错重叠于第1枚支架内面而成功封闭撕裂口,消灭内漏。除1例术后1个月因急性上消化道大出血死亡外,其余6例存活。6例的假腔均有血栓形成,无内漏,无新的夹层动脉瘤形成。结论DeBakeyⅠ型主动脉夹层动脉瘤的血管腔内治疗是可行、微创和有效的。病例选择应注意撕裂口距冠状动脉开口的距离。     

全弓置换和支架象鼻手术治疗A型主动脉夹层时左锁骨下动脉的处理分析

目的 总结选择性结扎左锁骨下动脉、仅重建无名动脉和左颈总动脉方法在A型主动脉夹层全弓置换和支架象鼻手术中应用的临床经验.方法 2008年1月至2010年6月,29例A型主动脉夹层患者在接受全弓置换和支架象鼻手术时,因左锁骨下动脉显露困难,术中将其直接结扎.本组男性21例,女性8例,年龄19～55岁,平均年龄(44±12)岁.其中急性夹层12例,亚急性夹层4例,慢性夹层13例.所有患者依据术前影像学和术中循环、压力指标判断患者大脑Willis环和双侧椎动脉的侧支循环情况,如侧支良好,则直接结扎左锁骨下动脉、仅重建无名动脉和左颈总动脉;如果侧支不足,则结扎后加行升主动脉-左腋动脉旁路术.结果 29例手术均顺利完成,1例术后死于肺部感染,其余恢复顺利.术后左上肢血压(78±17)mmHg(1 mmHg=0.133 kPa),明显低于右上肢的(126±24)mmHg(P＜0.01),但左侧指氧饱和度、皮温、肌力及感觉运动功能与右侧相比无明显差异.随访1～27个月,无左锁骨下动脉盗血综合征与左上肢肌萎缩发生.结论 在对A型主动脉夹层行全弓置换和支架象鼻手术时,如果动脉瘤体较大、左锁骨下动脉位置较深、显露困难时,可以在充分评估侧支循环的前提下直接予以结扎,可简化手术操作和手术难度,术后无明显不良后果.

Abstract：

Objective To summarize the experiences of ligating left subclavian artery(LSA)in total arch replacement and stented elephant trunk implantation for Stanford type A aortic dissection patients with difficulty in exposing the LSA. MethodsTotal arch replacement and stented elephant trunk implantation were performed on 79 consecutive patients from January 2008 to June 2010. Twenty-nine cases of the cohort undertook LSA ligation due to bad exposure. There were 21 males and 8 females patients, aged from 19 to 55 years with a mean of(44 ± 12)years. There were 12 acute dissections, 4 sub-acute dissections and 13 chronic dissections. Based on thoroughly evaluation of the Willis' circle and bilateral vertebral arteries through pre-operative imaging and inrto-operative circulative parameters, if the collateral circulation was considered sufficient, LSA was ligated directly and only the innominate artery and carotid artery were reconstructed; if considered insufficient, an additional bypass from ascending aorta to left axillary artery was performed. Results All the 29 operations were completed successfully. There was one patient died from pulmonary infection and the others recovered well. Blood pressure of left arms were lower than right postoperatively[(78 ± 17)mmHg vs.(126 ± 24)mmHg, 1 mmHg = 0. 133 kPa, P ＜ 0. 01], but oxygen saturation, skin temperature and strength of the left hand were normal compared to the right. All the survived patients have been followed 1-27 months and none of them presented with any symptoms of left subclavian artery steal syndrome and ischemia of left arms. Conclusions Ligation of LSA under strict evaluation of collateral circulation could be safe in Type A dissection patients with bad exposure due to big ascending aortic aneurysm and will simplify the procedure significantly.     

A remnant left aortic arch and a right aortic arch as well as Kommerell's diverticulum with an aberrant left subclavian artery

We report the case of a 63-year-old woman who had dysphagia and dyspnea for one year. Enhanced computed tomography revealed that she had an ascending aortic dorsal projection and a right aortic arch as well as Kommerell's diverticulum (KD) with an aberrant left subclavian artery (LSA). Her KD compressed her trachea and esophagus. We cut her aorta just distal to the KD and performed an ascending and total arch replacement through a midsternotomy. The LSA was reconstructed in front of her trachea. Her dysphagia and dyspnea disappeared following the operation and her postoperative course was uneventful.