主动脉腔内隔绝术治疗DeBakey III型主动脉夹层动脉瘤：附63例报告

目的：分析主动脉腔内隔绝术（EVAR）治疗DeBakey III型主动脉夹层动脉瘤的临床效果。 方法：回顾性分析2008—2014年采取EVAR手术治疗的63例DeBakey III型主动脉夹层动脉瘤患者临床资料,总结EVAR的手术方法、手术成功率、术后夹层假腔直径的变化。 结果：DeBakey III型主动脉夹层动脉瘤63例置入支架66个,其中有3例患者分别置入支架2枚,平均手术时间（159.1±21.7）min,手术中出现3例内漏,其中1例患者出现极少量内漏、术后CTA复查未发现,1例在支架置入后发现近端内漏、1例患者发现支架远端内漏,分别予以增加支架封堵,术后CTA复查仍然存在少许内漏;全组手术的技术成功率95.24%（60/63）,临床成功率为92.06%（58/63）;患者术后6个月左锁骨下动脉真腔开口直径、近端破口真腔水平直径mm、瘤体最大真腔直径、膈肌水平真腔最大直径均较术前明显增大（均P<0.05）,假腔大直径测定值均较术前明显减小（均P<0.05）,整体腔径最大值差异均无统计学意义（均P>0.005）。 结论：EVAR治疗DeBakey III型主动脉夹层动脉瘤效果显著,安全可靠。     

主动脉腔内隔绝术治疗DeBakey Ⅲ型主动脉夹层动脉瘤:附63例报告

目的:分析主动脉腔内隔绝术(EVAR)治疗De Bakey Ⅲ型主动脉夹层动脉瘤的临床效果。方法:回顾性分析2008—2014年采取EVAR手术治疗的63例De Bakey Ⅲ型主动脉夹层动脉瘤患者临床资料,总结EVAR的手术方法、手术成功率、术后夹层假腔直径的变化。结果:De Bakey Ⅲ型主动脉夹层动脉瘤63例置入支架66个,其中有3例患者分别置入支架2枚,平均手术时间(159.1±21.7)min,手术中出现3例内漏,其中1例患者出现极少量内漏、术后CTA复查未发现,1例在支架置入后发现近端内漏、1例患者发现支架远端内漏,分别予以增加支架封堵,术后CTA复查仍然存在少许内漏;全组手术的技术成功率95.24%(60/63),临床成功率为92.06%(58/63);患者术后6个月左锁骨下动脉真腔开口直径、近端破口真腔水平直径mm、瘤体最大真腔直径、膈肌水平真腔最大直径均较术前明显增大(均P0.05),假腔大直径测定值均较术前明显减小(均P0.05),整体腔径最大值差异均无统计学意义(均P0.005)。结论:EVAR治疗De Bakey Ⅲ型主动脉夹层动脉瘤效果显著,安全可靠。     

腔内修复治疗合并慢性肾功能不全的急性B型主动脉夹层

目的 探讨主动脉腔内修复(EVAR)治疗合并慢性肾功能不全的急性B型主动脉夹层患者的早期效果.方法 2009年2月至2011年12月,采用EVAR治疗30例合并慢性肾功能不全的急性B型主动脉夹层患者(CRI组),选取同一时间段连续EVAR治疗的30例非CRI的急性B型主动脉夹层患者作为对照(非CRI组).所有患者均为发病在14天以内的非马方综合征患者,通过主动脉CTA确诊.57例患者局部麻醉下完成EVAR,同期完成左锁骨下动脉“烟囱”支架置入2例、肾动脉支架置入2例.3例在全身麻醉下先行右腋动脉至左腋动脉和左锁骨下动脉的“Y”形人工血管转流术,后行EVAR.术后1个月和1年随访复查肾功能和CTA,评价疗效.结果 CRI组患者年龄显著低于非CRI组[(44.7±13.2)岁对(53.7±16.2)岁,P＜0.05],围手术期并发症发生率显著高于非CRI组(16.7％对3.3％,P＜0.05),均治愈.1例CRI组患者术后6个月因支架远端新发夹层破口,再次入院行EVAR后治愈.术后1个月和1年复查肾功能和CTA,所有患者无肾功能损害加重;CTA显示支架无明显变形、移位和内漏,主动脉真腔及分支动脉血供均有明显改善.结论合并CRI的急性B型主动脉夹层患者,积极行EVAR治疗后,早期效果满意,术后1个月和1年无内漏、夹层破裂出血、神经系统缺血和腹腔脏器缺血等并发症和死亡.     

采用胸分支型主动脉支架人工血管对主动脉弓降部夹层行腔内修复治疗

目的探讨采用胸分支型主动脉支架人工血管治疗累及左锁骨下动脉的主动脉弓降部夹层的临床效果。方法自2004年2月至2004年6月,采用血管腔内胸分支型主动脉支架人工血管治疗主动脉弓部夹层14例。14例均为StanforB型主动脉夹层,原发破裂口距左锁骨下动脉开口2～13mm,平均8．7mm。分支型支架由主动脉段支架和分支段支架组成,支架直径较相应支撑部位动脉直径大15％～20％。治疗在血管造影室进行,应用定位导丝、在透视下将分支型主动脉支架人工血管送人并连续释置入主动脉弓和左锁骨下动脉。结果支架释放全部成功。14例患者共放置14只分支型主动脉支架和2只可弯曲型支架人工血管,封闭夹层破裂口,夹层真腔全部恢复正常直径。无远端动脉并发症发生,无死亡病例。全部患者术后恢复正常活动。结论胸分支型主动脉支架人工血管适合于修复破裂口位于左锁骨下动脉开口旁的主动脉弓部夹层。     

血管腔内支架植入术的临床应用

目的 评价应用血管内支架治疗血管性疾病的临床价值。方法 对36例患有血管性疾病的患者施行了血管内支架植入术，包括胸主动脉夹层动脉瘤24例，腹主动脉真性动脉瘤3例，腹主动脉夹层动脉瘤1例，颈动脉动静脉瘘1例，左锁骨下动脉狭窄1例，左锁骨下动静脉瘘1例，髂动脉假性动脉瘤4例及股动脉狭窄1例。除1例左锁骨下动脉狭窄患者、1例股动脉狭窄患者使用了裸支架外，其余34例患者均采用带膜支架进行血管内治疗。结果 术中所有患者均未出现特殊不适，术后随访期间未见明显合并症发生。所有患者均完全消除了临床症状。结论 应用血管内支架治疗血管性疾病是一种实用且效果较好的治疗方法。     

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.     

开窗/分支支架技术腔内治疗巨大胸腹主动脉夹层动脉瘤及内漏处理1例

患者,女性,53岁,有高血压和脑出血病史,2010年因Stanford B型主动脉夹层行胸主动脉覆膜支架腔内隔绝术,术中完全覆盖左锁骨下动脉,术后未规律随访。2019年2月25日因复查发现腹主动脉夹层假腔增大而入院。CTA示胸腹主动脉巨大夹层动脉瘤,延续至双侧髂动脉(图1A)。综合评估患者的病史及一般情况,手术风险高、无法耐受开放手术,遂选择分2期行全腔内修复术。     

胸主动脉腔内修复应用原位开窗保留弓上分支动脉技术

目的:回顾性分析胸主动脉腔内修复使用原位开窗保留弓上分支动脉技术的初步经验。方法 :分析我院从2016年7月至2017年2月行胸主动脉腔内修复术中原位开窗15例病人的临床资料。弓部假动脉瘤3例,主动脉夹层12例。结果:病人均成功实施胸主动脉腔内修复术。23支目标血管中21支成功开窗(91.3%)。3例病人同时进行头臂干、左颈总动脉及左锁骨下动脉三开窗,平均手术时间为(550.0±155.6)min。2例行左颈总动脉及左锁骨下动脉双开窗,平均手术时间为(405.0±275.8)min。10例行左锁骨下动脉单开窗,平均手术时间为(175.0±43.5)min。术中发生穿刺侧髂外动脉损伤1例,术后发生脑梗死1例。围手术期无死亡病例。平均住院(15.3±4.3)(8~26)d。平均随访(3.1±2.0)(1~7)个月。随访病人均无不适症状。13例病人(86.7%)复查CTA,均未发现夹层进展。开窗支架通畅在位,无内漏及其他支架并发症发生。结论:原位开窗技术有效扩大胸主动脉腔内修复治疗主动脉病变适应证,安全可行,有微创优势。     

左锁骨下动脉重建在腔内修复 Stanford B 型夹层动脉瘤中的作用

Stanford B型夹层动脉瘤的内膜破口位于降主动脉,以左锁骨下动脉开口多见,腔内修补是通过封堵内膜裂口而达到治疗目的,但近端破口距离左锁骨下动脉开口的位置成了制约手术的一个重要因素,左锁骨下动脉开口被封堵引起的动脉缺血是手术的一个严重并发症.我院于2001年1月至2005年2月腔内修复（endovascular repair,EVR）治疗Stanford B型夹层动脉瘤120例,其中行左锁骨下动脉重建术5例,现报告如下.     

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.     

Coverage of the left subclavian artery during thoracic endovascular aortic repair

BACKGROUND: Thoracic aortic stent grafts require proximal and distal landing zones of adequate length to effectively exclude thoracic aortic lesions. The origins of the left subclavian artery and other aortic arch branch vessels often impose limitations on the proximal landing zone, thereby disallowing endovascular repair of more proximal thoracic lesions. METHODS: Between October 2000 and November 2005, 112 patients received stent grafts to treat lesions involving the thoracic aorta. The proximal aspect of the stent graft partially or totally occluded the origin of at least one great vessel in 28 patients (25%). The proximal attachment site was in zone 0 in one patient (3.6%), zone 1 in three patients (10.7%), and zone 2 in 24 patients (85.7%). Patients with proximal implantation in zones 0 or 1 underwent debranching procedures of the supra-aortic vessels before stent graft repair. In one patient who underwent zone 1 deployment, the left subclavian artery was revascularized before stent graft deployment. Among patients who underwent zone 2 deployment with partial or complete occlusion of the left subclavian artery, none underwent prior revascularization. Patients were assessed postoperatively and at follow-up for development of neurologic symptoms as well as symptoms of left upper extremity claudication or ischemia. RESULTS: Mean follow-up was 7.3 months. Among the 24 patients with zone 2 implantation, 10 (42%) had partial left subclavian artery coverage at the time of their primary procedure. A total of 19 patients experienced complete cessation of antegrade flow through the origin of the left subclavian artery without revascularization at the time of the initial endograft repair as a result of a secondary procedure or as a consequence of left subclavian artery thrombosis. Left upper extremity symptoms developed in three (15.8%) patients that did not warrant intervention, and rest pain developed in one (5.3%), which was treated with the deployment of a left subclavian artery stent. Two primary (type IA and type III) endoleaks (7.1%) and one secondary endoleak (type IA) (3.6%) were observed in patients who underwent zone 2 deployment. Three cerebrovascular accidents were observed. Thoracic aortic lesions were successfully excluded in all patients who underwent supra-aortic debranching procedures. CONCLUSION: Intentional coverage of the origin of the left subclavian artery to obtain an adequate proximal landing zone during endovascular repair of thoracic aortic lesions is well tolerated and may be managed expectantly, with some exceptions.     

Endovascular treatment of the descending thoracic aorta.

OBJECTIVES: to report our initial experience with endovascular stent graft repair of a variety of thoracic aortic pathology. DESIGN: retrospective single center study. MATERIAL AND METHODS: between February 2000 and January 2002, endovascular stent graft repair was performed in 26 patients: traumatic aortic isthmus rupture (n=3), Type B dissection (n=11) and descending thoracic aortic aneurysm (n=12). The deployed stent graft systems were AneuRx-Medtronic (n=1), Talent-Medtronic (n=13) and Excluder-Gore (n=12). RESULTS: successful deployment of the stent grafts in the intended position was achieved in all patients. No hospital mortality neither paraplegia were observed. Late, non procedure related, death occurred in four patients (15%). Access artery complications with rupture of the iliac artery occurred in two patients and were managed by iliac-femoral bypass. The left subclavian artery was overstented in seven patients (27%). Only the first patient received a carotido-subclavian bypass. The mean maximal aortic diameter decreased significantly in patients treated for descending thoracic aneurysm. Only one patient had an endoleak type II after 6 months without enlargement of the aneurysm. Complete thrombosis of the thoracic false lumen occurred in all but one patient treated for Type B dissection 6 months postoperatively. Two patients underwent a consecutive stent graft placement, due to a large re-entry tear distal to the first stent graft. CONCLUSIONS: endovascular stent graft repair for Type B dissection, descending thoracic aneurysm and aortic isthmus rupture is a promising less-invasive alternative to surgical repair. Further studies are mandatory to determine its long-term efficacy.     

Stroke in surgery of the arteriosclerotic descending thoracic aortic aneurysms: influence of cross-clamping technique of the aorta.

OBJECTIVE: The risk of stroke caused by dislodgment of loose atheromatous plaque or mural emboli is increased by cross-clamping of the aorta. Some patients undergo descending thoracic aortic aneurysm repair with proximal aortic cross-clamping between the left common carotid artery and the left subclavian artery. The objective of this study was to determine the influence of proximal aortic cross-clamping in arteriosclerotic aneurysm or dissecting aneurysm repair. METHODS: Between May 1984 and May 2003, 81 patients underwent elective surgery for distal arch or descending aortic aneurysm repair with proximal aortic cross-clamping between the left common carotid artery and the left subclavian artery. To evaluate the influence of the proximal aortic cross-clamping, patients were divided into two groups: patients who had undergone arteriosclerotic aneurysm repair (group I, n=25) and patients who had undergone dissecting aneurysm repair (group II, n=56). RESULTS: Eight (9.9%) of the 81 patients had a stroke. Six strokes occurred in operations for arteriosclerotic aneurysm repair group I and two strokes occurred in operations for dissecting aneurysm repair group II (24 vs 3.6%; p=0.009). In-hospital mortality rates were 12% in group I and 8.9% in group II (p=0.70). Major postoperative complications included renal failure requiring hemodialysis (in 4.2% of the patients in group I and in 8.3% of the patients in group II, p=0.99) and pulmonary complication (in 20% of the patients in group I and in 16% of the patients in group II, p=0.67). CONCLUSION: Cross-clamping between head vessels should be avoided if at all possible when operating on patients who have arteriosclerotic descending thoracic aneurysms.     

Left subclavian artery management in endovascular repair of thoracic aortic aneurysms and aortic dissections

PURPOSE: The purpose is to report our experience and revise our previously published results in endovascular repair of short-necked thoracic aortic aneurysms or aortic type B dissections, in which the left subclavian artery (LSA) was occluded by the stent graft intentionally.METHODS: Seven patients with an aortic type B dissection and three patients who had a thoracic aortic aneurysm were treated endovascularly with stent grafts. In all patients the ostium of the LSA was occluded by the stent graft, only in two patients a primary, prophylactic revascularization of the LSA was performed by transposition to the left common carotid artery (LCA). Two types of stent grafts were used: the Talent (Medtronic) and the Excluder (Gore) stent graft. RESULTS: In all patients the sealing of the entry tear in aortic dissections and the exclusion of existing thoracic aortic aneurysms were achieved. No immediate neurological deficit or left arm ischemia occurred. Nevertheless, during a mean follow-up of 18 months (2 to 31 months) in three patients a second surgical intervention had to be performed due to subclavian steal syndrome, left arm ischemia, or continuing perfusion of the dissected false aortic channel. CONCLUSION: Intentional occlusion of the LSA in stent-graft repair of thoracic aortic diseases seems to be a safe procedure. Close follow-up is needed due to arising subclavian steal syndrome, arm ischemia, or persistent perfusion of the false channel via LSA in aortic dissections after patients' discharge, requiring surgical intervention.     

巨大和长段胸主动脉瘤的血管腔内修复术治疗

目的探讨巨大和长段胸主动脉瘤行带膜支架主动脉腔内修复治疗的可行性。方法对3例10．6～28．0cm长真性胸主动脉瘤的男性患者,采用多个带膜支架相连接成一条长段支架型人工血管,行主动脉腔内修复治疗。对瘤体全长28．0cm、最大直径7．3cm的病例,采用4个长度为130mm的不同直径的带膜支架相连接覆盖胸主动脉;另2例分别用2枚、3枚带膜支架治疗。2例术中先行颈总动脉-颈总动脉和颈总动脉-锁骨下动脉旁路术。结果3例手术过程顺利,术后恢复良好。2例术后无内漏,分别随访1,2个月,瘤腔内血栓形成;1例在支架连接处有少量内漏,术后1年消失,瘤腔内血栓形成。1例术后出现短暂脑缺血表现,1个月后消失。结论采用多个带膜支架相连接对巨大和长段胸主动脉瘤行主动脉腔内修复治疗,安全、微创,疗效良好,远期效果有待观察。     

Outcome after celiac artery coverage during endovascular thoracic aortic aneurysm repair: preliminary results

BACKGROUND: Endovascular repair of descending thoracic aortic aneurysms has emerged as an alternative to open repair. Coverage of the left subclavian origin has been reported to expand the proximal sealing zone. We report the planned coverage of the celiac artery origin with a thoracic stent graft to achieve an adequate distal sealing zone. METHODS: All patients undergoing endovascular aneurysm repair are prospectively entered into a computerized database. All patients who underwent thoracic endovascular aneurysm repair with coverage of the celiac artery origin were identified and retrospectively analyzed. End points for evaluation included indications for covering the celiac artery, anatomic features of the distal landing zone, demonstration of collateral circulation between the celiac artery and the superior mesenteric artery, technical success of the procedure, and presence of clinical ischemic symptoms after the procedure. RESULTS: Between March 2005 and May 2006, 46 patients underwent endovascular repair of descending thoracic aortic aneurysms. Seven patients had planned celiac artery coverage with a thoracic stent graft to secure an adequate distal sealing zone. Six patients demonstrated collateral circulation through the gastroduodenal artery between the celiac and superior mesenteric arteries before deployment of the stent graft. One patient had a distal type I endoleak at the conclusion of the procedure related to inadequate sealing at the superior mesenteric artery origin. No type II endoleaks were evident at the final intraoperative angiogram or 30-day computed tomography scan. There were no postoperative deaths, no ischemic abdominal complications, and no clinical spinal cord ischemia. Short-term follow-up (1 to 10 months) has demonstrated no additional endoleaks (type I not fully assessed), no aneurysm growth, and no aneurysm ruptures. CONCLUSION: This limited series supports the suitability, in selected patients, of covering the celiac artery origin for a distal landing zone when the distal sealing zone proximal to the celiac artery is inadequate. We recommend the angiographic evaluation of the collateral circulation between the celiac and superior mesenteric arteries when covering the celiac artery origin is being considered.     

Feasibility and possibility of Inoue stent graft for thoracic aortic aneurysms

Open surgical repair is a traditional treatment for patients with thoracic aortic aneurysms. Despite recent advances in surgical techniques and anesthetic management, the surgical repair of thoracic aortic aneurysms is still associated with significant mortality and morbidity. Endovascular aneurysm repair of thoracic aortic aneurysms is emerging as an alternative method for repair in selected patients. Although endovascular stent grafting is less invasive than open surgical repair, involvement of branch vessels and precipitous curvature of the aortic arch limits the application of stent grafting. Inoue stent graft system consists of soft nitinol ring-type stent which enables very flexible stent graft, and it can well comply with the precipitous curvature of the aortic arch. The system also provides a stent graft with a side branch to manage the left subclavian artery. This system does not require the surgical revascularization of the left subclavian artery. In this report, we show the feasibility and possibility of Inoue stent graft system to manage the aortic arch aneurysm.     

一体式覆膜支架在腹主动脉腔内修复中的应用

目的:总结一体式覆膜支架在腹主动脉以及髂动脉病变中的应用效果。方法:回顾性分析应用一体式腹主动脉覆膜支架腔内修复腹主动脉瘤15例、髂动脉瘤5例及腹主动脉或髂动脉夹层5例的临床资料。结果:平均时间42.4 min,手术成功率100%(25/25)。术后无I、III型内漏,发生髂动脉血栓形成1例,围术期无死亡病例。随访3~16个月复查无动脉瘤复发和II型内漏。结论:一体式覆膜支架是腹主动脉瘤和夹层动脉瘤腔内治疗方法的一种较好选择,具有快速、简单、有效的优点;其远期疗效需进一步观察。     

Aortic debranching for descending thoracic aortic aneurysm repair by stent grafts

Endovascular repair of a descending thoracic aortic aneurysm may result in covering the ostia of the left carotid or left subclavian artery for proper proximal landing zones, and the celiac artery or superior mesenteric artery ostia in the abdomen for distal landing zones. To prevent possible complications of occluding the ostia of these vessels, the authors performed an innominate to left common carotid and left subclavian artery bypass as the first procedure in one patient. In the second patient they performed an aortoceliac and aortomesenteric bypass before stent graft placement. The stent graft repair of the descending thoracic aortic aneurysm was performed subsequently in both patients. This aortic debranching provides subsequent proper placement of thoracic stent grafts.