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.     

Endovascular stent-graft repair of penetrating descending thoracic aortic ulcer

This article presents a case in which covered stent-graft cuffs were used to treat a penetrating ulcer of the descending thoracic aorta. An 80-year-old woman presented with penetrating ulcer in the descending thoracic aorta. Two endovascular stent graft cuffs were used for total exclusion of the penetrating ulcer, because the patient had a high operative risk. Her postoperative course was uneventful, and follow-up computed tomographic angiography showed complete coverage of the ulcer without evidence of leak. This case demonstrates that endoluminal stent-graft repair of penetrating descending thoracic aortic ulcers is a safe, less-invasive treatment, especially for elderly, high-risk patients.     

Anesthetic consideration for descending thoracic aortic aneurysm repair

Anesthesia for surgery of the aorta poses some of the most difficult challenges for anesthesiologists. Major hemodynamic and physiologic stresses and sophisticated techniques of extracorporeal support are superimposed on patients with complex medical disease states. In this review, etiologies, natural history, and surgical techniques of thoracic aortic aneurysm are presented. Anesthetic considerations are discussed in detail, including the management of distal perfusion using partial cardiopulmonary bypass. Considerations of spinal cord protection, including management of proximal hypertension, cerebral spinal fluid drainage, and pharmacological therapies, are presented.     

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。     

Endovascular repair of a descending thoracic aortic aneurysm: a tip for systemic pressure reduction

A proposed technique for systemic pressure reduction during deployment of a stent graft was studied. A 67-year-old man, who had a descending thoracic aneurysm, was successfully treated with an endovascular procedure. An occluding balloon was introduced into the inferior vena cava (IVC) through the femoral vein. The balloon volume was manipulated with carbon dioxide gas to reduce the venous return, resulting in a transient and well-controlled hypotension. This IVC-occluding technique for systemic pressure reduction may be safe and convenient to minimize distal migration of stent grafts.     

Endovascular repair for ruptured thoracic aortic aneurysm and traumatic aortic injury

In contrast to high mortality of open surgery for thoracic aortic catastrophes including ruptured thoracic aortic aneurysm (RTAA) and traumatic aortic injury (TAI), excellent short-term outcomes of thoracic endovascular aortic repair (TEVAR) have recently been reported. We report our single-center experiences with TEVAR for aortic catastrophes. Thirteen patients with thoracic aortic catastrophes (RTAA in 7 patients, TAI in 6 patients) have received TEVAR from February 2004 to June 2010. In cases of RTAA, 5 descending aortic aneurysm ruptures and 2 aortic arch aneurysm ruptures were included. In patients with arch aneurysm ruptures, fenestrated stent grafting (SG) and SG combined with arch debranching were performed. In all cases of TAI, aortic injuries occurred near the isthmus and 5 patients received fenestrated SG. The initial success rate was 100% and there was no perioperative death. Mean duration of observation was 24 months, which revealed 4 late deaths. The causes of late death were liver failure, cerebral contusion, senility and unknown. A patient with RTAA experienced a type III endoleak as an aorta-related event 24 months after operation. There was no enlargement of aneurysm in any patient. TEVAR for aortic catastrophes seems to be performed safely with acceptable outcomes. Although morphological incompatibility, unstable preoperative haemodynamics and longer time for preparation may become impediments to perform TEVAR, we believe that TEVAR should be the 1st choice for life-threatening aortic catastrophes. However, a careful follow-up is necessary because TEVAR has several unique late complications.     

Endovascular repair of a right-sided descending thoracic aortic aneurysm with a right-sided aortic arch and aberrant left subclavian artery

Aneurysms involving a right-sided aortic arch and a right-sided descending thoracic aorta with an aberrant origin of the left subclavian artery are rare. We describe the successful surgical repair of this vascular anomaly by the combined use of a left carotid to subclavian artery bypass followed by endovascular stent-graft placement to exclude the aortic aneurysm. We also review the literature associated with this particular anatomic presentation.     

Endovascular repair of abdominal aortic aneurysm without preoperative arteriography

OBJECTIVE: Clinical trials of endovascular aortic aneurysm repair (EVAR) have required both preoperative aortography and computed tomography (CT). We codeveloped specialized three-dimensional (3-D) reconstruction and computer-aided measurement, planning, and simulation software (3-D CAMPS) based on CT or magnetic resonance imaging, to eliminate the need for preoperative arteriography. METHODS: EVAR with 3-D CAMPS as the sole preoperative imaging method was performed in 196 patients from 1996 to 2001, with six endograft types in three configurations. Physical examination, abdominal radiography, and CT (3D-CAMPS) were performed at 1, 6, and 12 months, then annually. RESULTS: For a subset of cases in which a comparison could be made, 3-D CAMPS was superior to angiography for prediction of endograft length and iliac access. Hospital mortality was zero, and 30-day mortality was 0.5%. In three patients immediate conversion to open repair (1.5%) was necessary because of previously unknown stent-graft mechanical limits. Incidence of endoleak was 15% at 1 month, 10% at 6 months, 6% at 12 months, and 7% at 24 months, and 92% of endoleaks were type II. Mean follow-up was 18 months. Aneurysm-related mortality was zero. Nineteen secondary procedures (all endovascular) were performed in 16 patients (8%). For all graft types, freedom from secondary procedure was 94% at 1 year and 90% at 2 years, and this was better for endografts ultimately approved by the US Food and Drug Administration (96% at 1 year, 95% at 2 years; P =.02). No known measurement-related complications occurred in the series. Results for secondary intervention and endoleak compare favorably to series with similar endograft types. CONCLUSIONS: EVAR can be performed with 3-D CAMPS as the sole preoperative imaging method to achieve outcomes comparable to the best series published for each endograft type. CT with 3-D CAMPS can effectively eliminate the need for preoperative arteriography and avert associated morbidity, expense, and exposure to contrast agent and radiation.     

Endovascular aneurysm repair of saccular descending thoracic pseudoaneurysm possibly associated with tuberculosis

In 2010, an 84-year-old man underwent thoracic endovascular aneurysm repair (TEVAR) for the saccular descending thoracic pseudoaneurysm (DTAA), which was adherent to the pulmonary lobe and thoracic vertebrae. Past medical history comprised twice anti-tuberculous medications for pulmonary tuberculosis and tuberculous vertebral osteomyelitis. The dilated aorta was detected at the time of medication for tuberculous vertebral osteomyelitis 24?years ago. However, he was not indicated for the operation, and he was lost to follow-up until now. The association of tuberculosis bacilli was suspected through clinical course as an origin of DTAA, although the histopathological examination was not performed because of invasion. TEVAR was performed considering: (1) no preoperative ongoing inflammation, (2) no evidence of tuberculosis recurrence, and (3) risk factors, such as pulmonary impairments and high age. Several months have been passed since the operation, and the patient remains well without perioperative anti-tuberculous medications.     

Endovascular repair of descending aortic dissections

Endoluminal aortic stent-grafts have revolutionized the contemporary management of abdominal aortic aneurysms. The application of this treatment option for aortic dissections has been hampered by the difficult anatomic constraints frequently encountered with both acute and chronic forms of the disease. Although the data are sparse, it is rapidly growing as technologic advances are made in the design and delivery of various stent-grafts. Reviewed is our current understanding of the pathophysiology of descending thoracic aortic dissections, available stent-graft designs, techniques of implantation, and alternatives for complex anatomy. The section concludes with an overview of published data on stent-graft repair of both acute and chronic aortic dissections.     

降主动脉假性动脉瘤腔内治疗临床分析

目的 分析评价降主动脉假性动脉瘤腔内修复(EVAR)的可行性、疗效和结果.方法 回顾性分析2007年4月到2010年11月20例降主动脉假性动脉瘤患者的临床资料.其中男性18例,女性2例;年龄28～82岁,平均(58±16)岁.20例中贝赫切特综合征4例,确诊感染性假性动脉瘤6例,疑诊感染性假性动脉瘤5例,医源性损伤1例,合并慢性粒-单核细胞白血病1例,原因不明3例.假性动脉瘤分布部位以腹主动脉多见(88.5％).20例中EVAR 15例,开放手术2例,未手术治疗3例.回顾性分析15例EVAR患者的治疗情况及随访结果.结果 15例降主动脉假性动脉瘤EVAR技术成功率15/15,共放置腹主动脉分叉型覆膜支架6个,腹主动脉直筒型覆膜支架6个,胸主动脉直筒型覆膜支架2个和肾上腹主动脉裸支架1个.1例采用了裸支架支撑下弹簧栓栓塞术.围手术期病死率为0,除2例原发性Ⅳ型内漏外,无原发性Ⅰ型内漏发生.14例获得随访,随访率14/15,平均随访时间538 d,随访期间总病死率4/14,动脉瘤相关事件发生率6/14,二次手术率1/14,无动脉瘤相关事件存活率8/14.结论 对降主动脉假性动脉瘤行EVAR,具备一定的技术可行性,其技术成功率高,围手术期间病死率低,但随访期间动脉瘤复发、增大、破裂以致死亡的风险较大.病因治疗、严密随访可能有助于改善主动脉假性动脉瘤EVAR的预后.     

Endovascular thoracic aortic aneurysm repair with concomitant myocardial and carotid revascularization

A 73-year-old woman presented with a large saccular aneurysm involving the distal aortic arch. Preoperative aortography and cardiac catheterization revealed left main coronary artery and left common carotid artery stenoses. Concomitant coronary artery bypass grafting to the left anterior descending and first diagonal arteries, ascending aorta-to-left common carotid artery bypass grafting, and endovascular thoracic aortic aneurysm repair with antegrade stent-graft deployment and intentional left subclavian artery coverage were performed.     

降主动脉瘤的腔内移植物治疗

目的 探讨腔内移植物治疗降主动脉瘤的可行性。方法 12例降主动脉瘤接受了血管腔内技术治疗,包括5例真性动脉瘤、6例Stanford B型夹层动脉瘤及1例假性动脉瘤。13枚支架型血管在局部（n=2)或全身麻醉（n=10)下经一侧股动脉切开安装在病变部位。结果 腔内技术成功率100％。无瘤体破裂、截瘫、脏器及肢体缺血等并发症。早期并发症：3例早期内漏血。CT及MRA随访1－30个月：5例真性动脉瘤4例被完全旷置,1例内漏转化为持续性。6例Stanford B型夹层入口4例一期封堵满意,2例少量内漏血自愈,4例假腔内完全血栓形成2,例部分形成。1例假性动脉瘤效果满意。结论 腔内移植物治疗降主动脉瘤是一种安全、可靠、实用的新方法。但其远期治疗效果有待继续观察,尤其是夹层动脉瘤的腔内治疗具有更多的不确定性。     

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.     

Wrapping of ascending aortic aneurysm with supra-aortic debranching and endovascular repair for aortic arch aneurysm and ruptured descending thoracic aortic aneurysm

We report a case of a hybrid surgical treatment of a 71-year-old fragile female with severe chronic obstructive pulmonary disease with a 5-year history of progressive back pain and diagnosis of descending thoracic aorta aneurysm (DTAA), but refused operation at first. Since the patient presented with an acute expanding painful pulsatile mass due to a ruptured DTAA contained by the subcutaneous tissue and had a high-risk surgical profile, we agreed that the simplest urgent operation should be performed. Cardiopulmonary bypass with or without deep hypothermic circulatory arrest was ruled out as an option. The initial approach would be permanent bypasses to the supra-aortic trunks and endovascular repair of the ruptured DTAA, but we ran into a problem: the absence of suitable diameter in the ascending aorta to land the prosthesis—zone 0. To overcome this obstacle, we opted to perform a diameter reduction of the ascending aorta by wrapping it with a Dacron tube to create a neck where we could land the endovascular prosthesis. Following this step bypasses from the proximal ascending aorta to the brachiocephalic artery, left common carotid artery and left subclavian artery were created. Since we gained ground to act in zone 0, the first endoprosthesis was landed in the wrapped zone and the aortic arch—from zone 0 to zone 3. The second and third endoprostheses covered the ruptured DTAA above the celiac trunk—zones 4 and 5. Good positioning of the endoprostheses was achieved and we attained procedural success.