左锁骨下动脉烟囱技术在Stanford B型胸主动脉夹层腔内修复术中的应用

目的探讨左锁骨下动脉烟囱技术在Stanford B型主动脉夹层腔内修复术(EVAR)中的意义和技术要点。 方法回顾性分析35例临床和影像学确诊的Stanford B型主动脉夹层,且主动脉撕裂累及到左锁骨下动脉的患者,以CTA作为术前评估方法,术中覆膜支架覆盖左锁骨下动脉,以球囊扩张支架对左锁骨下动脉进行介入再通。 结果35例胸主动脉覆膜支架和左锁骨下动脉球囊扩张支架均放置成功,术后随访3～24个月,35例左锁骨下动脉烟囱支架通畅率100%。 结论Stanford B型胸主动脉夹层的EVAR治疗时,覆膜支架的近侧锚定区选择在正常的主动脉壁,可以降低继发医源性夹层的发生;覆盖左锁骨下动脉后采用烟囱技术可有效预防"盗血综合征"的发生,其技术简捷、安全。     

Stanford B型主动脉夹层近端锚定区不足腔内治疗分析

目的 探讨胸主动脉夹层腔内修复术(TEVAR)治疗Stanford B型主动脉夹层时近端锚定区不足的3种处理方法.方法 回顾性分析36例B型主动脉夹层患者近端锚定区不足15 mm的处理方法,其中覆盖左锁骨下动脉(LSA)15例(A组),LSA烟囱支架植入14例(B组),头臂动脉转流7例(C组).结果 TEVAR术均获成功.ⅠA型内漏3例,Ⅳ型内漏1例,内漏发生率11.11％.双上肢平均收缩压差在A组为(41.68±17.52) mmHg,与B组(15.61±8.83) mmHg和C组(11.54±10.07)mmHg比较,差异有统计学意义(P＜0.01).无围手术期死亡、脑梗死、截瘫、严重左上肢缺血等并发症.术后随访3～12个月,CTA复查显示主动脉覆膜支架及烟囱支架无移位,人工血管及烟囱支架均通畅,原少量内漏消失,无新发内漏.结论 对近端锚定区不足的Stanford B型主动脉夹层患者施行TEVAR术时可通过覆盖LSA、植入LSA烟囱支架和头臂动脉转流技术,安全有效地拓展近端锚定区距离.     

85例Stanford B型主动脉夹层腔内修复治疗体会

目的 探讨胸主动脉腔内修复术(TEVAR)治疗Stanford B型主动脉夹层(AD)方法与疗效.方法 回顾性分析2010年1月至2016年4月采用TEVAR治疗的85例Stanford B型AD患者临床资料.85例患者均常规行左肱动脉穿刺,右侧股动脉直切口,升主动脉DSA造影明确AD破口位置、真假腔及与重要器官血管开口位置关系;置入覆膜血管内支架,封堵原发破口,升主动脉造影复查观察近端破口封闭情况及主动脉弓部分支血管、真假腔血流变化情况.结果 84例患者TEVAR手术成功,成功率100％;1例术前麻醉过程中突发AD破裂死亡.9例部分覆盖左锁骨下动脉,1例左锁骨下动脉“烟囱”支架完全封闭左颈总动脉和左锁骨下动脉,2例行无名动脉至左颈总动脉和左锁骨下动脉转流.Ⅰ型内漏2例,无住院期间死亡.术后随访3个月至3年,患者均存活,远端再发新破口2例.结论 TEVAR术治疗Stanford B型AD安全有效,严格把握手术指征、术中精细操作及加强术后院外管理是手术成功、提高远期生存率关键.     

主动脉几何构型对Stanford B型主动脉夹层腔内修复术后围手术期支架周围假腔残留的预测价值

目的:通过分析Stanford B型主动脉夹层患者行胸主动脉腔内修复(TEVAR)术前的主动脉三维空间构型,以期找到预测术后假腔残留风险的指标.方法:收集经双源CTA(DSCTA)诊断为Stanford B型主动脉夹层94例患者的术前和术后影像学资料;依据TEVAR治疗后1周DSCTA示支架周围假腔是否闭合分为假腔残留...     

胸主动脉覆膜支架并左锁骨下动脉烟囱术疗效分析

目的探讨胸主动脉覆膜支架植入术在支架近端锚定区不足时左锁骨下动脉的处理方法及支架直接覆盖左锁骨下动脉开口并左锁骨下动脉"烟囱"术的可行性。方法回顾分析2009年12月-2011年4月收治的支架近端锚定区不足的15例胸主动脉病变患者(B型夹层6例,假性动脉瘤1例,动脉瘤4例,穿透性溃疡4例),其中13例病变距左锁骨下动脉锚定区小于15 mm,2例大于15 mm。采用胸主动脉覆膜支架并左锁骨下动脉烟囱术治疗,观察脑及上肢缺血并发症发生情况。术后评价内漏、左锁骨下动脉显影等结果。结果 15例患者均成功地在主动脉内植入覆膜支架1枚,并在左锁骨下动脉植入"烟囱"支架1枚,术后患者均未出现神经系统并发症及左上肢严重缺血症状。术后5 d～3个月复查,主动脉覆膜支架形态良好,未发现I型内漏,"烟囱"支架内血流通畅。结论胸主动脉覆膜支架植入术中近端锚定区不足时,直接覆盖左锁骨下动脉开口并左锁骨下动脉"烟囱术"以延长锚定区并保持左锁骨下动脉通畅,更为安全。     

Hybrid手术在复杂Stanford B型夹层中的临床应用

目的 探讨Hybrid手术治疗累及主动脉弓部分支血管的Stanford B型主动脉夹层的临床效果及并发症。方法 回顾分析2014年1月—2016年1月武汉市中心医院收治87例行Hybrid手术治疗复杂Stanford B型主动脉夹层的患者,观察其术后疗效及并发症发生情况。累及Z0区9例,行头臂干（brachiocephalic trunk,BCT）-左颈总动脉（left common carotid artery,LCCA）+BCT-左锁骨下动脉（left subclavian artery,LSA）+胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)术;累及Z1区23例,行BCT-LCCA-LSA+TEVAR术;累及Z2、3区55例,行LCCA-LSA+TEVAR术;颈部血管旁路选用8 mm Gore-Tex人工血管,TEVAR选用美敦力或先健覆膜血管支架。结果 无病例死亡,术后即刻造影无病例内漏,61例术毕苏醒拔管,26例术后次日顺利脱机拔管;术后出现肾衰3例,脑梗1例;随访6～48个月,出现内漏1例,无截瘫发生,恢复良好。结论 Hybrid手术治疗复杂Stanford B型主动脉夹层患者,具有微创、安全、有效的临床疗效,具有低风险、低并发症发生率的策略优势;根据患者的夹层解剖学范围以及患者的综合条件,选择个性化的Hybrid手术策略是手术成功的关键。     

Stanford B型主动脉夹层腔内修复术后血管重塑分析

目的 探讨Stanford B型主动脉夹层患者经胸主动脉腔内修复术(TEVAR)治疗后血管形态学转归.方法 回顾性分析51例接受TEVAR术治疗的Stanford B型主动脉夹层患者术前及术后临床及影像学资料,分析术后1个月内、1～6个月、6个月后主动脉各段真假腔内径及假腔血栓化情况.结果 TEVAR术后胸主动脉真腔扩大、假腔缩小,与术前比较差异有统计学意义(P＜0.05),腹主动脉管径真腔和假腔变化较术前无统计学差异(P＞0.05),腹部重要分支动脉血供情况较术前有所改善.结论 TEVAR术治疗Stanford B型主动脉夹层患者的近中期效果确切,但仍需要远期随访观察.     

单分支型主动脉覆膜支架治疗Stanford B型主动脉夹层的临床价值

【摘要】 目的 探讨单分支型主动脉覆膜支架在Stanford B型主动脉夹层单纯腔内隔绝治疗中的临床价值。 方法 2017年7月至2018年10月采用国产CastorTM单分支型主动脉覆膜支架行单纯腔内隔绝治疗19例Stanford B型主动脉夹层患者,观察术后即时血管造影结果。术后1个月门诊随访,术后6个月复查主动脉CTA。以手术成功率、假腔消失率和分支支架通畅率为有效性终点指标,观察相应不良事件。 结果 19例患者支架均释放成功,技术成功率100%。围手术期无不良事件发生。随访期患者无死亡,4例门诊随访时出现左上肢缺血症状,经对症治疗后缓解。无严重内漏发生,分支支架通畅率100%,夹层假腔均出现血栓化,假腔直径平均缩小（10.3±1.2） mm（肺动脉分叉平面）。 结论 单分支型主动脉支架对于近端破口距左锁骨下动脉开口＜15 mm或逆撕至左锁骨下动脉根部的Stanford B型主动脉夹层,是有效的单纯腔内隔绝方法。     

急性Stanford B型主动脉夹层真腔次全闭塞治疗 ——单中心病例系列报道

【摘要】 目的 总结急性Standford B型主动脉夹层（AD）真腔次全闭塞患者的治疗经验。方法 回顾性分析2016年1月至2019年12月湖南省人民医院采用胸主动脉腔内修复术治疗的39例急性B型AD真腔次全闭塞患者临床资料。所有患者均接受主动脉覆膜支架腔内隔绝术,术中根据近端破口位置决定是否同时行左颈动脉或左锁骨下动脉重建修复（含支架开窗、烟囱支架）,远端受累分支血管根据AD真腔开通后具体情况选择保守、支架成形术或血液透析治疗。结果 39例患者共植入主动脉覆膜支架51枚（植入1枚27例, 2枚12例）,同时植入腹主动脉裸支架3枚,肠系膜上动脉支架8枚,髂动脉支架12枚,颈动脉原位开窗或烟囱支架9枚,锁骨下动脉开窗或烟囱支架枚17枚。介入治疗技术成功率为100%。围手术期并发症为肾功能不全15例（38.5%）;5例一侧肾动脉完全假腔供血遂接受覆膜支架开通;中重度肠道缺血表现8例（20.5%）,其中6例接受二次腔内治疗。围手术期死亡率为7.7%（3/39）,死因主要为重度肾功能不全和酸中毒多脏器衰竭。术后随访6～25个月,支架段假腔完全血栓化率为80.6%（25/31）,其中支架段主动脉完全重塑率为68%（17/25）。结论 B型AD真腔次全闭塞一经确诊,建议尽快手术。腔内开通过程需要多种技巧,部分患者两段式支架应用有利于真腔开通,降低假腔压力,促进血管重塑。     

Stanford B型主动脉夹层多型支架介入治疗的临床体会

目的 应用多种类型支架行Stanford B型主动脉夹层介入治疗,探讨扩大介入治疗适应证的可行性.方法 回颐性分析2004年5月-2009年12月,18例Stanford B型主动脉夹层患者行介入性腔内修复术治疗的临床资料.根据CTA和DSA结果,个体化选择合适覆膜支架,透视下将覆膜支架经股动脉导入封闭夹层破口.术后CTA随访观察内漏、支架移位、假腔变化等.结果 18例中2例放置分体式主动脉覆膜支架、1例放置分支型覆膜支架、2例放置预留孔型主动脉覆膜支架,13例放置普通主动脉覆膜支架.1例封堵左锁骨下动脉、2例不全封堵左锁骨下动脉均未出现左上肢和椎基底动脉缺血症状;1例因解剖变异右锁骨下动脉起自主动脉弓而行旁路手术.术后发生8例(44.4%)即刻I型内漏,其中1例腔内修复术后持续I型内漏再次放置支架后进展为Standford A型主动脉夹层瘤而行升主动脉人工血管置换术,其余CTA随访内漏逐渐消失;所有患者均无支架移位、断裂、塌陷以及术后截瘫及脑血管意外发生.结论 采取不同方法延长近端锚定区的距离、应用分体式主动脉支架可扩大介入治疗Standflord B 型主动脉夹层的适应证,且近期疗效好,中、远期疗效有待进一步观察.     

In Situ Laser Stent Graft Fenestration of the Left Subclavian Artery during Thoracic Endovascular Repair of Type B Aortic Dissection with Limited Proximal Landing Zones: 5-Year Outcomes

PurposeTo assess safety and feasibility of in situ laser stent graft fenestration to revascularize the left subclavian artery (LSA) during thoracic endovascular repair (TEVAR) of type B aortic dissection (TBAD) with limited proximal landing zones with 5 years of follow-up.Materials and MethodsIn a single-center retrospective study, 130 patients with TBAD with limited proximal landing zones (≤ 1.5 cm) underwent in situ laser stent graft fenestration revascularizing the LSA during TEVAR from April 2014 to April 2019. Outcomes were assessed by CT angiography and clinic visits, including technical success rate, operative time, LSA patency, ischemic events, and late aorta-related complications during follow-up.ResultsMean age of patients was 53 y (range, 33–73 y). Primary technical success rate was 96.9% (126/130). Three chimney stents were placed instead of fenestration, and 1 LSA fenestration was combined with a left common carotid artery (LCCA) chimney stent. Mean operative time was 53 min ± 28 with fluoroscopy time of 40 min ± 15. There were no neurologic complications and no deaths, with a mean duration of hospital stay of 9 d (range, 5–21 d). At a mean follow-up of 42 mo (range, 5–60 mo), there was a 97% primary LSA patency. Four patients had a type I endoleak, which disappeared during follow-up. One LCCA became occluded after 6 months. No type II or III endoleaks were found. Retrograde type A aortic dissection and stent graft–induced new distal entry were not found during follow-up.ConclusionsIn situ laser fenestration to revascularize the LSA during TEVAR of TBAD with limited proximal landing zones was efficient, safe, and feasible based on 5-year follow-up.     

腔内修复术治疗非复杂性急性B型主动脉夹层及随访结果

目的评价覆膜支架胸主动脉腔内修复术(TEVAR)治疗非复杂性急性Stanford B型主动脉夹层(ATBAD)的近中期效果,并与复杂性ATBAD作比较。方法回顾性分析2003年5月至2012年6月收治的122例ATBAD患者临床资料。根据临床特征,分为非复杂性ATBAD组(A组,n=73)和复杂性ATBAD组(B组,n=49)。TEVAR术后随访5年,对比两组围手术期并发症、30 d死亡率、5年主动脉相关事件、免于主动脉相关事件发生率和中期生存率。结果 A组与B组相比,围手术期并发症发生率(8.2%对42.9%,P<0.01)、30 d死亡率(0%对12.2%,P=0.008)均显著降低;5年中期随访显示,主动脉相关事件发生率(5.5%对7.0%,P=1.000)、中期死亡率(2.7%对7.0%,P=0.352)均相似,免于主动脉相关事件发生率(P=0.661)、中期生存率(P=0.245)差异均无统计学意义。结论 TEAVR治疗非复杂ATBAD可行、有效。与复杂ATBAD相比,非复杂ATBAD经TEVAR治疗获得了更好的近期效果,中期效果相似。     

Midterm Outcomes of Endovascular Repair for Stanford Type B Aortic Dissection with Aberrant Right Subclavian Artery

PurposeTo evaluate the early and midterm outcomes of endovascular repair of Stanford type B aortic dissection (TBAD) with an aberrant right subclavian artery (ARSA).Materials and MethodsFrom November 2012 to July 2018, 15 patients (13 male, 2 female) who had TBAD with ARSA underwent total endovascular repair, including thoracic endovascular aortic repair (TEVAR), left subclavian artery (LSA) chimney technique, LSA fenestration technique, and double chimney technique (LSA chimney and ARSA periscope). The mean age was 55 years. Kommerell diverticulum (KD) occurred in 2 patients, which were covered by means of oversized aortic stents. All patients had preoperative imaging examinations for assessing cerebral blood flow and the dominant vertebral arteries.ResultsAll procedures were completed successfully. There was no in-hospital mortality. The mean procedural time was 98 ± 40 minutes (range 50–190). The mean preoperative diameters of the maximum descending aorta, false lumen, and true lumen in the descending aorta versus postoperative were 37 ± 10 mm (range 28–67), 18 ± 9 mm (range 9–41), and 19 ± 6 mm (range 10–35) versus 34 ± 9 mm (range 25–64), 5 ± 8 mm (range 0–28), and 28 ± 5 mm (range 19–37), respectively. Right upper extremity weakness was observed in 2 patients, which recovered gradually during follow-up. Immediate type Ia endoleak was detected in 1 patient. The mean follow-up time was 33 ± 20 months. During follow-up, no ARSA steal syndrome, spinal cord ischemia, or strokes were not observed.ConclusionsEndovascular treatment for TBAD with ARSA was feasible and safe with a satisfactory midterm follow-up outcome.     

循环中脂蛋白相关磷脂酶A2与stanford B型主动脉夹层支架置入术后不良事件的相关性

 目的 探究循环中脂蛋白相关磷脂酶A₂(Lp-PLA2)与stanford B型主动脉夹层支架置入术后不良事件的相关性。方法 回顾性分析2017-09至2021-05因Stanford B型夹层在陆军军医大学第二附属医院心血管内科住院并行胸腹主动脉腔内支架置入术的369例患者,分为康复组(332例)和不良事件组(37例),随访6个月,采集两组患者一般情况及血常规、肾功能、肝功能、C反应蛋白(CRP)和Lp-PLA2等指标,分析结局的独立影响因素,检验水准为0.05,探究循环中Lp-PLA2与支架术后的不良事件发生率之间的相关性。结果 不良事件组患者Lp-PLA2、白细胞计数(WBC)、CRP、尿酸(UA)均高于康复组,差异均具有统计学意义(P＜0.05)。进一步多因素分析显示,不良事件与Lp-PLA2(OR=1.024,95%CI:1.000～1.037)、WBC(OR=1.557,95%CI:1.189～2.671)、CRP(OR=1.005,95%CI:1.005～1.027)呈正相关。结论 Lp-PLA2的水平可能作为Stanford B型患者主动脉腔内血管修复术后不良事件的预测因子。     

急性期Stanford B型主动脉夹层腔内治疗研究进展

随着胸主动脉腔内修复术（TEVAR）的广泛应用及迅速发展,腔内治疗已成为了Stanford B型主动脉夹层的一线治疗方法。腔内治疗主动脉夹层的预后除了依赖于术前个体化方案的制定和术中操作者的经验,更依赖于手术指征及时机的掌握。对于急性期复杂性B型夹层,提倡在药物治疗的基础上早期行TEVAR手术;对于急性期非复杂性B型夹层是否可行TEVAR手术仍存在争议。文章主要就急性期B型主动脉夹层行腔内治疗的研究进展进行综述。     

Outcomes of Endovascular Management for Complicated Chronic Type B Aortic Dissection: Effect of the Extent of Stent Graft Coverage and Anatomic Properties of Aortic Dissection

PurposeTo assess the effect of the extent of stent graft coverage and anatomic properties of aortic dissection on the outcomes of thoracic endovascular aortic repair (TEVAR) for complicated chronic type B aortic dissection (CCBAD) in terms of survival, reintervention, and false lumen thrombosis.Materials and MethodsA retrospective analysis was performed of 71 patients who underwent TEVAR for CCBAD. Mean patient age was 54.7 years. Distal extent of stent graft coverage was categorized as short (≤ T7) or long (≥ T8) coverage. Indications of reintervention were categorized into three groups: proximal, alongside, and distal according to the anatomic relationship of the culprit lesion and the stent graft. Overall survival, reintervention-free survival, and extent of false lumen thrombosis were compared.ResultsThe technical success rate was 97.2%. The 1-year, 3-year, and 5-year overall survival rates were 97.1%, 88.9%, and 88.9%, and 1-year, 3-year, and 5-year reintervention-free survival rates were 80.7%, 73.8%, and 60.6%. There were no differences in overall survival, reintervention-free survival rates, and extent of false lumen thrombosis between the groups. In the short coverage group, distal reintervention was more frequent in patients with an abdominal aortic diameter ≥ 37 mm compared with patients with an abdominal aortic diameter < 37 mm (P = .005).ConclusionsTEVAR was effective for CCBAD with a high technical success rate and low mortality. The extent of stent graft coverage did not make a difference in terms of survival and false lumen thrombosis. Reinterventions were more frequently performed in patients with a large baseline abdominal aortic diameter who were treated with short stent graft coverage, and so longer coverage is recommended in such patients.