Gore C-TAG分段释放联合潜望镜技术处理B型主动脉夹层远端破口

目的 探讨胸主动脉覆膜支架分段释放技术联合"潜望镜"技术在Stanford B型主动脉夹层腔内修复术后远端破口处理中的临床应用价值.方法 回顾性分析2019～2020年5例Stanford B型主动脉夹层腔内修复术后胸主动脉远端假腔扩张患者的临床资料.结果 5例患者均为男性.主动脉CTA影像资料显示内脏区主动脉存在夹层...     

带膜支架治疗Stanford B型胸主动脉夹层动脉瘤

近年来血管腔内支架隔绝术治疗胸主动脉夹层（TAD）取得了较好的效果。2002年8月到2005年9月，我们共收治Stanford B型胸主动脉夹层动脉瘤32例，均行支架治疗并取得满意效果，现总结报道如下。     

慢性Stanford B型主动脉夹层的腔内治疗

<正>慢性主动脉夹层在传统意义上是病程超过2周的主动脉夹层,这是根据尸检发现74%的主动脉夹层患者死于最初的14天内来确定的急性与慢性的分界[1]。慢性Stanford B型主动脉夹层(chronic Stanford type B aortic dissection,CBAD)与急性主动脉夹层的病理过程差异很大,其僵硬的夹层内膜片以及相对固化的真假腔形态,使得其腔内修复术(thoracic endovascular aortic repair,TEVAR)后的主动脉重塑及假腔血栓化较差,从而影响了TEVAR的疗效。     

主动脉夹层腔内治疗的问题与前景

主动脉夹层的腔内治疗包括三种技术：一是腔内夹层远端破膜术以解决假腔远端流出道问题，二是主动脉或分支血管真腔内支架成型术以解决内脏和肢体缺血问题，三是腔内修复术（endovascular repair，EVR）致力于封堵夹层裂口达到降低假腔内压力和改善脏器肢体供血的目的。前两种技术从原理上既不能解决主动脉夹层的主要问题，又只能在特定的病变中才能起到一定的治疗效果，因此并没有在临床中广泛应用。而主动脉夹层的EVR从理论上实现了封闭夹层裂口的目的，实践中也已被证实其良好的安全性。因此一经出现，主动脉夹层的EVR便得到广泛认同并在近年来取得了快速的发展。良好的EVR解决了两个问题：一是封闭了夹层第一裂口，二是改善了分支血管供血。鉴于主动脉夹层致命的形式即是破裂和脏器及肢体缺血，因此EVR解决了主动脉夹层的主要问题。但是，取得成功的EVR并不简单，仍存在很多问题与挑战。     

复杂Stanford B型主动脉夹层的腔内治疗策略

目的探讨复杂Stanford B型主动脉夹层的腔内治疗策略。方法回顾性分析2010年1月至2014年6月期间我院血管外科采用腔内治疗36例复杂B型主动脉夹层患者的临床资料。结果 36例患者的腔内治疗均获成功。22例行主动脉腔内修复并覆盖左锁骨下动脉开口,10例结合左锁骨下动脉"烟囱"技术行主动脉腔内修复,2例先实施左颈总动脉-左锁骨下动脉人工血管转流后再行腔内修复,2例先实施右颈总动脉-左颈总动脉人工血管转流(左颈总动脉近心端结扎)后再行主动脉腔内修复。内脏动脉及下肢动脉缺血逐渐恢复,无内漏等并发症发生。结论对于复杂Stanford B型主动脉夹层的腔内治疗,结合覆盖左锁骨下动脉、"烟囱"技术、小切口的杂交手术等策略来延长锚定区,从而拓展了主动脉夹层的腔内治疗范围,提高复杂Stanford B型主动脉夹层的疗效和减少并发症。     

A型主动脉夹层合并降主动脉真腔狭小的外科治疗策略

目的:探讨A型主动脉夹层合并降主动脉真腔狭小的外科治疗方法及疗效。方法:回顾性分析本中心2017年1月至2019年12月9例A型主动脉夹层合并降主动脉真腔狭小患者的临床治疗资料。其中男7例,女2例,年龄21～56(41.6±9.2)岁;急性夹层2例,慢性夹层7例,马方综合征5例。术前全主动脉CTA检查证实为A型主动脉夹...     

腔内隔绝术治疗主动脉夹层的现今认识

近年腔内隔绝术治疗主动脉夹层良好的近中期疗效得到了验证,世界范围内多数学者对该技术的态度已从谨慎的观望转为积极的尝试和推广,因此近年该技术呈现出加速发展的趋势,报道的病例数迅速增加,临床应用的推广也同时带动了相关基础理论的研究和发展。本文拟从基础理论和治疗技术两方面分述腔内隔绝术治疗主动脉夹层的进展。相关基础理论的发展一、分型传统主动脉夹层分型方法中应用最为广泛的是Stanford分型和Debakey分型。Debakey将胸主动脉夹层动脉瘤分为三型:Ⅰ型,胸主动脉夹层动脉瘤起源于升主动脉并累及腹主动脉;Ⅱ型,胸主动脉夹层动…     

腔内治疗A型主动脉夹层的难点与突破

<正>随着腔内技术的进步,主动脉弓以及主动脉弓部以远的主动脉病变腔内治疗技术已广泛开展,其安全性和有效性均得到证实。得益于多种创新腔内技术和移植物设计的提出与临床应用,分支受累的复杂主动脉病变完全腔内治疗也已逐步推广,而升主动脉疾病是主动脉腔内治疗“最后一公里”。按照Stanford分型^[1],A型只涉及升主动脉血管相关层次,与远端夹层与否及解剖无关。A型主动脉夹层是一种心脏及血管外科的灾难性疾病。研究表明,     

Stanford B型主动脉夹层远端破口的腔内治疗策略

目前,胸主动脉腔内修复术是复杂型Stanford B型主动脉夹层的首选治疗方法。但该手术并未封闭夹层远端破口,假腔血流可持续存在,导致主动脉无法重塑甚至发生夹层进展。尤其是慢性Stanford B型主动脉夹层患者,内膜瓣已发生增厚和纤维化,主动脉重塑更加困难。研究结果显示,远端破口的存在可增加患者发生远期主动脉事件的可...     

主动脉夹层腔内隔绝术后并发症

腔内隔绝术治疗Stanford B型主动脉夹层已进入第二个十年.在第一个十年中,我们大量关注腔内隔绝术与药物保守治疗的对比,比如:研究复杂B型夹层的STABLE (staged total aortic and branch vessel endovascular reconstruction)试验,研究非复杂B型夹层的ADSORB (acute dissection stentgrafting or best medical treatment)试验、INSTEAD (the INvestigation of STnt Grafts in Aortic Dissection)试验等,其结果表明,腔内隔绝术在改善远期主动脉夹层重构、降低远期腔内治疗需要等方面有着积极作用.得到这一肯定的结果,进入第二个十年,我们应该更加关注主动脉夹层腔内隔绝术后的各种并发症,从临床和基础科研的不同角度分析其原因,改进手术技巧和腔内移植物,不断降低术后的死亡率和并发症发生率,从而进一步改善主动脉夹层的腔内治疗效果.以下我们对主动脉夹层腔内隔绝术后可能发生的主要并发症、处理原则及存在的问题等作一分述.     

A new paradigm in the management of acute type A aortic dissection: Total aortic repair

The currently accepted guidelines of open surgical repair for acute type A aortic dissection include the resection of the primary entry tear, replacement of the ascending aorta and “hemi-arch” with an open distal anastomosis, and aortic valve resuspension and some form of obliteration of the aortic root false lumen. The principal aim is protection against aortic rupture, aortic regurgitation, and coronary ischemia and restoration of antegrade preferential true lumen perfusion. Proponents argue that this operation is tailored to be in the armamentarium of most cardiac surgeons and deliver the lowest early operative risk while leaving the infrequent long-term sequelae to be dealt with electively by experienced aortic centers. Although this may sound to be a compelling argument, the actual outcomes suggest that it falls significantly short of achieving its noble goals on both acute and chronic counts. This led us to develop a seemingly more radical paradigm, which aims to achieve total aortic healing in the acute phase. We describe a total aortic repair technique for acute type A aortic dissection consisting of “branch first” total arch repair, followed by thoracoabdominal stenting and balloon rupture of the septum. The total aortic repair technique ensures that the aortic valve, ascending aorta, and arch are surgically securely repaired, and provides complete decompression of the false lumen as well as internal support in the remainder of the aorta. This has provided excellent early results and will hopefully minimize future complications and interventions.     

B型主动脉夹层98例报告

目的探讨B型主动脉夹层的治疗效果,急、慢性主动脉夹层的治疗措施。方法 2001年7月～2011年6月98例B型主动脉夹层(胸主动脉夹层96例,腹主动脉夹层2例;急性主动脉夹层89例,慢性9例)行胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)83例,外科手术修复1例,保守治疗10例,术前夹层动脉瘤突然破裂死亡4例。采用直型带膜支架修复80例,分支带膜支架修复3例。杂交手术7例,先行右腋动脉-左腋动脉人工血管旁路移植5例,行左颈动脉-左锁骨下动脉人工血管旁路移植2例。保守治疗的10例中,4例经1周治疗痊愈。9例慢性主动脉夹层发现夹层不断扩大,采取腔内修复治疗。结果 83例腔内修复手术围手术期死亡2例,病死率2.4%(2/83),死亡原因:1例术后1周因心包填塞(尸检结果),1例为不明原因于术后第2天死亡,考虑为其他位置再次破裂所致;余81例术后恢复良好,无脑卒中发生。腔内手术发生Ⅰ型内漏14例(16.9%);81例出院时夹层内血栓形成69例,12例夹层中仍可见部分血流。保守治疗的10例,6例显示夹层内血栓形成,其余变化不大。84例随访2～121个月,平均36.5月,随访率91.3%(84/92),其中TEVAR随访75例,保守治疗随访8例,外科手术随访1例:1例腔内修复术后3个月胸降主动脉再次破裂死亡,2例Ⅰ型内漏存在,夹层不断扩大,再次放置带膜支架后消失,其余病例情况良好。结论急性B型主动脉夹层的治疗要积极,TEVAR为首选,可以取得比较好的疗效;慢性B型主动脉夹层应注意随访,必要时采用TEVAR治疗。     

Toronto PowerWire fenestration technique to access false lumen branches in fenestrated endovascular aneurysm repair for chronic type B dissection

Chronic type B aortic dissection with aneurysmal degeneration requiring intervention presents significant therapeutic challenges. Thoracic endovascular aortic repair with a fenestrated endograft is a feasible option, but false lumen branches without an adjacent re-entry or perforation in the septum can pose a significant challenge. We present two cases of fenestrated endovascular aneurysm repair for chronic type B aortic dissection in which a renal artery from the false lumen was cannulated by creating a “neofenestration” through the dissection flap using a radiofrequency PowerWire (Baylis Medical Inc, Montreal, Quebec, Canada) technique (Toronto PowerWire fenestration technique).     

Creating an appropriate access for endovascular repair by replacing a dissected femoral artery in aortic dissection

Transfemoral endovascular repair has been widely accepted as an effective treatment for type B aortic dissection. However, if the dissection extends to the femoral artery, the transfemoral approach increases the risk of access complications. We describe a case of acute complicated type B aortic dissection involving the dissected bilateral femoral arteries. Successful endovascular repair without access complications was performed through an appropriate access route created by a femoral arterial conduit. We believe that this approach results in reliable cannulation of the true lumen and the reduction of the risk for intimal injury in aortic dissection with the dissected femoral artery.     

Staged hybrid repair of thoracoabdominal aortic aneurysm after chronic type B aortic dissection

The purpose of this study was to evaluate clinical outcomes of combined endovascular and open techniques to eradicate false lumen dilatation in the visceral aortic segment after type B aortic dissection associated with aortic aneurysm. We reviewed eight patients with distal thoracic and abdominal false lumen dilatation treated with a staged procedure. These included arch debranching as needed, proximal thoracic endovascular repair, and open surgical correction with abdominal aortic replacement of the visceral and infrarenal aorta. False lumen eradication was successful in all patients. There were no operative deaths, and paraplegia or paraparesis occurred in two patients. During a mean follow-up of 30 months, no complications or secondary interventions were necessary. The thoracic false lumen remained thrombosed in all patients, with no evidence of aortic dilatation or stent graft complications. Complete thrombosis and eradication of the false lumen can be achieved through a three-stage repair of chronic type B aortic dissection with aneurysmal dilatation. A prospective randomized trial is needed to establish the viability of this approach versus standard open repair of type II thoracoabdominal aortic aneurysms.     

Treatment of chronic aortic type A dissection with a new designed hybridprosthesis.

This report describes the use of a new combined surgical and endovascular treatment for chronic type A aortic dissection after Cabrol operation. Intraoperative antegrade stenting of the descending aorta combined with distal ascending aorta and aortic arch repair was performed using the E-vita open endoluminal stentgraft. The stentgraft was deployed under direct vision into the true lumen. Postperative CT scan revealed a partially thrombosed false lumen. This report shows that a combined surgical and endovascular approach of chronic type A aortic dissection in a single stage procedure is a feasible option and extends aortic repair without increase of risk.     

Endograft repair of acute aortic dissection. Promises and challenges

Acute dissection is a uniquely complex, relatively common, and frequently lethal aortic catastrophe. Historically, surgical treatment has been reserved for cases with complications including rupture; the results have been less than optimal because of excessive morbidity and mortality. This is the main reason why conservative management emerged as the standard of care for management of acute type B aortic dissection (TBAD). While more patients would appear to survive with a conservative treatment strategy, the outcome in terms of 30-day mortality (20%) and occurrence of late complications - such as enlarging aneurysms of the thoracic false lumen (30-40%) - leaves (again) much to be desired. Stent-graft endovascular repair has emerged as a very promising, less invasive treatment option. These devices, when used appropriately, can achieve the important therapeutic goals of entry-site coverage, depressurization of the false lumen, and expansion of the compressed true lumen - overcoming ischemic (malperfusion) manifestations. The early results of stent-graft repair of TBAD are encouraging, and even exciting, but much more work needs to be done in various critical areas surrounding this condition. Thoracic endograft technology has lagged behind its abdominal counterpart. The design of acute dissection-specific devices is imperative, reflecting the significant differences between TBAD and degenerative thoracic aortic aneurysm disease. Needs for this and other important developments notwithstanding, it is generally acknowledged that stent-graft intervention does represent an important advance in the treatment of patients with TBAD. Well-designed, controlled clinical trials will be necessary to elucidate the relative value of several endovascular thoracic strategies.     

B型主动脉夹层病人主动脉内径分析

目的 探讨胸主动脉的解剖特点,以证明B型主动脉夹层病人主动脉弓直径与降主动脉真腔直径存在显著差异.方法 20名健康成年人为对照组,接受计算机X射线断层血管造影(CTA)测量主动脉弓直径(近端Φ)和降主动脉中段直径(远端Φ).病程小于1个月的急性组23例和病程大于2年的慢性组19例病人均接受了主动脉夹层腔内修复术,利用术中的数字减影(DSA)和术前、术后的CTA,测量主动脉弓直径(近端Φ)和降主动脉中段真腔直径(远端Φ).分别计算3组的渐细率[(近端φ-远端Φ)/近端Φ)×100%].结果 对照组的CTA渐细率为(13.0±4.7)%.急性组DSA和CTA的渐细率分别为(23.6±11.3)%和(21.9±12.1)%.慢性组DSA和CTA的渐细率分别为(31.5±13.6)%和(30.1±11.4)%.结论 在急性和慢性B型夹层病人中,主动脉弓直径显著大于降主动脉真腔直径.在B型主动脉夹层腔内修复术中使用渐细型覆膜支架是一个更合理的选择.     

Endovascular repair of a ruptured chronic type B aortic dissection

Aneurysm formation is a common sequel of chronic type B aortic dissection. Ruptured false lumen aneurysms have traditionally been treated with open repair. These procedures are associated with high morbidity and mortality rates. We report the first successful endovascular repair of a ruptured chronic type B aortic dissection in a patient who had been turned down for elective surgery. The endovascular management of chronic dissection with rupture is difficult and may necessitate stenting of both entry and reentry points to induce false channel thrombosis. The long-term efficacy of this technique is unknown.     

Aortic arch repair for Stanford type A aortic dissection with distal anastomosis to the proximal level of the distal aortic arch

BACKGROUND: In acute type A dissection, replacing the ascending aorta with the transverse aortic arch recently has been recommended for event-free long-term survival. Since 1994, we have performed our new transverse aortic arch replacement, in which the distal end of the graft is anastomosed between the left common carotid artery and the left subclavian artery to reduce the risk by obtaining a good surgical view, resulting in good hemostasis. The "elephant trunk technique" was used in anticipation of a staged descending aortic operation for residual dissecting aorta. We analyzed the surgical survival of patients with Stanford type A aortic dissection undergoing our operative procedure using hypothermic selective antegrade cerebral perfusion. METHODS: We performed our new technique in 27 patients (aged 61 +/- 11 years, 15 male and 12 female patients, 22 patients with acute type A dissection, and 5 patients with chronic dissection). RESULTS: One in-hospital death (3.7% in total: 4.5% in acute dissection, 0% in chronic dissection) occurred in patients undergoing our new technique. Actuarial survival (including early death) was 91% at 5 years after the operation. One late death occurred as the result of a malignant tumor. Four patients underwent a staged reoperation for aneurysmal dilatation of the residual descending aorta or renal and splenic embolism as the result of thrombus from the false lumen 2 to 11 months (mean interval 6 months) after the initial operation. They have been doing well since the reoperation. CONCLUSIONS: Our "distal anastomosis to the proximal level of the distal aortic arch" technique made aortic arch replacement easier and improved the survival of the arch replacement for aortic dissection, especially for acute type A dissection, by securing hemostasis in the suture line. Combining the elephant trunk technique with our new procedure is useful to perform a staged aortic replacement for dilatation and complication of the false lumen in the descending aorta.