气候变化对主动脉夹层发生的影响

目的研究气侯变化对主动脉夹层发生的影响,为主动脉夹层的预测和预防提供思路。方法收集2010年1月1日至2016年12月31日阜外医院收治来自河北省的所有急性主动脉夹层患者临床资料,与河北省每月气象数据,利用广义模型探索气候变化与主动脉夹层发病的关系。结果阜外医院6年期间共接诊来自河北省急性主动脉夹层患者1 121例,男873例、女248例,平均年龄(51.4±12.0)岁。通过单因素分析发现温度、湿度、气压差异均有统计学意义(P0.01),进一步通过多因素分析发现温度与主动脉夹层的发生相关(P0.01)。最低温度对主动脉夹层的发生具有最佳预测作用,相对危险度为1.02,95%置信区间为(1.02,1.03)。结论气候条件的变化会影响主动脉夹层的发生,低温是引起主动脉夹层发病的重要触发因素。     

妊娠晚期及产褥期合并急性主动脉夹层的临床治疗策略

目的探讨妊娠晚期(孕晚期)及产褥期合并急性主动脉夹层的临床特点、治疗策略及治疗效果。方法回顾性分析2012年8月至2017年6月间上海长海医院7例妊娠合并急性主动脉夹层患者的临床资料。5例妊娠晚期、2例产褥期,Stanford A型主动脉夹层6例(85.7%)、B型1例(14.3%),年龄26~34(30.8±3.1)岁。患者发病时间为孕28周至产后18 d,其中5例孕妇发病时间平均(31.8±2.63)周。A型夹层患者心脏超声显示升主动脉最宽内径4.2~5.7(4.7±0.6)cm,2例合并主动脉窦瘤,3例为马方综合征(42.8%)。A型夹层患者主动脉处理方式为:Bentall手术1例,Bentall+Sun’s手术2例,升主动脉置换+Sun’s手术+冠状动脉旁路移植术1例,主动脉根部成形+升主动脉置换+Sun’s手术2例。B型夹层患者先行剖宫产后再行胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)。结果主动脉阻断时间51~129(85.5±22.9)min,体外循环时间75~196(159.0±44.0)min,中低温停循环+选择性脑灌注时间为20~30(23.8±3.5)min。所有母体及胎儿均存活,其中先行主动脉修复而后期行剖宫产的1例胎儿经诊断为脑瘫。孕妇及新生儿随访9个月至4年,随访期内除脑瘫胎儿外其余婴幼儿均发育生长良好;7例孕妇均恢复良好;早期先行主动脉修复的孕妇(仅1例),在后期剖宫产时发现乙状结肠破裂同期行乙状结肠造瘘术治疗;另1例A型夹层的产妇,出院2年后经诊断为胡桃夹综合征。结论妊娠晚期合并主动脉夹层多为A型夹层患者,马方综合征是妊娠合并急性主动脉夹层患者的高危因素。尽早手术并根据主动脉夹层类型及胎龄选择相应的治疗策略,妊娠晚期及产褥期合并主动脉夹层患者可获得良好的母儿结局。     

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...     

急性A型主动脉夹层合并尿毒症患者的外科治疗结果及预后

目的:总结急性A型主动脉夹层合并终末期肾病需透析治疗的患者行手术治疗的经验及随访结果。方法:2014年1月至2020年3月,共收治20例尿毒症合并急性A型主动脉夹层患者,男11例,女9例;年龄26～63岁,平均(47.8±11.3)岁。18例血液透析,2例腹膜透析,透析时间为1周～11年,平均(4.5±3.9)年。17...     

糖尿病对主动脉壁内血肿预后的影响

目的探讨糖尿病对主动脉壁内血肿的预后影响。方法纳入2012年10月至2014年11月我院连续24例主动脉壁内血肿患者,其中男17例、女7例,年龄(58.83±10.42)岁,定期复查主动脉CTA(复查时间为3~4周),观察糖尿病患者和非糖尿病患者主动脉壁内血肿的进展情况。结果 24例患者在复查时,出现A型主动脉夹层2例,B型主动脉夹层3例(均为腹部局限性夹层);4例患者合并糖尿病,复查时2例进展为主动脉夹层,2例血肿及溃疡加重。结论主动脉壁内血肿整体呈吸收趋势,无并发症发生。手术事件的发生率与患者合并糖尿病有密切关系。     

Stanford B型主动脉夹层腔内修复术后并发A型夹层的外科治疗

目的总结Stanford B型主动脉夹层胸主动脉腔内修复术(TEVAR)后并发A型夹层的临床特点及外科治疗经验。方法自2013年11月至2018年3月,南京鼓楼医院外科治疗Stanford B型主动脉夹层TEVAR术后并发的A型夹层患者14例,其中男13例、女1例,年龄24～66(52±3)岁,合并高血压13例,糖尿病2例,马方综合征1例。所有患者在深低温停循环选择性脑灌注下施行手术,近心端13例行升主动脉置换术,1例行Bentall术。共实施全弓置换加象鼻手术13例,弓部开窗支架植入术1例。结果全组无死亡,1例术后右上肢单瘫,1例术后血行感染,1例出现右侧偏瘫及肾功能不全行肾脏替代治疗。随访6～45个月,随访期间1例患者术后1个月因原介入支架远端胸降主动脉发生新的夹层再次行TEVAR,其余患者CT血管造影检查未见吻合口造影剂渗漏及人工血管扭曲。结论 B型主动脉夹层TEVAR术后并发A型夹层及时给予外科手术治疗可取得良好疗效。     

Stanford A型主动脉夹层腔内治疗后并发症的原因和预防

自从1998年Shimono等[1]报道第1例完全通过血管腔内修复的方法治疗Stanford A型主动脉夹层以来,有许多专家分别报道了类似的经验,所完成的病例数也越来越多.我中心于2001年1月为1例Stanford A型主动脉夹层患者(60岁)成功施行了腔内修复术[2],至2012年5月30日止,已为58例Stanford A型主动脉夹层患者完成了腔内治疗,总体手术成功率为98.3％,围手术期死亡率为12.1％.     

Bentall手术治疗胸主动脉瘤和主动脉夹层54例

胸主动脉瘤和主动脉夹层临床上较常见,其病情凶险,病变血管随时可能突然破裂导致患者死亡。Bentall手术是治疗胸主动脉瘤或主动脉夹层的经典手术。2007年10月至2010年10月我科采用Bentall手术治疗54例胸主动脉瘤或主动脉夹层患者,现总结其临床经验。1临床资料与方法1.1一般资料本组共54例,男41例,女13例;年龄18~63岁,平均年龄43.8岁。     

孙氏手术治疗升主动脉替换术后残余主动脉夹层

目的 探讨Stanford A型主动脉夹层近端主动脉替换术后残余主动脉夹层的手术时机和手术方式.方法 2009年3月至2011年11月,连续收治16例Stanford A型主动脉夹层术后残余夹层的患者,男13例,女3例;年龄23 ～ 61岁,平均44岁.其中8例为马方综合征.中低温停循环、低流量顺行脑灌注下行孙氏手术(主动脉弓替换+支架象鼻术).其中单纯行孙氏手术12例;同期行主动脉根部替换术(Bentall手术)3例,主动脉根部替换术+冠状动脉旁路移植术(Bentall+ CABG)1例,冠状动脉吻合口漏修补术1例,二尖瓣置换术(MVR)1例.结果 再次手术距离首次手术时间(66±40)个月.体外循环(193±49)min,心肌阻断(90±28) min,选择性脑灌注(22±10) min.术后气管插管(17±10)h.无住院死亡.术后并发症4例,其中左下肢轻瘫1例随访期间好转;开胸止血、乳糜胸和胸骨后感染各1例,均于治疗后痊愈出院.患者出院前均行主动脉CT血管造影检查,示人工血管血流通畅,降主动脉真腔较术前明显扩大,支架段假腔血栓形成.随访3～42个月,平均17个月.1例术后3个月因远端夹层破裂死亡,1例术后6个月行全胸腹主动脉替换术,1例因胸降主动脉扩张合并内膜残余破口行胸主动脉腔内修复术.结论 Stanford A型主动脉夹层升主动脉替换术后残余夹层的患者,当主动脉弓扩张速度超过0.5 cm/年,或直径扩张至5 cm以上(或扩张至4.5 cm但合并弓部破口或马方综合征)时,应再次接受手术治疗,孙氏手术治疗安全有效,手术死亡及相关并发症发生率较低,近期结果良好.     

创伤性主动脉损伤的外科治疗策略

目的总结创伤所致主动脉损伤的外科治疗策略。方法纳入2009年1月至2018年1月北京安贞医院心血管外科治疗的34例创伤性主动脉损伤患者(交通肇事伤31例、坠落伤2例、物体砸伤1例)。男23例,女11例。患有高血压病10例,胸主动脉假性动脉瘤9例,胸主动脉离断6例,主动脉夹层共19例。开放手术5例,年龄(44.80±20.57)岁;2例A型主动脉夹层行Bentall+孙氏手术,1例B型夹层及2例胸主动脉假性动脉瘤行术中支架人工血管置入术。胸主动脉腔内修复术29例,年龄(45.93±11.01)岁。结果开放手术时间(403.20±30.30)min,患者住院(19.00±6.04)天;胸主动脉腔内修复术手术时间(105.72±27.76)min,患者住院(5.76±3.08)天。所有患者术后随访(45.09±23.10)个月,两组均无死亡,2例胸主动脉腔内修复术患者因封闭左锁骨下动脉未开通而出现左上肢乏力麻木。结论创伤性主动脉损伤应根据患者全身情况、损伤等级、损伤累及部位及解剖特点来选择不同的治疗方案。但远期预后仍有待确定。     

Spontaneous dissection and rupture of common iliac artery in a patient with fibromuscular dysplasia: a case report and review of the literature on iliac artery dissections secondary to fibromuscular dysplasia

Spontaneous dissection and rupture of the iliac artery is an unusual finding in patients with fibromuscular dysplasia (FMD). We report the case of a patient with FMD who required emergent surgery because of rupture of an iliac artery dissection, and review 9 previously reported cases of iliac artery dissection associated with FMD. A 30-year-old man had abdominal pain, and went into shock. Angiograms revealed dissection of the left common iliac artery with extravasation. At emergent surgery the rupture site was in the proximal left common iliac artery and extended to the left external iliac artery. Interposition of the diseased artery with a Dacron graft was attempted, but cardiac arrest occurred, and resuscitation was unsuccessful. Pathologic examination showed typical characteristics of diffuse medial FMD. Ten cases (5 male and 5 female patients), including the present case, with dissection of iliac arteries associated with FMD have been reported. Median patient age was 45 years (range, 29-56 years). Three of the 10 patients had acute onset of symptoms, and the remainder had gradual development of intermittent claudication or groin pain. Only the present case had evidence of rupture. The site of dissection was in the external iliac artery in 8 patients and the common iliac artery in 2 patients. Anatomic bypass or interposition of the diseased artery was performed in 8 patients; the others received conservative treatment. There was no mortality in the 9 previously reported cases. Fatal acute dissection and rupture of the common iliac artery occurred in a patient with FMD, even though the clinical course of this disease is relatively benign. FMD should be considered the cause of dissection and rupture of the iliac artery in a patient with symptoms but of non-atherosclerotic age.     

Video-assisted thoracoscopic left upper lobectomy for lung cancer patients: bronchial dissection technique prior to pulmonary artery dissection

BACKGROUND: Dissection of anterior segmental artery anatomically crossing over apico-posterior segmental bronchus during left upper lobectomy may sometime cause life-threatening vascular injury. PATIENTS AND TECHNIQUE: Between August 2006 and July 2007, 12 patients with clinical stage IA-lung cancer underwent the video-assisted thoracoscopic left upper lobectomy with bronchial dissection prior to anterior and apico-posterior pulmonary artery dissections following dissection of lingular segmental artery. RESULTS: Operation time ranged from 75 minutes to 190 minutes (average 132 +/- 39 minutes). Operative blood loss ranged from 10 ml to 400 ml (124 +/- 112 ml). Postoperative course was uneventful except 1 patient who had left recurrent nerve palsy. CONCLUSIONS: Bronchial dissection prior to the upper segmental pulmonary artery dissections can produce better surgical field around left main pulmonary artery, leading to safe pulmonary arterial dissection during video-assisted thoracoscopic left upper lobectomy.     

Extended resection of the pulmonary artery and the aorta for primary lung cancer. Report of a case

We report a case of squamous cell carcinoma of the lung in which a left pneumonectomy combined resection of the pulmonary artery and aorta was performed using a cardiopulmonary bypass. The bifurcation of the pulmonary artery was repaired with a pericardial patch and the descending aorta was replaced with an artificial vessel Eleven months later, the patient underwent dissection of the contralateral mediastinal lymph nodes because of a recurrence of the disease. Even though pulmonary metastases have again recently appeared, he is alive and doing well two years after operation. To obtain a better prognosis in cases demonstrating an involvement of the bifurcation of pulmonary artery, more effective combined treatment still needs to be developed.     

A rare complication of pre-Eisenmenger patent ductus arteriosus: Pulmonary artery dissection

INTRODUCTIONPulmonary artery dissection associated with patent ductus arteriosus is usually seen in patients with pulmonary hypertension and Eisenmenger's syndrome. This paper presents a case with pre-Eisenmenger patent ductus arteriosus complicated by pulmonary artery dissection, and explains how she was surgically treated.PRESENTATION OF CASEThe transthoracic echocardiography of a 21-year-old woman complaining of effort dyspnea revealed patent ductus arteriosus. Contrast-enhanced thoracic computed tomography scan showed patent ductus arteriosus and dissection in the main pulmonary artery extending from the edge of the patent ductus arteriosus orifice to the pulmonary valve. The patent ductus arteriosus was divided with pledgeted prolene suture and the dissected aneurysmal portion of the pulmonary artery was resected by surgery. Dacron graft interposition was applied to the main pulmonary artery.DISCUSSIONBecause rupture causes cardiogenic shock and sudden death, diagnosis is rare in the living subject and pulmonary artery dissection is frequently detected in autopsy. A case with pulmonary artery dissection as a result of patent ductus arteriosus has been reported in the literature, but the patient died in the preoperative period. In our study, the patient was not diagnosed to have Eisenmenger's syndrome, but had pulmonary artery dissection, a complication arising from patent ductus arteriosus. The patient underwent curative surgery that included pulmonary artery dissection repair and closure of the patent ductus arteriosus.CONCLUSIONIn addition to pulmonary artery aneurysm, pulmonary artery dissection must also be considered as a complication in cases of patent ductus arteriosus with high pulmonary artery pressure diagnosed in adulthood.     

自发性孤立性肠系膜上动脉夹层16例诊治分析

目的:探讨自发性孤立性肠系膜上动脉夹层(SISMAD)的临床特点及诊治路径。方法:回顾性分析2012年9月—2017年10月中南大学湘雅医院收治的16例SISMAD患者的临床资料。其中男12例,女4例;年龄47~70岁,中位数年龄56.5岁;其中14例表现为急性上腹痛或脐周痛,另外2例分别因肾结石及胸腺癌复查CT时发现SISMAD。所有患者均经过CTA扫描检查明确诊断。治疗方法包括保守治疗、腔内血管重建术及开放手术治疗。结果:保守治疗成功10例,腔内血管重建术治疗成功5例,1例保守治疗中出现血压下降,怀疑夹层破裂出血急诊行开放动脉修补术,成功重建肠系膜上动脉血运。16例患者全部获得随访,随访时间4~60个月,平均(28±13)个月,在随访期内无腹痛复发及肠道缺血症状。随访CT显示,保守治疗的患者无夹层瘤样扩张,腔内治疗成功的患者支架均通畅。结论:对于SISMAD,当诊断明确、肠系膜血运没有受到夹层严重影响、无腹膜炎征象时,应先给予保守治疗;没有缺血性肠坏死或腹膜炎征象、经保守治疗腹痛症状没有明显缓解时,应考虑采取腔内修复术;若出现夹层破裂出血、肠坏死或腹膜炎征象则应积极采取开放手术治疗。     

Basilar artery dissection

OBJECT: Little is understood about the clinical manifestations of basilar artery (BA) dissections, which can present with subarachnoid hemorrhage (SAH), brainstem compression, or ischemia. In any instance, the prognosis seems poorer than that for vertebral artery (VA) dissection. The authors analyzed clinical presentations and radiological features of BA dissection with and without rupture. METHODS: Between 1998 and 2003, the authors treated 10 patients (eight men and two women, ranging in age from 32-78 years; mean age 54 years) with BA dissection. Diagnosis was based on clinical and radiological findings, including those from magnetic resonance imaging and cerebral angiography studies. Of the 10 patients, five had impaired consciousness at disease onset. Among four patients presenting with SAH, two were treated conservatively and had fair outcomes without recurrent hemorrhage. The other two patients with SAH were treated using unilateral endovascular VA occlusion, but one of them subsequently suffered fatal rebleeding. A fifth patient presented with progressive signs of a mass involving the brainstem, whereas the remaining five patients showed brainstem ischemia; all were treated conservatively. Four patients could not return to their previous daily activities. CONCLUSIONS: Basilar artery dissections are rare lesions associated with significant morbidity and death. The natural course of and the treatment options for BA dissection differ considerably from those for VA dissections. Management of these lesions is controversial and difficult, and requires particular care.     

Pulmonary artery dissection complicating lung transplantation for primary pulmonary hypertension

We report a case of pulmonary artery (PA) dissection complicating lung transplantation. A 30-year-old man with primary pulmonary hypertension underwent bilateral single lung transplantation. Thirty hours postoperatively he had signs of obstruction of the right main pulmonary artery develop due to dissection demonstrated on transesophageal echocardiography and pulmonary arteriography. Surgical repair of the dissection with reanastomosis of the pulmonary artery was successfully carried out, and the patient subsequently improved to a favorable condition. Pulmonary hypertension is a risk factor of pulmonary artery dissection; our case suggested that underlying chronic pulmonary hypertension might have led to this rare and life-threatening anastomotic problem after lung transplantation.     

Platelet-derived growth factor inhibition--a new treatment of pulmonary hypertension in congenital diaphragmatic hernia?

Increased pulmonary vascular resistance causing pulmonary artery hypertension is a major problem in the treatment of congenital diaphragmatic hernia with a strong association to mortality. We here report a patient with intractable pulmonary hypertension at 4 weeks of age unresponsive to conventional treatment. After administration of the platelet-derived growth factor (PDGF) receptor antagonist imatinib, pulmonary artery pressure gradually decreased to acceptable levels and the patient's clinical condition gradually improved.     

Ascending aortic dissecting aneurysm with isolated right pulmonary arterial medial intramural hematoma

On rare occasions, acute aortic dissection may cause pulmonary artery obstruction when there is aortic rupture with hemorrhage into the common adventitia of the aorta and pulmonary artery. We report an extremely unusual case of an ascending aortic dissecting aneurysm associated with an isolated medial intramural hematoma in the right pulmonary artery in an 86-year-old woman with clinical manifestations mimicking pulmonary embolism. We believe that this rare pulmonary arterial complication of aortic dissection without involvement of the common adventitia has not been previously described.     

升主动脉和头臂干双动脉插管在急性A型主动脉夹层手术中应用的倾向性评分匹配分析

目的 探讨升主动脉、头臂干双动脉插管在急性A型主动脉夹层手术中的应用.方法 筛选2017年1月至2020年1月我院急性A型主动脉夹层患者183例,其中42例采用升主动脉、头臂干双动脉插管建立体外循环,为DAC组(男33例、女9例,中位年龄50岁);141例采用单独腋动脉插管建立体外循环,为AAC组(男116例、女25例...