主动脉弓部病变腔内修复术的研究

目的探讨进行腔内修复术(EVAR)时头、臂动脉的处理方案。方法1998年9月至2006年2月,共63例EVAR涉及到头、臂动脉的处理。左锁骨下动脉的处理:一期部分或全部覆盖;不行重建;先外科重建,然后腔内覆盖;完全腔内重建。左颈总动脉的处理:先外科重建,然后腔内覆盖;腔内覆盖大部分,然后腔内重建。无名动脉的处理:先外科重建左颈总动脉和左锁骨下动脉,然后应用分叉支架型血管完全重建主动脉弓。结果54例仅须处理左锁骨下动脉,8例须处理左颈总动脉和左锁骨下动脉,1例须处理弓上3分支血管。所有辅助技术均取得成功。左锁骨下动脉未进行重建者术后左肱动脉平均收缩压(62.6±24.2)mmHg(1mmHg=0.133kPa)。EVAR后30d内漏发生率17.5%。结论对有选择的病人,一期覆盖左锁骨下动脉是安全的。通过辅助技术,可以扩大EVAR的手术适应证。长期结果须行进一步随访。     

选择性覆盖左锁骨下动脉在胸主动脉腔内修复术中的应用

目的:探讨胸主动脉腔内修复术中一期覆盖左锁骨下动脉(LSA)对预后的影响。方法:回顾分析2007年6月—2012年1月76例胸主动脉病变行胸主动脉腔内修复术患者的临床资料,包括主动脉夹层56例,壁间血肿6例,胸主动脉瘤5例,外伤性胸主动脉破裂9例。腔内修复术中一期覆盖LSA 32例,部分覆盖9例,保留35例。观察疗效和并发症发生情况。结果:围手术期死亡1例(1.3%),死于急性脑梗死。32例覆盖LSA的患者中,发生脑血管意外3例(9.4%),左锁骨下动脉窃血1例(3.1%),左上肢乏力4例(12.5%),并发症发生率为25.0%(8/32);9例部分覆盖LSA患者和35例LSA未覆盖患者中,发生脑血管意外各1例。随访3~40个月,死亡1例,I型内漏2例,均再次手术干预获得成功。结论:胸主动脉腔内修复术有选择性地一期覆盖左锁骨下动脉是可行的。     

腔内治疗主动脉瘤时锚定区不足的处理

目的 探讨主动脉夹层、胸主动脉瘤、胸腹主动脉瘤腔内治疗远近端锚定区缺乏的现阶段处理体会.方法 2005年8月至2009年2月,我科共治疗主动脉扩张性疾病包括主动脉夹层、胸主动脉瘤、胸腹主动脉瘤129例,其中主动脉夹层近端锚定区不足6例,胸主动脉瘤近端锚定区不足3例,腹主动脉瘤远端锚定区不足4例.分别进行升主动脉一双侧颈总动脉一左锁骨下动脉转流、双侧颈总动脉一左锁骨下动脉转流、腹主动脉一肠系膜上动脉一双侧肾动脉转流、髂内动脉栓塞重建锚定区后成功腔内治疗.结果 患者均获技术和临床成功,无围手术期死亡和重大并发症.随访期间支架人造血管无移位,夹层或动脉瘤腔血栓形成良好,无明显内漏,瘤体未增大;桥血管通畅.结论 对于缺乏锚定区的主动脉扩张性病变,通过人造血管旁路手术或栓塞非必须血管等方法重建或扩大锚定区是扩大腔内治疗适应证的安全、有效的手段.     

裂口位于主动脉弓远端Stanford A型主动脉夹层的腔内修复

目的总结腔内修复术治疗裂口位于主动脉弓远端Stanford A型主动脉夹层的临床经验。方法2001年1月至2006年6月在中山大学附属第一医院血管外科通过股动脉入路行主动脉腔内修复术,对21例内膜撕裂口位于主动脉弓远端和近端降主动脉的Stanford A型主动脉夹层进行血管腔内治疗,根据椎动脉造影确定是否重建左锁骨下动脉。结果全组21例中,急性夹层13例,慢性夹层8例,均接受了血管腔内带膜支架修复术,手术成功率100%。17例同时封闭了左锁骨下动脉,其中4例行左锁骨下动脉重建。4例发生内漏,1例术后发生脑梗死。平均随访22.3个月(6~65个月),所有病例均存活。假腔内完全血栓形成12例,部分血栓形成9例。结论主动脉腔内修复术治疗内膜撕裂口位于主动脉弓远端和近端降主动脉的Stanford A型主动脉夹层是有效和安全的,具有微创、成功率高和并发症少等特点。     

“烟囱”技术在Ⅲ型夹层动脉瘤和腹主动脉瘤腔内修复术中的应用

目的 总结“烟囱”技术在主动脉瘤腔内修复术中的应用体会和一期效果.方法 在30例主动脉瘤腔内修复术中使用“烟囱”技术增加近端覆膜支架锚定区,其中25例DebakeyⅢ型夹层动脉瘤使用“烟囱”支架保留左锁骨下动脉(23例)或左颈总动脉(3例),肾下腹主动脉瘤使用“烟囱”支架保留肾动脉(5例).结果 所有病例均顺利完成操作,放置“烟囱”支架的分支动脉术中造影均通畅.其中2例夹层动脉瘤(8％)和1例腹主动脉瘤残留(20％)少量Ⅰ型内漏,1例夹层动脉瘤左锁骨下动脉“烟囱”病例术后5d猝死,考虑为远侧破口所致夹层动脉瘤破裂.其余22例夹层动脉瘤和4例肾下腹主动脉瘤均无内漏.随访28例(90.3％),随访1～19个月,平均(6±5)个月.随访期超声或CTA示“烟囱”血管血流均通畅.1例腹主动脉瘤仍有内漏,2例夹层内漏病例随访中(尚未行CTA),其他病例瘤腔血栓形成.结论 “烟囱”技术能够有效的延长覆膜支架在主动脉瘤腔内修复术中的近端锚定区并保持重要分支动脉通畅.     

胸主动脉腔内修复扩展近端锚定区的探讨

目的探讨胸主动脉腔内修复(EVR)近端锚定区不足的两种处理。方法回顾分析近端锚定区<15mm的9例DeBakeyⅢ型主动脉夹层动脉瘤(ADA)和1例胸降主动脉瘤(DTAA)患者的治疗经过、结果和并发症。其中DTAA患者和3例ADA患者行辅助性右左颈总动脉、左颈总左锁骨下动脉旁路联合腔内修复(EVR)治疗(联合治疗组),另6例ADA患者直接行EVR,覆盖左锁骨下动脉开口(直接修复组)。结果10例患者都取得技术成功。DTAA病例动脉旁路术后无并发症,EVR术后并发脑梗塞、成人呼吸窘迫综合征、上消化道大出血、肾功能衰竭,第12天死亡。9例ADA患者功能围手术期无与血管有关的并发症。直接修复组中2例术后早期出现头晕,静滴甘露醇4～5d后缓解。9例患者都获随访,随访期3～12个月(平均9个月),未发生神经系统或肢体缺血性并发症,术后3个月CT证实所有病例原发破口封闭,胸主动脉假腔内完全血栓形成,真腔扩大。结论处理胸主动脉EVR近端锚定区不足时,辅助性动脉旁路和直接覆盖左锁骨下动脉开口是可行的,可以拓展EVR在DeBakeyⅢ型ADA和DTAA中的应用。     

腔内修复术中主动脉弓分支血管的处理

血管腔内修复术（endovascular repair，EVR）对胸主动脉瘤（thoracic aortic aneurysm，TAA）及胸主动脉夹层（thoracic aortic dissection，TAD）的治疗以其微创、迅速、安全、有效等特点正广泛被医患双方接受，但近端锚定区条件是保障主动脉弓部病变腔内修复术后效果的关键因素。由于主动脉弓的自然弯曲和弓上分支血管所供靶器官的特殊性，瘤体或夹层破口上缘距左锁骨下动脉开口〈15mm曾被认为是EVR的手术禁忌。目前，随着研究深入，EVR正走向主动脉弓部复杂的解剖区域。人们正以不同的思维模式、医疗技术、设备条件对这类复杂病变实施不同的手术方案，其目的是既保持腔内修复术的安全、有效特点，又保证主动脉弓重要分支血管的血流不受严重影响。主动脉弓分支血管包括左锁骨下动脉（left subclavian artery。LSA）、左颈总动脉（lefc ommon carotid artery，LCCA）和无名动脉（也称头臂干动脉）（innominate artery，IA），上述动脉通称为三支头臂动脉。从技术上讲，人们正以两类技术处理主动脉弓的分支血管，一是EVR时应用腔内技术重建这些血管．二是EVR时结合传统血管外科技术重建这些血管。由于三支头臂动脉对靶器官供血的意义不同，造成在处理方式上也有显著差异。本文根据笔者临床经验并结合文献，讨论主动脉弓部EVR时三支头臂动脉的处理方法。     

胸主动脉腔内修复术中左锁骨下动脉重建的现状及进展

胸主动脉腔内修复术目前已成为Stanford B型主动脉疾病的首选治疗方法。为了保证支架的成功释放以及良好的近端锚定效果, 需要尽可能保留或重建左锁骨下动脉血运。随着各类腔内辅助技术的不断进步, 多种左锁骨下动脉重建的方式得到广泛采用。到目前为止, 通过烟囱技术、开窗技术、分支支架技术、血管转流或转位技术可以重建左锁骨下动脉以及弓上其他分支血管。本文对胸主动脉腔内修复术中左锁骨下动脉重建的现状以及各种重建方式的选择进行综述。     

原位开窗重建左锁骨下动脉在胸主动脉腔内修复术中的应用

目的探讨利用穿刺破膜技术进行原位开窗的可行性及效果。方法回顾性分析2014年7月～2018年1月10例原位开窗胸主动脉腔内修复术(thoracic endovascular repair,TEVAR)的资料,其中5例胸主动脉瘤,5例主动脉夹层。在覆膜支架封盖左锁骨下动脉后,利用打磨过的导丝硬头进行穿刺破膜、球囊扩张,重建左锁骨下动脉血流通路。结果 9例开窗成功,1例胸主动脉瘤开窗失败,改行烟囱支架植入。开窗成功的9例术后随访13～53(29. 8±16. 1)月,左锁骨下动脉血流通畅,无内漏发生。结论利用穿刺破膜技术行原位开窗的技术简单,经济,有效,适用于累及左锁骨下动脉的胸主动脉瘤和主动脉夹层的治疗。     

胸主动脉腔内修复术中覆盖左锁骨下动脉的回顾性分析

胸主动脉瘤和主动脉夹层是危及生命的疾病,发病1周内病死率为60％ ～ 70％[1].近年来,胸主动脉腔内修复术(TEVAR)已成为治疗胸主动脉瘤和B型主动脉夹层的重要方法.有选择性地覆盖左锁骨下动脉(LSA)是较常采用的扩大近端锚定区的方法[2],但仍存在争议.我们回顾性分析2004年5月至2012年1月TEVAR手术患者的资料,探讨LSA封堵的可行性.     

急性B型主动脉夹层的腔内治疗

目的 讨论腔内修复术(endovascular repair,EVR)对治疗急性B型主动脉夹层(acuteaortic dissection,AAD)的安全性及有效性.方法 回顾性分析2002年2月至2008年3月收治的39例急性B型主动脉夹层患者的临床资料.EVR按常规方法进行,2例需覆盖左颈总动脉而行旁路术,其中1例同时无名动脉支架型血管(stent graft,SG)开窗术;1例因肢体严重缺血同期行左下肢截肢术.13例完全覆盖左锁骨下动脉,1例覆盖迷走右锁骨下动脉,5例部分覆盖左锁骨下动脉(leftsubclavian artery,LSA).术后全部病例均经CTA(computer tomography angiography)随访,并监测支架覆盖段(Ll)及支架远端(L2)主动脉段的假腔变化.结果 所有支架释放到预定位置;30 d死亡率10.3%.术后1个月L段假腔血栓率100%,完全血栓率77.8%(21/27例),部分血栓率22.2%(6/27例),其中18.5%(5/27例)达到血栓完全吸收、主动脉重塑;L2段假腔血栓率28%,完全血栓率8%(2/25例),部分血栓率20%(5/25例).结论 急性B型主动脉夹层腔内修复术治疗效果肯定,30 d内死亡主要与术前伴随的并发症有关.     

Anatomic exclusion from endovascular repair of thoracic aortic aneurysm

OBJECTIVES: We sought to define the current anatomic barriers to thoracic aortic aneurysm (TAA) stent grafting to guide future device development. METHODS: All patients presenting with TAA requiring repair were evaluated for endovascular repair during a 4-year period (2000 to 2004). The TAAs evaluated were those beginning distal to the left common carotid artery (LCCA) and ending proximal to the celiac artery. All patients in whom endovascular repair was indicated underwent cross-sectional imaging by computed tomography angiography and three-dimensional modeling of their thoracic and abdominal arterial anatomy. Patients were evaluated for endovascular TAA repair in the context of the inclusion/exclusion criteria of pivotal United States Food and Drug Administration trials of the Gore TAG and Medtronic Talent devices. Anatomic requirements included >or=20 mm of suitable proximal and distal neck length, and proximal and distal neck diameters of 20 to 42 mm. These trials allowed the use of femoral or iliac access, including the use of conduits, and permitted stent graft coverage of the left subclavian artery (LSA) after preliminary carotid-subclavian bypass. Patients rejected for medical reasons or who died during evaluation were not included in the review. RESULTS: A total of 126 patients (73 men, 53 women) with TAA located between the LCCA and celiac artery were screened for endovascular repair, and 33 (26%) were rejected for anatomic reasons. The remaining 93 patients underwent endografting (59 Talent, 34 TAG). Rejection was not significantly different by gender (16/73 men, 17/53 women, P = .22, NS). Most patients (28/33) were rejected for more than one criterion. Hostile proximal neck characteristics were the most prevalent reason for disqualification, despite the ability to cover the LSA to extend the proximal seal zone. Many of these patients (16/28) also had distal neck anatomy unsuitable for grafting. Overall, 19 patients had hostile distal necks. Difficulties with vascular access (diseased or tortuous iliac arteries, or a small caliber aorta) that could not be overcome even by use of conduits occurred in a significant fraction of patients (10/33). CONCLUSIONS: Most patients with a TAA located between the LCCA and the celiac artery can be treated by endovascular repair. Patients excluded from TAA stent graft protocols for anatomic reasons most commonly have hostile proximal neck features that preclude endovascular repair with currently available devices. Transposition of arch vessels to facilitate greater use of existing stent grafts or development of new stent graft designs are needed to expand the applicability of TAA endovascular repair.     

Endovascular management of traumatic thoracic aortic injuries.

BACKGROUND: Endovascular surgery has recently been extended to the treatment of blunt traumatic aortic injuries. Since most of these injuries occur at the aortic isthmus, graft fixation in proximity to the origin of the left subclavian artery (LSA) has been a concern. Covering the LSA with graft fabric lengthens the proximal fixation site and should minimize proximal endoleaks. We therefore wished to evaluate the feasibility and safety of endovascular repair of thoracic aortic injuries after blunt trauma, both with and without deliberate coverage of the LSA. METHODS: At a tertiary care teaching hospital in London, Ont., we reviewed our experience with endovascular repair of 7 traumatic aortic injuries. We reviewed the technical success rate and the incidence of left subclavian coverage. Major morbidity, including rates of paraplegia and death were noted. The patients were followed-up with serial CT to look for endoleaks, stent migration or aneurysm growth and to determine whether they had symptoms related to left subclavian coverage. RESULTS: The time from injury to treatment ranged from 7 hours to 7 days (mean 36 h). The mean Injury Severity Score was 36. All injuries were at the aortic isthmus, and among the 7 patients treated, 6 had deliberate coverage of the LSA. One patient underwent carotid-to-subclavian artery bypass, but the other 5 did not. There were no cases of paraplegia; 1 patient had symptoms of claudication in the left arm but did not want revascularization. No procedure-related complications occurred, and all patients survived the event. Follow-up ranged from 2 to 30 (mean 13) months, and no endoleaks, stent migration or aneurysm expansion were noted in follow-up. CONCLUSIONS: Although long-term results are unknown, we conclude that endovascular repair of traumatic aortic injuries after blunt trauma can be performed safely with low morbidity and mortality and that coverage of the LSA without revascularization is tolerated by most patients.     

胸主动脉腔内修复术中原位开窗重建左锁骨下动脉

目的:探索一种新的安全有效全腔内重建左锁骨下动脉(LSA)的方法。方法:针对2例胸主动脉腔内修复术中需要重建LSA的患者,采用目前市售的介入器材并改进,先释放胸主动脉覆膜支架覆盖LSA,再于LSA开口处行体内穿刺破膜、球囊扩张并置入左锁骨下动脉支架,原位开窗重建LSA。结果:患者2例均取得技术成功,主体支架无移位,无内漏;重建的LSA通畅,无内漏。结论:原位开窗的方法可以有效的重建LSA,长期疗效有待进一步随访。     

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??Objective:To discuss the methods of Endovascular aneurysm repair (EVAR) for artic arch aneurysm or dissection. Methods:From Sep.1998 to Feb.2006,63 cases related with the super??arch branches.Three methods were used in the lesions with left subclavain artery (LSA) invasion only,covering the LSA without reconstruction,LSA bypass before EVAR or covering LSA completely and then re??open it by endovascular technique.To the lesions with LSA and left common carotid artery (LCCA) invasion,a traditional bypass of LCCA and LSA was done before EVAR,or covering most of LCCA first,and then reconstructed it through LCCA by endovascular technique.To the lesions with three super??arch branches invasion,a bifurcated stent??graft was planted for reconstructing the artic arch. Results:LSA was treated in 54 cases,LSA and LCCA were treated in 8 cases and all of the super??arch branch arteries were treated in 1 case.All of the auxiliary techniques were enforced successfully.The primary average systolic pressure of left brachial artery was ??62.6±24.2??mmHg in cases without LSA reconstruction.The 30??days endoleak rate was 17.5%. Conclusion:Covering the LSA is safe to the patients with normal contraliteral vertebral and basilar artery.EVAR combined with supplementary techniques can expand the EVAR indications of aortic arch lesions.The long term result still keep in follow up.     

腔内修复主动脉弓动脉瘤或夹层动脉瘤14例

目的探讨腔内修复主动脉弓动脉瘤或夹层动脉瘤的疗效。方法回顾性分析2003年6月至2004年8月腔内修复主动脉弓动脉瘤或夹层动脉瘤14例的临床资料。其中,DebakeyⅢ型主动脉夹层动脉瘤(aorticdissectionaneurysm, ADA)12例,动脉瘤2例。8例ADA直接行腔内修复,覆盖左锁骨下动脉开口;另4例ADA和2例动脉瘤接受辅助性右左颈总动脉、左颈总左锁骨下动脉旁路联合腔内修复。结果14例均取得技术成功。1例动脉瘤患者腔内修复术后并发缺血性脑卒中死亡。生存的13例围手术期和随访期间(1 ~14个月,平均11个月)无神经系统或肢体缺血性并发症。3个月CT证实所有ADA患者原发破口封闭。存活动脉瘤患者术后1个月CT显示瘤腔内血栓形成。结论腔内修复主动脉弓动脉瘤或夹层动脉瘤是安全、有效的。     

主动脉腔内修复术后中远期并发症与二次处理策略

目的探讨主动脉腔内修复术后中远期并发症的处理方法与效果。方法1999年5月至2007年6月对21例主动脉病变腔内修复术后中远期并发症进行了再次处理。其中腹主动脉瘤（AAA）15例,胸主动脉动脉瘤（TAA）3例,主动脉夹层（TAD）3例。并发症：Ⅰ型内漏11例,Ⅱ型内漏4例,Ⅲ型内漏2例;移植物阻塞4例。应用延长支架型血管技术处理Ⅰ、Ⅲ型内漏（6例）,应用“侧孔”、“凹口”、“分叉”支架型血管结合颈部血管旁路手术重建主动脉弓处理Ⅰ型内漏（3例）,应用栓塞技术处理Ⅱ型内漏（4例）,应用取栓和旁路手术技术处理移植物阻塞（4例）,应用开放手术技术处理动脉瘤破裂（1例）。结果20例（95．2％）应用腔内技术作为二次处理主要手段,二次处理30d内死亡1例（4．7％）,因技术需要而修改器材结构者3例。二次术后仍存在内漏者5例（29．4％,5／17）。二次干预瘤体相关性死亡3例（14．3％）。结论内漏和移植物阻塞是腔内修复术后主要中远期并发症,其主要原因是原发性内漏的延续和移植物移位。腔内技术可作为二次处理的主要手段。主动脉弓部病变进行二次干预有更大的挑战性。     

胸主动脉夹层动脉瘤腔内隔绝术中椎动脉缺血的预防

目的:探讨腔内隔绝术治疗StanfordB型胸主动脉夹层动脉瘤时椎动脉缺血的预防方法。方法:对136例接受腔内隔绝术治疗的StanfordB型胸主动脉夹层动脉瘤病人,尤其是左锁骨下动脉血流受干扰者的病史资料进行回顾性分析。结果:136例病人中135例手术成功,66例左锁骨下动状脉开口受到干扰,其中5例因左锁骨下动脉距夹层破口太近,而有意将其封堵。8例有椎动脉缺血症,仅1例为急性脑缺血表现。2例术后被迫行颈动脉鄄椎动脉旁路术以缓解椎动脉缺血情况。而术前接受预防性颈动脉鄄椎动脉旁路术的4例病人,完全遮蔽左锁骨下动脉后无不适症状。结论:完全遮蔽左锁骨下动脉可能会引起左侧椎动脉的急性缺血而致严重并发症。根据夹层破口与左锁骨下动脉开口间的距离,术前选择性实施左颈动脉鄄左椎动脉旁路术可预防椎动脉缺血的发生。     

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.