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目的 开展带膜支架腔内植入升主动脉治疗DeBakey Ⅰ型主动脉夹层的临床研究。方法 报告采用带膜支架腔内植入治愈DeBakey Ⅰ型主动脉夹层1例。结果 从左颈总动脉送入导丝和带膜支架至升主动脉封闭撕裂口。此前先建立左锁骨下动脉至左颈总动脉的内转流通道。二枚带膜支架重叠放置成功封闭升主动脉撕裂口，术后复查彩超示胸腹主动脉夹层消失，假腔内血栓形成，病人痊愈出院。结论 带膜支架腔内植入是治疗DeBakey Ⅰ型主动脉夹层的有效方法。通过颈总动脉送入支架和预先建立颈总动脉内转流通道可保证手术的成功进行。     

腔内修复联合旁路手术治疗DeBakeyⅠ型升主动脉夹层

目的探讨腔内修复联合人造血管旁路手术治疗DeBakeyⅠ型升主动脉夹层的临床应用价值。方法分析2005年中山大学附属第一医院血管外科运用腔内修复联合人造血管旁路手术治愈的2例DeBakeyⅠ型升主动脉夹层临床资料。结果腔内修复前先行左锁骨下动脉-左颈总动脉-右颈总动脉人造血管旁路手术,然后从右股总动脉将带膜支架植入升主动脉封闭内膜撕裂口,并同时封闭无名动脉和左颈总动脉,1例术后即时造影和术后2个月随访造影均显示升主动脉夹层消失,无内漏,颈部人造血管旁路血流通畅,病人健康生存;另1例术后2个月随访,一般情况良好。结论对于内膜撕裂口靠近无名动脉和左颈总动脉的DeBakeyⅠ型升主动脉夹层,腔内修复联合人造血管旁路手术是一种安全而有效的治疗方法。     

腔内隔绝术、联合血管旁路移植术治疗主动脉夹层动脉瘤

目的总结腔内隔绝术、联合血管旁路移植术治疗主动脉夹层动脉瘤的临床经验，以提高其治疗效果。方法自2002年9月至2006年12月，共完成腔内隔绝术或联合血管旁路移植术8例。对4例近端支架固定区〈15mm的患者于腔内隔绝术前行椎动脉-左颈总动脉端侧吻合术1例，应用8mm人工血管行左锁骨下动脉-左颈总动脉旁路移植术2例，左锁骨下动脉-左颈总动脉-右颈总动脉旁路移植术1例，手术后8～10d，行腔内隔绝手术。4例破口距左锁骨下动脉开口〉15mm的患者直接行腔内隔绝手术。结果行血管旁路移植的4例患者术后恢复良好，术后8～10d行腔内隔绝手术，8例患者腔内隔绝手术操作顺利，隔绝术后3～8d出院，无住院死亡。出院前增强CT扫描无内漏发生。随访4例，随访时间2～48个月，其中1例患者长期胸痛，经对症处理胸痛缓解；4例患者夹层内血栓机化良好，无内漏出现或夹层剥离的现象发生。结论腔内隔绝手术是一种创伤小、恢复快、疗效好的治疗方法，腔内隔绝术联合血管旁路移植术治疗主动脉夹层动脉瘤，扩大了腔内隔绝术的手术适应证。     

主动脉腔内隔绝术治疗DeBakey III型主动脉夹层动脉瘤：附63例报告

目的：分析主动脉腔内隔绝术（EVAR）治疗DeBakey III型主动脉夹层动脉瘤的临床效果。 方法：回顾性分析2008—2014年采取EVAR手术治疗的63例DeBakey III型主动脉夹层动脉瘤患者临床资料,总结EVAR的手术方法、手术成功率、术后夹层假腔直径的变化。 结果：DeBakey III型主动脉夹层动脉瘤63例置入支架66个,其中有3例患者分别置入支架2枚,平均手术时间（159.1±21.7）min,手术中出现3例内漏,其中1例患者出现极少量内漏、术后CTA复查未发现,1例在支架置入后发现近端内漏、1例患者发现支架远端内漏,分别予以增加支架封堵,术后CTA复查仍然存在少许内漏;全组手术的技术成功率95.24%（60/63）,临床成功率为92.06%（58/63）;患者术后6个月左锁骨下动脉真腔开口直径、近端破口真腔水平直径mm、瘤体最大真腔直径、膈肌水平真腔最大直径均较术前明显增大（均P<0.05）,假腔大直径测定值均较术前明显减小（均P<0.05）,整体腔径最大值差异均无统计学意义（均P>0.005）。 结论：EVAR治疗DeBakey III型主动脉夹层动脉瘤效果显著,安全可靠。     

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。     

Stanford A型主动脉夹层的腔内修复术后并发症分析

目的总结Stanford A型主动脉夹层(TAAD)腔内修复术后常见并发症的诊治经验。方法对2001年1月至2012年5月接受腔内治疗的58例TAAD患者资料进行回顾性分析。平均年龄54.3(41～79)岁。35例单纯接受腔内治疗,23例接受杂交手术:升主动脉-左颈总动脉-左锁骨下动脉旁路3例,左颈总动脉-左锁骨下动脉旁路3例,右颈总动脉-左颈总动脉旁路15例,左锁骨下动脉-左颈总动脉-右颈总动脉旁路2例。结果总技术成功率为98.3%(57/58)。并发症包括内漏14例,脑卒中5例,支架源性新破口1例,血管旁路术后吻合口假性动脉瘤2例。术后30天内死亡7例。随访(35.5±5.4)个月,随访期间死亡2例,其余患者均健康生存。结论 TAAD腔内治疗后并发症较累及降主动脉疾病的腔内修复术更为常见,脑卒中是重要的致死性并发症,应引起足够重视。     

杂交技术治疗主动脉弓降部病变的临床研究

目的:探讨杂交技术治疗主动脉弓降部病变的效果。方法:采用杂交技术(解剖外旁路联合血管腔内修复术)手术治疗10例患者,包括累及主动脉弓部分支的B型主动脉夹层4例和主动脉弓降部真性动脉瘤6例。其中左颈总动脉至左椎动脉旁路1例,右颈总动脉至左颈总动脉旁路5例,右颈总动脉至左颈总动脉及左颈总动脉至左锁骨下动脉旁路1例和升主动脉至无名动脉及左颈总动脉旁路3例。均经股动脉入路植入覆膜支架。结果:10例患者均获得技术成功,1例发生少量I型内漏,未处理。术后1例因脑梗塞伴肺炎、肾功能衰竭不治自动出院;其余9例均痊愈出院。9例随访时间3～33个月,均恢复正常生活,术后3个月CTA示:覆膜支架无移位,1例内漏已消失,无新的内漏发生,夹层假腔或动脉瘤腔内已有血栓形成,远端夹层假腔无明显扩大,旁路人工血管通畅。结论:杂交手术避免体外循环损害,减轻外科手术创伤,提高了治疗效果,是治疗累及分支的主动脉弓降部病变的重要方法。     

经颈动脉腔内技术重建主动脉弓治疗Stanford A型夹层动脉瘤(附1例报告)

目的探讨血管腔内技术重建主动脉弓治疗升主动脉、主动脉弓病变的可行性。方法2005年,对1例StanfordA型夹层动脉瘤,腔内修复主动脉病变之前做右颈总动脉-左颈总动脉-左锁骨下动脉的旁路术;经右颈总动脉将修改的分叉支架型血管主体放入升主动脉,长臂位于无名动脉。短臂应用延长支架型血管延伸至降主动脉。通过腔内技术重建主动脉弓实现累及升主动脉和主动脉弓主动脉病变的微创治疗。结果腔内修复术后移植物形态良好,血流通畅,病变被隔绝,脑、躯干、四肢循环稳定。无严重并发症。结论该手术方案设计合理、技术可行。可能成为复杂胸主动脉病变新的腔内治疗模式。     

腔内激光原位开窗覆膜支架植入术治疗Stanford A型主动脉夹层7例疗效分析

目的探讨主动脉弓腔内修复术联合体内激光原位开窗覆膜支架植入术治疗Stanford A型主动脉夹层的近期疗效。方法 2016年11月至2017年5月柳州市工人医院血管外科对7例Stanford A型主动脉夹层病人应用体内激光原位开窗技术进行覆膜支架腔内修复术。术中头臂干+左颈总动脉+左锁骨下动脉开窗4例,头臂干+左颈总动脉开窗2例,左颈总动脉+左锁骨下动脉开窗1例。急性期手术5例,慢性期手术2例。结果 7例病人植入锥形大动脉支架13枚、Fluency plus直管型覆膜支架18枚。术中因升主动脉破裂死亡1例(14.3%),术后早期并发症发生率为28.6%,所有病人经治疗后均痊愈出院。术后1个月、3个月随访结果均显示夹层破口隔绝良好,无内漏,开窗血管通畅。结论主动脉弓腔内修复术联合体内激光原位开窗覆膜支架植入术治疗Stanford A型主动脉夹层安全、有效,且创伤小、恢复快、术中成功率高、内漏发生率低,近期效果良好,中、远期疗效尚需随访进一步证实。     

Ⅲ型夹层动脉瘤介入治疗误堵颈动脉的处理

目的 总结Ⅲ型夹层动脉瘤介入治疗误堵左颈总动脉的处理和经验教训.方法 4例Ⅲ型夹层动脉瘤患者行支架型人工血管封堵降主动脉内膜破口时不慎误堵塞左颈总动脉.4例患者均为男性,年龄37～45岁,平均年龄41岁.1例因存在内漏加Cuff时将第一个支架推向近侧导致左颈总动脉和左锁骨下动脉堵塞,经球囊拖向下方后解决;1例放置支架时支架前跳堵塞左颈总动脉和左锁骨下动脉.立即从股动脉进抓捕器抓住从左上肢肱动脉进入升主动脉的刻度猪尾导管将支架拖向远侧后恢复左颈总动脉和左锁骨下动脉血流;1例因定位误差导致支架堵塞2/3左颈总动脉和左锁骨下动脉,立即显露左颈总动脉分叉经颈外动脉置入左颈总动脉支架(chimney技术)后左颈总动脉血运完全恢复;1例是在心外科误将前端无裸支架的支架型人工血管当成有裸支架而将一半的无名动脉、左颈总动脉和左锁骨下动脉封堵,经正中开胸行升主动脉双颈动脉及左腋动脉人工血管搭桥后缓解.结果 4例患者均成功封堵Ⅲ型主动脉夹层的近侧内膜破口,无明显内漏,无脑梗死和左上肢缺血表现.结论 介入治疗Ⅲ型主动脉夹层误堵颈动脉后需立即通过手术或介入手段解决以避免发生脑缺血并发症.     

Percutaneous Insertion of a Jacketed Stent to Close the Entry of Dissecting Aortic Aneurysms of DeBakey Types I and II

Abstract: As a treatment for dissecting aortic aneurysms of DeBakey Types I and II, a percutaneous insertion method using a new jacketed stent was developed. The efficacy of the method was evaluated in an animal study. We developed a special stent prepared by modifying the original Gianturco self-expandable metallic stent and a fabric patch. A model of a dissecting aortic aneurysm of DeBakey Type I was created in dogs. The device was inserted into the ascending aorta from the left carotid artery through a sheath-introducer system. The aortogram showed the bloodstream through the false lumen before the insertion, but no bloodstream after the stent insertion. The autopsy showed that the entry, the reentry, and the false lumen were completely filled with fresh thrombus. By using this stent, we successfully achieved an interventional treatment for dissecting aortic aneurysms of DeBakey Types I and II.     

血管腔内治疗主动脉夹层和夹层动脉瘤

目的 探讨血管腔内治疗主动脉夹层和夹层动脉瘤的技术方法和疗效。方法 对20例主动脉夹层和夹层动脉瘤患者的临床资料进行分析。Stanford A型2例,其中1例内膜撕裂口位于升主动脉。Stanford B型18例。5例在不同部位有2个以上撕裂口。全组均以带膜支架型人工血管腔内植入行隔绝术。其中1例加作腹主动脉开窗和人工血管置换术,1例先行升主动脉．左锁骨下动脉和左颈总动脉Y形人工血管旁路术,再行腔内隔绝术。结果 无一例患者术中死亡,术后3d 1例Stanford B型患者死于心肌梗死,其余19例健康存活,生存率95％。术后随访1—20个月,各例主动脉夹层和动脉瘤均消失,无内漏,各器官灌注良好。结论 血管腔内植入带膜支架型人工血管是治疗主动脉夹层和夹层动脉瘤的简便、安全而有效的方法。手术死亡率低,手术成功率和生存率高。     

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.     

腔内修复术治疗胸主动脉夹层动脉瘤

目的 探讨应用支架人工血管行腔内修复术治疗胸主动脉夹层动脉瘤的临床效果.方法 回顾性分析采用腔内修复术治疗胸主动脉夹层动脉瘤32例患者的临床资料.男26例,女6例;平均年龄61岁.术前根据CTA结果 确诊,并对病变部位及解剖条件进行评估.手术在DSA监控下进行,全麻或局麻,应用Telent 8例(美敦力公司),国产支架24例(2例上海微创,22例北京裕恒佳).结果 7例破口距左锁骨下动脉开口＜1.0 cm,3例将覆膜支架跨过左锁骨下动脉开口将其封闭后,夹层动脉瘤消失,无上肢及脑缺血症状.治愈31例,死亡1例.31例夹层动脉瘤患者随访3～56个月均健在,其中5例CTA复查有内漏存在.结论 EVAR手术为夹层动脉瘤的治疗开辟了一个新的方法 ,具有比传统手术并发症少、病死率低等优点.在Stanford B型夹层动脉瘤的治疗中,EVAR可代替传统的开胸手术.     

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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.     

Double-chimney technology for treating secondary type I endoleak after endovascular repair for complicated thoracic aortic dissection

Endovascular repair continues to pose a formidable technical challenge in the cases of aneurysm, dissection, and proximal type I endoleak involving the aortic arch. During the process of covering the aortic arch by stent graft to achieve better sealing, maintaining blood flow to the vital supra-aortic branches is difficult. We present a case of successful endovascular treatment of secondary type I endoleak by a double-chimney technique in a 36-year-old woman who had previously undergone a complicated descending aortic dissection repair. This endovascular technology might offer a new option to simultaneously preserve the innominate artery and the left carotid artery for total reconstruction of the aortic arch.     

A case of surgical repair of aortic dissection associated with tear of the right coronary artery]

A 39-year-old female with dissecting aortic aneurysm of DeBakey type I, underwent replacement of the ascending aorta. We found that the right coronary artery originated just distally from the left sinus of Valsalva, run transversally in the aortic wall. Because the entry of dissection occurred at the right coronary artery, it was torn longitudinally. Aorto (graft)-rt. coronary bypass grafting was performed. She had no ischemic heart symptoms postoperatively. It is supposed that the dissecting aortic aneurysm was caused by the anomalous origin of the right coronary artery.     

腔内支架人工血管治疗主动脉弓部动脉瘤

目的 探讨腔内支架人工血管治疗主动脉弓部动脉瘤的基本方法。方法 采用国产腔内支架人工血管治疗主动脉弓部动脉瘤患者46例,其中主动脉瘤累及主动脉弓中部23例(50％),单纯累及弓降部22例(48％),累及胸降主动脉1例(2％)。选择支架直径是夹层破裂口或瘤口近端相应部位主动脉直径宽的1．15～1．20倍。支架近端直径34～38mm,长度90～120mm。支架材料为国产形状记忆镍钛合金。结果 支架释放成功45例(98％),无远端动脉并发症发生。支架释放后即刻封闭瘤口或破裂口43例(96％),早期内漏2例(4％)。夹层真腔全部恢复正常。急性期患者中转手术1例,死亡2例。术后43例患者获随访,随访时间1～23个月,远期内漏3例(7％),但所有随访患者均恢复正常生活。结论 腔内支架人工血管可用于主动脉弓部动脉瘤的治疗,其治疗的长期效果还需进一步观察。     

一体式覆膜支架在腹主动脉腔内修复中的应用

目的:总结一体式覆膜支架在腹主动脉以及髂动脉病变中的应用效果。方法:回顾性分析应用一体式腹主动脉覆膜支架腔内修复腹主动脉瘤15例、髂动脉瘤5例及腹主动脉或髂动脉夹层5例的临床资料。结果:平均时间42.4 min,手术成功率100%(25/25)。术后无I、III型内漏,发生髂动脉血栓形成1例,围术期无死亡病例。随访3~16个月复查无动脉瘤复发和II型内漏。结论:一体式覆膜支架是腹主动脉瘤和夹层动脉瘤腔内治疗方法的一种较好选择,具有快速、简单、有效的优点;其远期疗效需进一步观察。     

Selective Delayed Management of Blunt Traumatic Left Common Carotid Artery Injury Using Hypothermic Circulatory Arrest

Most traumatic carotid artery aneurysms occur at or close to its bifurcation, and traumatic aneurysm of the intrathoracic carotid arteries are rare. We describe a case of false aneurysm at the origin of the left common carotid artery (LCCA) after blunt trauma. A 53-year-old man suffered a blow from a broken steel plate, which flew from a working concrete crusher over his neck when he looked down the machine. Chest computed tomography revealed aneurysm of the LCCA, and aortic arch arteriography demonstrated a false aneurysm of about 3 × 5 cm at the origin of the LCCA, with loss of arterial continuity and abnormal tortuosity above the aneurysm. An ascending aorta to LCCA bypass graft was placed during the cooling period of cardiopulmonary bypass, and mattress sutures were placed in the normal aorta to close the origin of the LCCA under hypothermic circulatory arrest because of the extreme danger of dissection. The LCCA was transected partially at its origin from the aorta. We speculated that the direct lifting force which caused the carotid artery to move upward might produce a tear at the junction of the LCCA and the aortic arch.