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。     

Transcarotid artery endovascular reconstruction of the aortic arch by modified bifurcated stent graft for Stanford type A dissection

A 40-year-old man with Stanford type B dissection underwent his first endovascular repair (EVAR) in April 2004 by Talent thoracic stent graft. He had an uncomplicated recovery and maintained good blood pressure control. However, a new retrograde dissection appeared in September 2004. The new dissection involved his aortic arch and ascending thoracic aorta to the opening of the coronary arteries. To reconstruct the aortic arch, bypasses between the right common carotid artery (RCCA), left common carotid artery and left subclavian artery were performed before endovascular repair. A modified bifurcated Talent stent graft was deployed from the RCCA to the ascending thoracic aorta with a long limb in the innominate artery and a short limb in the aortic arch. A further two pieces of graft were deployed via the common femoral artery. The ascending thoracic aorta and aortic arch were reconstructed completely by the bifurcated stent graft. The final angiography confirmed that there was good stent graft configuration, normal blood flow, and stable haemodynamics. No endoleak or other major complications were encountered. This result indicated that it is possible to reconstruct the aortic arch with a bifurcated stent graft and could be a new endovascular repair model for complex thoracic aortic aneurysm and dissection.     

Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection

PURPOSE: We describe a modular stent graft for use in endovascular repair of aneurysms of the aortic arch. METHOD: Carotid-carotid and left carotid-subclavian bypass grafts are created surgically. Two large, fully stented grafts are inserted endoluminally. The proximal component is bifurcated, with a wide proximal trunk and two distal limbs, one long and narrow, the other short and wide. This component is inserted through the carotid artery and deployed with the trunk and short wide limb in the ascending thoracic aorta; the long narrow limb opens into the innominate artery. After delivery system removal and carotid artery repair, a distal component is inserted through a femoral approach to bridge the gap between the short, wide distal limb of the proximal component and the nondilated descending thoracic aorta. The result is a branched stent graft, implanted proximally into the ascending aorta and distally into the innominate artery and descending thoracic aorta. CONCLUSION: The system has been used successfully to treat a large wide-necked pseudoaneurysm of the aortic arch.     

Repair of the thoracic aorta by transaortic stent grafting (open stenting)

BACKGROUND: The late results of direct open stent grafting of the aortic arch for aortic arch repair have not been reported previously. METHODS: Between September 1997 and December 2000 19 patients underwent open stent grafting with carotid artery bypass for thoracic arteriosclerotic aneurysms (TAA) of the distal aortic arch. In addition, 21 patients underwent open stent grafting with total aortic arch replacement for Stanford type A acute aortic dissection and 7 patients underwent stenting with carotid bypass for Stanford type B chronic aortic dissection. RESULTS: The early mortality rate was 11% for TAA, 10% for type A dissection, and 0% for type B dissection. Whereas none of the TAA or type A dissection required a second operation on the thoracic aorta, 1 TAA patient died 6 months postoperatively after sudden aortic rupture and 1 type B patient required descending aortic replacement because of ulceration caused by the stent graft at 11 months postoperatively. On follow-up computed tomography scan, in TAA patients, true aneurysms excluded by the stent graft showed early thrombosis, but the absorption of thrombosed aneurysms started from 1 to 6 months postoperatively and gradually progressed. In patients with type B chronic dissection, the false lumen showed early thrombosis and the true lumen was dilated at the central portion of the graft, which might increase turbulent flow by interaction with the stent. In patients with type A acute dissection, the false lumen showed both early thrombosis and early absorption. CONCLUSIONS: Early and late results of open stenting are acceptable and follow-up computed tomography scan may be able to predict late results of open stenting.     

升主动脉根部瘤的外科治疗

目的总结升主动脉根部瘤的外科治疗经验。方法101例升主动脉根部瘤患者（年龄14～72岁，平均年龄42．7岁）的主要病因为马方综合征（Marfan syndrome，58例），主动脉瓣环扩张症（34例），主动脉瓣二叶瓣畸形（5例），大动脉炎（4例）；术前有主动脉瓣关闭不全96例，主动脉瓣狭窄4例，术前合并有A型夹层26例，急性左心衰竭（5例）。手术类型：Wheat手术4例，传统或改良Cabrol手术13例，David手术1例，Bentall手术83例。同期行主动脉半弓置换术或降主动脉腔内支架植入术16例，全弓置换术或降主动脉腔内支架植入术4例，二尖瓣置换术或成形术14例，冠状动脉旁路移植术8例。结果全组手术死亡率为6．9％（7／101），2000年后降至3．6％（3／83）；术后主要并发症为低心排血量10例，呼吸功能不全9例，肾功能不全9例。术后随访94例，随访期间死亡1例，5例马方综合征患者术后出现B型夹层。结论Bentall手术是治疗升主动脉根部瘤的首选手术方法，术前左心功能及手术技术是影响手术效果的关键因素。     

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。     

Off-Pump Extraanatomic Bypass from the Ascending to the Descending Aorta for Re-Operation of Interrupted Aortic Arch in an Adolescent

Abstract   The appearance of re-stenosis after repair of an interrupted aortic arch may be a surgical challenge due to adhesions. Here, we describe an approach using off-pump coronary artery bypass grafting techniques to reach the descending aorta through a median sternotomy in a patient with aortic arch stenosis after conduit repair. The 17-year-old patient with diagnoses of interrupted aortic arch and ventricular septal defect presented after two previous operations (one left lateral thoracotomy and one median sternotomy) with a stenosed vascular graft between ascending and descending aorta. Surgery was done via re-sternotomy without cardio-pulmonary bypass. An extraanatomic graft was used to connect ascending and descending aorta. When performing the distal anastomosis, the heart was exposed using a standard suction device. This case demonstrates that the use of modern techniques may facilitate surgical approaches dramatically. In our opinion the above-described technique is the first choice for all patients requiring arch repair following multiple previous operations, performed via sternotomy and thoracotomy.     

Transapical aortic cannulation via left lateral thoracotomy for descending thoracic and thoracoabdominal aortic surgery

Two patients underwent surgery for a chronic type B dissection using a total cardiopulmonary bypass (CPB) with transapical arterial cannulation. At surgery, a total CPB was established by cannulating the left femoral artery and the ascending aorta via the ventricular apex. The patients were cooled to 30°C. The proximal anastomosis was done after cross-clamping the aortic arch between the left carotid artery and the left subclavian artery in both cases. In the first case, the entire descending thoracic aorta was replaced, and two pairs of intercostal arteries were reconstructed. The other patient underwent replacement of the proximal descending thoracic aorta. Neither patient experienced any complications. Transapical aortic cannulation is a useful option during descending thoracic and thoracoabdominal aortic surgery. It can provide more stable circulation during the cross-clamping, more gentle manipulation of the aorta by nonpulsatile flow, and more liberty in temperature control.     

Endovascular thoracic aortic aneurysm repair with concomitant myocardial and carotid revascularization

A 73-year-old woman presented with a large saccular aneurysm involving the distal aortic arch. Preoperative aortography and cardiac catheterization revealed left main coronary artery and left common carotid artery stenoses. Concomitant coronary artery bypass grafting to the left anterior descending and first diagonal arteries, ascending aorta-to-left common carotid artery bypass grafting, and endovascular thoracic aortic aneurysm repair with antegrade stent-graft deployment and intentional left subclavian artery coverage were performed.     

Total aortic arch aneurysm repair using a stent graft without cardiac or cerebral ischemia

A 74-year-old man with an aortic arch aneurysm and a chronic type IIIb aortic dissection underwent total aortic arch repair without cerebral or cardiac ischemia. After confirming no atheromatous change in the ascending aortic wall, a custom-designed 4-limbed graft, prepared for both arterial return of cardiopulmonary bypass and reconstruction of the arch vessels, was anastomosed onto the right side of the ascending aorta. The 3 arch vessels were then bypassed sequentially during systemic cooling and monitoring cerebral perfusion with near-infrared oxymetry. After aortic cross-clamping, a stent graft was inserted into the distal arch from the distal ascending aorta, maintaining cerebral and cardiac perfusion. This procedure is indicated especially in a high-risk patient who has an aortic arch aneurysm without severe atheromatous change in the ascending aorta and the arch vessels.     

Total Endovascular Debranching of the Aortic Arch

Background

Significant morbidity and mortality are related to conventional aortic replacement surgery. Endovascular debranching techniques, fenestrated or branched endografts are time consuming and costly.

Objective

We alternatively propose to use endovascular approach with parallel grafts for debranching of aortic arch.

Methods

Under general anesthesia, 12 F sheaths were inserted in the femoral, axillary and common carotid arteries for vascular accesses. ViaBahn grafts 10 – 15 cm in length were placed into the aortic arch from right common carotid, left common carotid and left axillary arteries, until the tip of each graft reached into the ascending aorta. Through one femoral artery, the aortic stent –graft was positioned and delivered. Soon after, the parallel grafts were sequentially delivered. Self-spanding Wallstents^R were used for parallel grafts reinforcement. Ballooning was routinely used for parallel grafts and rarely for aortic graft.

Results

This technique was used in 2 cases. The first one was a lady with 72 years old, with an aortic retrograde dissection from left subclavian artery and involving remaining arch branches. Through right common carotid artery a stent-graft was placed in the ascending aorta and through the left common carotid artery a ViaBahn was inserted parallel to the former. A thoracic endograft then covered all the aortic arch dissection extending into the ascending aorta close to the sinu –tubular junction. The second case was a 82 year old male patient with a 7 cm aortic arch aneurysm. Through both common carotid arteries ViaBahn grafts were introduced and positioned into the ascending aorta. Soon after, the deployment of the thoracic stent graft covered all parallel grafts of the aortic arch, excluding the aneurysm. Both cases did not have neurologic or cardiac complications and were discharged 10 days after the procedure.

Conclusions

This technique may be a good minimal invasive off-the-shelf technical option for aortic arch ‘‘debranching’’. More data and further improvements are required before this promising technique can be widely advocated.     

Double-barrel technique for preservation of aortic arch branches during thoracic endovascular aortic repair

Thoracic endovascular aortic repair (TEVAR) may involve either planned or inadvertent coverage of aortic branch vessels when stent grafts are implanted into the aortic arch. Vital branch vessels may be preserved by surgical debranching techniques or by placement of additional stents to maintain vessel patency. We report our experience with a double-barrel stent technique used to maintain aortic arch branch vessel patency during TEVAR. Seven patients underwent TEVAR using the double-barrel technique, with placement of branch stents into the innominate (n = 3), left common carotid (n = 3), and left subclavian (n = 1) arteries alongside an aortic stent graft. Gore TAG endografts were used in all cases, and either self-expanding stents (n = 6) or balloon-expandable (n = 1) stents were utilized to maintain patency of the arch branch vessels. In three cases the double-barrel stent technique was used to restore patency of an inadvertently covered left common carotid artery. Four planned cases involved endograft deployment proximally into the ascending aorta with placement of an innominate artery stent (n = 3) and coverage of the left subclavian artery with placement of a subclavian artery stent (n = 1). TEVAR using a double-barrel stent was technically successful with maintenance of branch vessel patency and absence of type I endoleak in all seven cases. One case of zone 0 endograft placement with an innominate stent was complicated by a left hemispheric stroke that was attributed to a technical problem with the carotid-carotid bypass. On follow-up of 2-18 months, all double-barrel branch stents and aortic endografts remained patent without endoleak, migration, or loss of device integrity. The double-barrel stent technique maintains aortic branch patency and provides additional stent-graft fixation length during TEVAR to treat aneurysms involving the aortic arch. Moreover, the technique uses commercially available devices and permits complete aortic arch coverage (zone 0) without a sternotomy. Although initial outcomes are encouraging, long-term durability remains unknown.     

杂合技术在主动脉夹层病变治疗中的应用

目的探讨"杂合技术"——主动脉人工血管替换并降主动脉覆膜支架置入术治疗复杂主动脉夹层病变的效果。方法对4例主动脉夹层分离病人实施了同期外科手术结合支架置入的杂合技术治疗。结果全组手术经过顺利,主动脉阻断时间平均(147.0±30.1)min,体外循环时间平均(164.3±34.4)min,2例Stanford A型深低温停循环时间分别为45 min和43 min。1例术后因胸腔内大出血分别于术后第1 d和第8 d再次开胸止血,术后持续昏迷至第4 d清醒,气管切开接呼吸机辅助通气时间长达53 d,最终于术后77 d治愈出院。1例术后发生严重肺部感染和脓胸,最终诱发多器官功能衰竭,放弃治疗出院。另2例患者术后恢复顺利,痊愈出院。术后随访复查CTA显示升主动脉及主动脉弓部人工血管无扭曲、狭窄,血流通畅,血管内支架位置良好,降主动脉真腔较术前明显扩大,无内漏、假腔血栓形成。结论应用杂合技术治疗复杂主动脉病变方法简单,疗效可靠,并发症少,具有良好的应用前景。     

腔内修复联合辅助技术治疗累及主动脉弓的Stanford B型夹层动脉瘤

目的 探讨主动脉腔内修复手术联合辅助技术治疗累及主动脉弓部的Stanford B型主动脉夹层动脉瘤.方法 分析腔内治疗累及主动脉弓部,破口邻近左锁骨下动脉或位于其近端的46例StanfordB型主动脉夹层动脉瘤的临床资料.腔内封堵左锁骨下动脉43例;PDA封堵器封堵左锁骨下动脉6例次;颈部动脉搭桥术9例次;“烟囱”技术重建左颈总动脉8例次;“开窗”技术封堵夹层破口,同时保留主动脉弓部所有分支动脉1例次.结果 患者术后均存活,随访时间(25±16)个月.未发生严重神经系统并发症.10例发生左锁骨下动脉Ⅱ型内漏,其中6例通过PDA封堵器隔绝,2例保守治疗后自愈;9例发生左上肢缺血症状,其中8例行保守治疗,另1例症状严重,行颈部动脉搭桥术重建左锁骨下动脉.随访中,所有人工血管和分支动脉支架均保持通畅,降主动脉真腔直径显著扩大,假腔直径逐渐缩小.结论 对累及主动脉弓部,破口邻近左锁骨下动脉或位于其近端的StanfordB型主动脉夹层,腔内治疗联合PDA封堵器、颈部动脉搭桥术、“烟囱”技术或“开窗”技术是安全有效的治疗方法.     

Unusual traumatic rupture of the thoracic aorta with avulsion of the left subclavian artery]

Of the many cases of traumatic rupture of the aorta diagnosed each year at l"H?pital du Sacré-Coeur, Montreal, most patients are already in irreversible shock when seen. However, during the period Oct. 1, 1974 to Sept. 30, 1975, prompt surgical treatment saved six patients. One of these six patients had a complete trans-section of the aortic arch between the left carotid and left subclavian arteries with avulsion and slight retraction of the left subclavian artery. Repair of the aortic arch and left subclavian artery was accomplished without extracorporeal circulation. A sutureless temporary bypass shunt was created by (a) cannulating the ascending and descending aorta, the cannulas being secured with purse-string sutures and joined by a 3/8-inch (94-mm) polyvinyl chloride (PVC) tube connected to a "double T" adapter, and (b) joining two small PVC tubes from the adapter with two straight cannulas, a no. 14 being inserted into the innominate artery and a no. 12 being inserted into the left carotid artery. With this temporary bypass created, the ascending and descending aorta and aortic arch vessels were all clamped. Aortic continuity was re-established with a tubular Dacron graft (diameter, 19 mm) to which was anastomosed a side-arm of knitted Dacron (diameter, 10 mm) to repair the left subclavian artery. Throughout the temporary perfusion the brain, spinal cord and all abdominal viscera were well protected. No sign of ventricular distension was detected. This report is the first in which complete transsection of the aortic arch has been managed by a sutureless bypass shunt allowing perfusion of all aortic arch vessels without extracorporeal circulation.     

Combined Surgical Treatment in Aortic Type A Dissection

Abstract   Acute Stanford type A aortic dissection is a fatal event that, for its high mortality when left untreated, requires urgent surgical intervention. The established treatment includes repair of the ascending aorta and various portions of the aortic arch, leaving the descending aorta untreated. We report the case of a 62-year-old man in whom a combined approach of the ascending aorta with surgical correction and transluminal placement of a stent in the aortic arch was performed.     

The hybrid total arch repair: brachiocephalic bypass and concomitant endovascular aortic arch stent graft placement

BACKGROUND: Repair of aortic arch aneurysm is technically demanding, requiring complex circulatory management. Very large atherosclerotic saccular aneurysms of the arch are grave markers of extensive arch and brachiocephalic atheromatous disease and represent high surgical risks for perioperative neurologic complications. Operative morbidity and mortality may be prohibitive with traditional surgical intervention. We described our experience with a hybrid procedure for total arch repair with a brachiocephalic bypass with a trifurcated graft followed by concomitant placement of a stent graft in the arch. METHODS: Since June 2005, we have performed the hybrid total arch repair in eight patients. A retrospective review was performed to evaluate the new technique. RESULTS: The mean age of the patients was 67 years with a mean aneurysm size of 8 cm (range, 4.4 to 10 cm). Significant comorbidities included carotid stenosis, chronic renal insufficiency, peripheral vascular disease, hypertension, and coronary artery disease. Two patients had previous Abdominal aortic aneurysm (AAA) repairs. Three patients had previous sternotomy for type A dissection, ascending aortic aneurysm repair, and coronary artery bypass grafting. Transesophageal echocardiogram demonstrated grade IV or V atheromatous disease in the arch and ascending aorta. Stent grafts were deployed antegrade directly into the ascending aorta in three patients and retrograde from the femoral artery in five patients. Technical success with complete aneurysmal exclusion was achieved in all patients (100%). At a mean follow-up period of 11.7 months, there was no incidence of endoleak. There was one death resulting from a perioperative myocardial infarction (first patient). Documented perioperative neurologic events (stroke) occurred in two patients, with both patients demonstrating no residual deficit at the time of discharge. CONCLUSIONS: Saccular arch aneurysms can be technically treated by total arch repair with brachiocephalic bypass and concomitant aortic arch stent graft placement. Hybrid arch repair provides an alternative to patients otherwise considered prohibitively high risk for traditional open arch repair.     

主动脉弓三分支覆膜支架在Stanford A型急性主动脉夹层外科治疗中的应用

目的 总结外科处理升主动脉加主动脉弓三分支覆膜支架置入治疗Stanford A型急性主动脉夹层的临床经验.方法 对2010年1月至12月收治的14例Stanford A型主动脉夹层患者行升主动脉手术处理加主动脉弓三分支覆膜支架置入,其中男性12例,女性2例,年龄20～70岁,平均49岁.手术包括升主动脉置换术加支架置入4例,主动脉根部置换术(Bentall术)加支架置入5例,主动脉瓣置换加升主动脉置换术(Wheat术)加支架置入4例,主动脉瓣成形加升主动脉置换术加支架置入1例;其中6例为急诊手术.结果 平均心肺转流时间(186±38)min,心肌阻断时间(101±27)min,选择性脑灌注时间(39±11)min.无住院死亡病例;术后出现短暂性神志障碍1例,肢体活动障碍1例,急性肾功能衰竭1例,二次开胸手术1例,消化道出血1例,乳糜胸1例,治疗后均痊愈.出院前及出院后3个月内行大血管CT血管造影检查:升主动脉及弓部覆膜支架内血流通畅,主动脉弓段及降主动脉假腔缩小,主动脉管壁结构恢复.随访1～12个月,无晚期死亡及需要再次手术纠治血管病变者.结论 主动脉弓三分支覆膜支架置入的主要适应证为内膜破口位于升主动脉但需重建弓部形态的Stanford A型急性主动脉夹层.其同期结合手术处理升主动脉是治疗急性Stanford A型主动脉夹层安全、有效的一种新手段.

Abstract：

Objective To sum up the experience of performing ascending aorta replacement combined triple-branched stent graft implantation for acute Standford type A aortic dissection. Methods From January 2010 to December 2010, 14 patients with acute Standford type A aortic dissection underwent the procedure of performing ascending aorta replacement combined triple-branched stent graft implantation.Right axiuary artery cannulation was used for cardiopulmonary bypass and selected cerebral perfusion.When the body temperature drops below 18 ℃, the ascending aorta was transected near the base of the innominate artery.From the incision, the triple-branched stent graft was implantated into the true lumen of the arch,descending aorta and the aorta bifurcation vessel. The transected stump of the ascending aorta was anastomosis to the proximal of the branched blood vessel prosthesis.Results Cardiopulmonary bypass time was (186 ±38) min,cross clamp time was (101 ±27) min,and average selective cerebral perfusion and lower body arrest time was ( 39 ± 11 ) min.The in-hospital mortality was zero.One patient of transient postoperative neurologic dysfunction, one of acute renal failure, one of transient limbs disturbance, one of secondary thoracotomy operation, one of gastrointestinal hemorrhage and one of postoperative chylothorax were observed.CT angiography rechecked showed the position of the vascular stent were satisfactory and the blood flow of arterial branches stents were lucid .The false lumen of the aortic arch and descending aorta closed with thrombus or shrinked.Conclusions The patients required aortic arch to be reconstructed which had no main tearing of intima in the arch may be best candidates for this technique.Open triple-branched stent graft placement combined ascending aorta replacement is an effective means for aortic arch reconstruction in acute Stanford type A aortic dissection.     

Combined surgical and endovascular treatment of acute aortic dissection type A: preliminary results

BACKGROUND: The established treatment modality of acute Stanford type A dissection includes repair of the ascending aorta and various portions of the aortic arch, whereas the descending aorta is left untreated. We report a simultaneous approach of open repair of the ascending aorta with transluminal stent grafting of the descending aorta to minimize the consequences of an untreated descending aorta. METHODS: From April 2001 to February 2002, 8 consecutive patients (3 women [37.5%] and 5 men [62.5%]) with a mean age of 55.7 years (range, 45 to 70 years) were intended to be treated with the combined method of surgical repair of the ascending aorta and transluminal stent grafting into the descending aorta during the period of deep hypothermic circulatory arrest. Circulatory arrest time ranged between 30 and 67 minutes (average, 38.8 minutes). Specially designed Talent stent grafts (32 to 40 mm in diameter, length 13 cm) were inserted under direct vision and deployed with the proximal end at the origin of the left subclavian artery. RESULTS: Intraoperative stent graft placement was successful in 7 patients (87.5%). Because of severe kinking of the distal arch, stent insertion failed in 1 patient (12.5%). One patient with a history of preoperative stroke in the middle cerebral artery died because of intracerebral bleeding on postoperative day 2, resulting in an in-hospital mortality of 12.5%. Mean intensive care unit stay was 6.4 days (range, 2 to 21 days) and overall hospital stay was 18.2 days (range, 7 to 33 days). Completion computed tomographic scans revealed complete thrombosis of the false lumen in 2 patients and partial thrombosis in 4 patients. Follow-up was complete and ranged from 1 to 9 months (mean, 5.4 months). CONCLUSIONS: This preliminary study shows that combined surgical and endovascular treatment of acute type A dissection is feasible, and at least partial thrombosis of the false lumen can be achieved, potentially minimizing the risk of further dilatation or rupture. Additionally, the stent graft expands the otherwise sickle-shaped true lumen, thereby ameliorating distal aortic perfusion. Long-term results are warranted to demonstrate the effectiveness of this new combined treatment modality.     

主动脉夹层的细化分型及其应用

目的探讨在Stanford分型的基础上根据主动脉夹层的部位和病变程度再进行细化分型,对指导临床选择手术时机、确定治疗方案和手术方式,以及判断预后的价值。方法1994年1月至2004年12月我院治疗主动脉夹层708例。其中Stanford A型夹层477例：（1）根据主动脉根部病变程度分为3型。A1型（主动脉窦部正常型）212例,行保留主动脉窦部的主动脉替换;A2型（主动脉窦部轻度受累型）72例,行主动脉窦部成形63例、David手术9例;A3型（主动脉窦部重度受累型）193例,行主动脉根部替换术（Bentall手术）。（2）根据主动脉弓部病变分为2型。C型（复杂型）78例,行主动脉弓部替换＋象鼻术;S型（单纯型）399例,行部分主动脉弓部替换。Stanford B型夹层231例,（1）根据主动脉扩张的范围分为3型：B1型：降主动脉无扩张或仅有近端扩张,147例,行腔内带膜支架主动脉腔内修复术103例（B1S型）、部分胸降主动脉替换术32例、部分胸降主动脉替换术＋远端支架象鼻术12例;B2型：全部胸降主动脉扩张,53例,行部分胸降主动脉替换术＋主动脉成形32例、全部胸降主动脉替换术21例;B3型：全部胸降主动脉及腹主动脉扩张,31例行胸腹主动脉替换术。（2）根据左锁骨下动脉和远端主动脉弓部是否受夹层累及分为2型：C型（复杂型）：夹层累及左锁骨下动脉或远端的主动脉弓部,44例,在深低温停循环下手术治疗;S型（单纯型）：远端主动脉弓部和左锁骨下动脉未受夹层累及,187例,介入治疗103例、手术治疗84例（常温阻断下手术60例,股动脉-股静脉转流下手术24例）。结果Stanford A型夹层住院病死率为4．6％（22／477）,并发症发生率为14．5％（69／477）。Stanford B型夹层：介入治疗组病死率1．9％（2／103）,并发症发生率为2．9％（3／103）,轻度内漏发生率为9．7％（10／103）;手术治疗组住院病死率为3．1％（4／128）,并发症发生率为18．8％（24／128）。结论细化主动脉夹层的分型对于术前判断手术时机、制定手术方案和初步判断预后,具有重要的指导作用。