腔内修复治疗Stanford A型主动脉夹层的现状与挑战

急性Stanford A型主动脉夹层(TAAD)起病急、病死率高、手术风险大。虽然开放手术是目前治疗TAAD的首选, 但仍有10%～30%的TAAD患者由于手术风险高而选择保守治疗, 使患者病死率大大增加。随着腔内技术的进步及各种腔内器具的革新, 腔内治疗TAAD有良好的发展前景。虽然胸主动脉腔内修复已成为复杂Stanford B型主动脉夹层的首选治疗, 然而其治疗TAAD的证据较少, 且 TAAD破口位于升主动脉, 封堵破口的同时需要重建弓上分支, 亟需更加符合主动脉生理特性的腔内移植物及更安全的输送系统。技术方面, 近远端锚定区的选择及术中脑保护等仍是目前的重点和难点问题。同时, 在主动脉根部处理、弓上分支重建方面亦缺乏成熟的方案。     

1例Stanford B型主动脉夹层胸主动脉腔内修复术中封闭左锁骨下动脉的安全性观察

Dake等 [1]报道使用支架型移植物腔内治疗Stanford B型主动脉夹层患者并获得良好的临床疗效,随着经验积累和技术进步,目前胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)凭借其微创、安全、有效的特点已成为Stanford B型主动脉夹层的首选治疗方案 [...     

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,     

DAVID-Ⅰ式手术治疗主动脉根部动脉瘤12例

长期以来应用带主动脉瓣（机械瓣或生物瓣）的人工血管替换病变主动脉及主动脉瓣并重新移植冠状动脉开口（BENTAL手术）是治疗升主动脉及主动脉根部动脉瘤的标准术式，但其存在与人工瓣相关的问题。1992年David和Feindel提出了保留主动脉瓣的主动脉根部修复术（DAVID手术）治疗升主动脉瘤和主动脉根部扩张。我们于2002年10月至2003年10月在法国冈城大学医疗中心研修期间参加了12例DAVID-Ⅰ式手术，现报告如下。     

血管腔内穿刺系统辅助原位开窗术用于腔内修复胸主动脉夹层

正胸主动脉病变(如Stanford B型主动脉夹层、主动脉瘤、主动脉穿透性溃疡)为极其凶险疾病,对患者生命造成严重危害[1-2]。传统主动脉人工血管置换方法具有较高死亡率和并发症发生率[3]。目前腔内修复胸主动脉(thoracic endovascular aortic repair,TEVAR)已成为治疗胸主动脉病变的主要术式,但用于治疗累及弓上动脉、升主动脉及锚定区不足病变时仍面临挑战。本研究观察TEVAR术中应用血管腔内穿刺系统辅助原位开窗技术的效果。     

升主动脉-颈动脉旁路联合腔内修复术治疗主动脉弓部病变

目的 总结升主动脉-颈动脉旁路联合腔内修复术治疗主动脉弓部病变的经验与体会.方法 回顾性分析2002年1月至2013年6月在中山大学附属第一医院血管外科接受升主动脉-颈动脉旁路联合腔内修复术治疗的10例主动脉弓部病变高危患者的临床资料.其中男性9例,女性1例,年龄34 ～71岁,平均年龄(54±14)岁.原发病包括主动脉夹层8例,胸主动脉瘤2例.行正中开胸行升主动脉-无名动脉-左颈总动脉旁路7例,升主动脉-左颈总动脉-左锁骨下动脉旁路3例,同期(5例)或二期[5例,平均间隔(7±4)d]经股动脉植入覆膜支架修复主动脉弓病变.结果 全部手术取得技术成功.术后30 d死亡3例,1例死于脑干梗死,1例死于循环衰竭,1例死于主动脉气管瘘.术后发生Ⅱ型内漏1例.随访1 ～ 132个月,中位随访时间24个月(四分位数间距14个月),术后1个月、3个月、1年及其后每年复查CT,随访期间7例患者均健康存活、人工血管旁路通畅,除1例Ⅱ型内漏继续存在外,其余支架均无移位和内漏.结论 升主动脉-颈动脉旁路联合腔内修复术可用于治疗一般情况差、难以耐受主动脉置换的主动脉弓部疾病高危患者.     

升主动脉及主动脉弓部病变的腔内技术应用

目前血管腔内修复术（endo vascular repair，EVR）在胸主动脉疾病中的应用越来越广泛，经过十多年的临床经验可以确认EVR创伤小、恢复快、疗效确切，故腔内治疗目前已呈现出取代传统开放性手术成为主动脉疾病治疗首选的趋势，本篇综述回顾了从EVR开始应用于胸主动脉疾病到目前的主要文献，较详细地阐述了目前EVR泊疗升主动脉及弓部病变的各种方法。     

Bentall术后再发Debakey Ⅲ型主动脉夹层动脉瘤一例

患者男。46岁。于1999年1月因突发胸痛、心悸以马凡综合征、升主动脉瘤伴夹层（DebakeyⅡ型）及主动脉瓣重度关闭不全行Bentall术，术后一直口服华法令。2002年11月出现反复高热并伴有胸闷，行彩色超声检查见人工金属瓣膜有赘生物附着。主动脉根部与主动脉右前方囊腔相通，遂又以感染性心内膜炎，主动脉根部脓肿行升主动脉人工血管替换加主动脉根部脓腔清除及右冠状动脉开口再植术。2005年2月，患者下蹲时再次突发胸背部剧痛第3次人院。查体：患者身高180cm，肢体细长，左侧桡动脉搏动（＋）。     

Stanford B型主动脉夹层术中主动脉内膜脱套的腔内处理策略

术中主动脉内膜脱套（AII）是胸主动脉腔内修复术（TEVAR）术中一种罕见但致命的并发症，补救处理难度大且易漏诊、误诊、误判，正确识别术中AII并快速有效地给予治疗是一大挑战。术中AII属于继发性AII，具体病因仍不明确，可能与手术操作原因和潜在的主动脉病变等原因相关。本文结合相关文献及临床诊疗经验，对主动脉夹层患者TEVAR术中AII的发生原因、分型、诊断评估要点及紧急腔内处置方法等进行介绍和探讨。首先，笔者提出基于脏器血流灌注的细化分型方案：即在原分型的基础上增加脏器分支缺血严重程度的评价，依据术中数字减影血管造影显示的脏器分支灌注情况细分为a、b两个亚型。新分型法的优势在于除了可以区分脏器缺血严重程度，还可用于指导腔内紧急处置策略。第二，对于疑诊术中AII的患者，需要进行术中详细造影确定分型。笔者建议分三步完成主动脉支架近端、支架远端造影及腹主动脉真腔内造影，这有助于明确近端锚定区的稳定性以及术中AII类型，确定灌注不良的脏器分支、严重程度及缺血阻塞类型，对下一步采取的补救措施至关重要。最后，腔内补救支架治疗效果良好且具备创伤小、术后恢复快等优势，已成为术中AII治疗的首选；腔内补救支架治疗应按照先近端再远端、先主干再分支的顺序进行。针对重建支架远端胸腹主动脉真腔血供，现有主流方案存在一定局限性，笔者推荐采用“两步法”方案重建主动脉真腔血供，该方案可以避免脱套内膜进一步向远端撕脱。     

主动脉疾病的封堵器治疗

在过去的十几年中,随着腔内技术的日益成熟,应用腔内技术治疗主动脉疾病已成为临床重要的方法。但对于一些复杂的主动脉病变,应用支架移植物既良好隔绝主动脉瘤或主动脉夹层,又保持分支动脉通畅往往十分困难,而且长期随访之后发现一些患者出现腔内治疗的并发症,甚至需要再次手术,比如主动脉夹层远端裂口部位的假腔瘤样扩张等[1]。故近年来陆续有学者提出以传统的治疗先天性心脏病的封堵器来治疗复杂的主动脉病变的想法,其应用目前主要集中于主动脉夹层和主动脉假性动脉瘤。     

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.     

Current state and future directions of endovascular ascending and arch repairs: The motion towards an endovascular Bentall procedure

Endovascular repair of the ascending aorta and aortic arch has evolved at an astonishing pace in the past several decades. Results of endovascular arch repair in experienced centers have been improving and the technology evolving, and it has begun to challenge the current gold standard status of open surgery in some groups of patients. Hybrid strategies with adjunctive cervical debranching for distal arch lesions are being replaced by fenestrated arch repairs. Total endovascular repair for proximal aortic arch pathologies with the use of inner branches has achieved the best results; however, the main current limitations of endovascular arch repair are diameter-, length-, and angulation-related issues with the ascending aorta (proximal landing zone). Ascending aorta endovascular repair has allowed extending treatment further proximally in patients with post-surgical pseudoaneurysms of the ascending aorta or post–type A chronic aortic dissections. However, sufficient proximal landing zone is still needed in the proximal aorta for these repairs; in a significant number of patients, this is not feasible with simple proximal tubular grafts. Therefore, new technologies and techniques are being developed to deal with this limitation, including the endovascular Bentall concept, with incorporation of the aortic valve and coronary ostia. In this review, the current state and future directions of endovascular ascending and arch repairs and the motion towards an endovascular Bentall procedure are discussed.     

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。     

Endovaskulärer Aortenklappen- und Aszendensersatz

Currently there is no standard endovascular treatment option for ascending aortic aneurysms or dissection combined with aortic valve malformations. Our aim was to design a composite endovascular device consisting of a transcatheter aortic valve prosthesis and integrated thoracic aortic stent graft. The endovascular composite valve graft design is based on five integrated concepts: 1) individualization of prosthesis size according to the anatomy, 2) intraoperative coupling of both components, 3) free diastolic coronary perfusion, 4) distribution of the radial force to three anatomical structures, namely the aortic valve annulus (zone  A), the sinotubular junction (zone B) and the distal ascending aorta (zone C) and 5) single stage implantation. The short distance between the coronary arteries and zone B and significant angulation between the planes of zones B and C must be considered in the composite valve graft designing process. The novel conduit device will enable simultaneous endovascular repair of aortic valve malformations and ascending aorta aneurysms or dissection.     

Aortic insufficiency secondary to aortic root aneurysm or dissection.

Twenty-four patients with aortic regurgitation secondary to aortic root aneurysm (13 patients) or dissection (11 patients) were operated on, utilizing a variety of surgical procedures to cope with the varied pathological findings. These ranged from primary repair of the ascending aorta without any prostheses in patients with acute aortic dissection to replacement of the valve and the entire ascending aorta for aortic root aneurysm. In four patients with Marfan syndrome the right coronary artery was transplanted to the ascending aortic graft, allowing an extension of the graft to the valve anulus and excision of the entire aneurysmal aorta. The immediate and late results have been most encouraging.     

Simultaneous repair of arch and abdominal aortic aneurysms

Objective: Atherosclerotic aneurysms in the aortic arch are associated with abdominal aortic aneurysms in up to 37% of cases. We have developed a single-stage approach to the repair of both aneurysms using a temporary bypass. Subjects: Since November 1996, 5 patients underwent simultaneous repair of aneurysms in the aortic arch and in the infrarenal abdominal aorta, using a new temporary bypass graft technique. Entire arch replacement with simultaneous abdominal aortic aneurysmectomy was performed in one patient. The other 4 patients underwent distal hemiarch replacement distal from the orifice of the brachiocephalic artery with simultaneous repair of the abdominal aortic aneurysm. Method: For the entire arch replacement procedure, blood flow to all major branches of the aortic arch was established using a bifurcated graft. This graft anastomosed to the ascending aorta was used as the proximal inflow of the temporary bypass graft. For the hemiarch replacement procedure, the proximal inflow segment of the temporary bypass graft was anastomosed to the brachiocephalic artery. In both cases, the distal outflow segment of the temporary bypass graft was the graft used for repair of the abdominal aortic aneurysm. In order to prevent any clamp injury, Teflon felt was tightly wrapped around the aorta before the clamp was applied. Results: Evaluation of the hemodynamic parameters measured during cross-clamping of the aortic arch revealed stable distal perfusion to the visceral organs and no excessive increase in cardiac afterload. All patients had an uneventful postoperative course and were discharged within 1 month of surgery. Conclusion: Our temporary bypass method is recommended for simultaneous replacement of aneurysms in the aortic arch and the abdominal aorta.     

Complete extra-anatomic bypass of the aortic root: treatment of recurrent mediastinal infection

A 45-year-old woman underwent complete extra-anatomic bypass of the aortic root for recurrent mediastinal infection. Operative repair consisted of removal of an aortic valve prosthesis and an ascending aortic graft. The aortic root and transverse aortic arch were closed primarily and a valved conduit was placed from the left ventricular apex to the descending aorta. Coronary flow was reestablished with saphenous vein grafts taken from the innominate and subclavian arteries to the coronary artery orifices. Infection did not recur, but the patient died 9 months following operation apparently of right coronary artery graft occlusion.     

Evaluation of composite graft replacement of the aortic root and ascending aorta

Replacement of the entire aortic root and ascending aorta with a composite graft was done in 7 patients with ascending aortic aneurysm and aortic regurgitation. There was no worrisome postoperative bleeding, and follow-up aortography has demonstrated correction of the aortic root disease in all patients and no complications referable to the coronary artery implantation.     

Alternative surgical approach to repair of the ascending aorta

We describe a case of complete endovascular repair of the ascending aorta using a transfemoral approach. A 59-year-old man with a history of two previous sternotomies experienced an ascending aortic pseudoaneurysm arising from the graft-to-graft anastomosis of a previous DeBakey type I aortic dissection repair. A custom-made Zenith TX2 (William Cook Europe ApS, Bjaeverskov, Denmark) thoracic aortic aneurysm endovascular graft, designed specifically for the ascending aorta, was introduced through the left femoral artery and deployed under a rapid ventricular pacing protocol to achieve precise placement between the sinotubular junction and the aortic arch.     

Simultaneous repair of arch and abdominal aortic aneurysms. A simple new technique using a temporary bypass graft.

OBJECTIVE: Atherosclerotic aneurysms in the aortic arch are associated with abdominal aortic aneurysms in up to 37% of cases. We have developed a single-stage approach to the repair of both aneurysms using a temporary bypass. SUBJECTS: Since November 1996, 5 patients underwent simultaneous repair of aneurysms in the aortic arch and in the infrarenal abdominal aorta, using a new temporary bypass graft technique. Entire arch replacement with simultaneous abdominal aortic aneurysmectomy was performed in one patient. The other 4 patients underwent distal hemi-arch replacement distal from the orifice of the brachiocephalic artery with simultaneous repair of the abdominal aortic aneurysm. METHOD: For the entire arch replacement procedure, blood flow to all major branches of the aortic arch was established using a bifurcated graft. This graft anastomosed to the ascending aorta was used as the proximal inflow of the temporary bypass graft. For the hemi-arch replacement procedure, the proximal inflow segment of the temporary bypass graft was anastomosed to the brachiocephalic artery. In both cases, the distal outflow segment of the temporary bypass graft was the graft used for repair of the abdominal aortic aneurysm. In order to prevent any clamp injury, Teflon felt was tightly wrapped around the aorta before the clamp was applied. RESULTS: Evaluation of the hemodynamic parameters measured during cross-clamping of the aortic arch revealed stable distal perfusion to the visceral organs and no excessive increase in cardiac afterload. All patients had an uneventful postoperative course and were discharged within 1 month of surgery. CONCLUSION: Our temporary bypass method is recommended for simultaneous replacement of aneurysms in the aortic arch and the abdominal aorta.