腔内隔绝术治疗主动脉夹层动脉瘤

目的评价血管内支架置入治疗夹层动脉瘤的安全性和临床疗效。方法2000年1月至2006年12月,48例StanfordB型夹层动脉瘤患者行腔内修复术。所有患者在DSA下行左肱动脉穿刺插管、造影,了解主动脉真、假腔、夹层裂口及其与重要血管分支位置关系。腹股沟区纵切口显露股动脉,送入人工血管输送器至病变处,准确定位后,释放人工血管进行腔内修复。术后复查造影,观察真假腔血液动力学变化、内脏及下肢动脉供血的改变。结果48例患者一次性成功置入人工血管支架,2例支架未能完全封堵漏口、内漏明显,手术成功率95.8%。支架置入后假腔血压下降,机体脏器缺血状况改善,临床症状好转或消失。结论支架性人工血管腔内修复术治疗夹层动脉瘤安全可行、效果明显,值得临床进一步推广。     

主动脉夹层多层螺旋CT血管造影的影像学表现

目的 探讨主动脉夹层多层螺旋CT血管造影(CTA)的影像学表现.方法 回顾性分析2010年2月至2013年8月于本院行CTA检查的主动脉夹层患者52例的临床资料,均采用256层螺旋CT进行全主动脉增强扫描,分析其CT平扫、增强图像及后处理重建图像,对主动脉夹层进行DeBakey分型并分析其影像学表现.结果 主动脉夹层患者52例中DeBakey Ⅰ型21例,DeBakeyⅡ型3例,DeBakeyⅢ型28例,其中Ⅲa型4例、Ⅲb型24例.CTA检查显示典型主动脉夹层43例,不典型主动脉夹层9例.典型主动脉夹层均能显示主动脉内膜内移、真假两腔及破口.不典型主动脉夹层8例不能显示明确破口,7例表现为主动脉壁新月形或环状增厚,8例增强扫描假腔无对比剂进入,2例溃疡形成.结论 CTA对典型及不典型主动脉夹层均具有重要的诊断价值.     

杂交手术治疗累及弓部的主动脉夹层的临床研究

目的 探讨杂交手术治疗累及主动脉弓部的主动脉夹层的方法及疗效.方法 自2009年1月至2012年1月,成都军区总医院共对16例累及主动脉弓部的主动脉夹层患者完成了杂交手术治疗.其中男性11例,女性5例,年龄50～72岁[(56.3±7.1)岁].Stanford A型主动脉夹层(夹层起源于升主动脉)5例,B型夹层(夹层起源于降主动脉)11例,病变均累及主动脉弓,不适宜单独行腔内隔绝治疗.11例采用胸骨正中切口或加颈部切口行升主动脉至头臂动脉旁路移植,5例单纯颈部切口行头臂动脉间旁路移植,然后行股动脉切口逆行主动脉腔内覆膜支架植入.术后即刻行升主动脉造影,术后3个月、1年及2年随访CT资料,观察支架和人工血管通畅情况.结果 所有患者均成功完成血管旁路手术,并植入覆膜支架.术中血管造影证实支架植入定位准确,无明显内漏和移位.主动脉夹层真腔血流恢复正常,旁路血管血流通畅,围手术期无死亡和严重并发症发生.随访16例,随访时间3.0 ～ 48.0个月[(24.O±8.2)个月],所有患者均生存,并恢复正常生活.术后3个月和术后1年、2年复查主动脉增强CT示:支架无移位和内漏,支架内及人工血管旁路血流通畅,未见脑部和肢体的缺血征象.结论 累及弓部的主动脉夹层可根据受累的部位及程度采用不同的杂交手术方法,杂交手术治疗累及主动脉弓部的主动脉夹层安全、有效,能明显减轻患者的创伤和痛苦,该治疗方法扩大了介入覆膜支架腔内治疗的适应证,但远期疗效有待迸一步观察.     

主动脉夹层腔内隔绝术围术期护理

主动脉壁内膜破裂,高速的血流通过破口将动脉的内膜和中膜分离,血液从中流动,过去称为主动脉夹层动脉瘤,现称为主动脉夹层血肿,简称主动脉夹层。血管腔内隔绝术（endovasculargraftexclusion,EVGE）是指经股动脉导入人工导管,以内支架固定于动脉壁上,将血液与瘤壁隔绝,使瘤壁免受血流冲击,以达到治疗目的的一种介入治疗方法。我院2006年1月至2010年3月共收治DeBakeyⅢ型主动脉夹层51例,现将主动脉夹层腔内隔绝术围术期护理报告如下。     

国产支架型人工血管的实验研究与临床应用

目的研究和开发国产支架型人工血管经腔内治疗动脉疾病.方法1993年6月至1999年8月,用北京地区杂种狗24条,分别制作了腹主动脉瘤(8条)、降胸主动脉瘤(6条)、升主动脉瘤(4条)、主动脉弓瘤(4条)和动静脉瘘(2条)模型,用自制的支架型人工血管置入.置于腹主动脉的支架是编织式镍钛合金记忆金属,长3cm,直径8cm;胸主动脉支架是联体不锈钢“Z“型支架,长3cm,直径2cm.覆膜均为国产超薄涤纶人工血管.临床应用20例,男17例,女3例.主动脉夹层11例,肾下腹主动脉瘤7例和创伤性动静脉瘘2例.结果17条狗术后存活,分别于2、4、8周获取标本,支架型人工血管通畅良好,无血栓形成.临床病例中,有1例腹主动脉瘤并发肾功能不全,于术后20天血液透析中死于心肌梗塞,其余病人均被成功治疗.随访2个月至5年,除1例夹层动脉瘤术后3个月支架移位外,所有病人恢复良好.结论自制的支架型人工血管费用低,操作简便,应用前景可观.     

覆膜支架介入治疗外伤性主动脉夹层动脉瘤术后的护理

目的 讨论覆膜支架植入治疗外伤性主动脉夹层动脉瘤术后的护理.方法 2006年12月～2010年10月,采用先健AnkuraTM大动脉覆膜支架系统施行EVGA术的病人有5例,男4例,女1例,年龄31～55岁.护理积极配合医生治疗,严密观察病人的生命体征,做好健康教育.结果 5例患者支架全部成功植入.术前血压控制平稳,5例术中无并发症及死亡发生.术后2月～4年随访,所有患者复查CT示假腔径缩小并见腔内血栓形成,真腔径增大,未发生瘤体破裂及支架移位等并发症.结论严密、认真的护理措施对外伤性主动脉夹层覆膜支架植入术的成功和病人的康复有重要意义.     

腔内隔绝术在主动脉瘤外科治疗中的应用

目的：探讨腔内隔绝术治疗主动脉夹层动脉瘤、腹主动脉瘤的操作方法及近期疗效。方法：采用腔内隔绝术治疗主动脉夹层动脉瘤3例、腹主动脉瘤2例。结果：5例主动脉瘤腔内隔绝术均获得成功，术后3例主动脉夹层动脉瘤的假腔立刻消失，2例腹主动脉瘤瘤体成功隔绝。无支架移位；术中发生内漏1例，经及时处理后消失；2例术后出现移植后综合征，经对症处理后缓解。随访3-21个月，无移植物移位及器官缺血，假腔内见血栓形成。结论：腔内隔绝术治疗主动脉瘤创伤小．安全、恢复快，有着较好的近期效果。     

覆膜支架植入治疗B型主动脉夹层分离

目的总结覆膜支架植入治疗B型主动脉夹层分离的临床经验和疗效。方法2002年12月至2006年5月,16例B型主动脉夹层分离患者,男:14例,女:2例,平均年龄50.2岁(34～岁)。临床除2例无胸、背痛等症状外,其余均有典型的胸、背痛症状,3例有胸腔积液,12例伴高血压。术前行CT增强或MRI扫描确诊。局麻下切开一侧股动脉,在DSA监测下行覆膜支架植入治疗。结果16例患者术后即刻造影示:13例患者一枚支架将假腔破口完全封堵;1例患者支架近端少量造影剂外溢,再串联1枚支架,后封堵完全;一例患者支架近端极少量造影剂外溢,未补支架,术后一月复查CT无造影剂外溢;一例患者为双破口,植入2枚支架,复查造影,破口封堵完全。16例患者共植入Talent支架18枚,全部成功。平均随访17.2月(3～个月),复42查CT示:16例患者血管管腔通畅,均无造影剂外溢。无一例死亡。结论主动脉夹层分离患者死亡率极高,覆膜支架植入术是一种安全、有效的方法,尤其是对外科手术风险大,死亡率高的患者意义更大。     

搭桥术治疗DeBakey Ⅲ型主动脉夹层的流固耦合数值模拟

目的研究旁路搭桥转流术治疗DeBakey Ⅲ型主动脉夹层的力学机理,并探讨该术式的有效手术方案。方法构建升-腹搭桥和锁-腹搭桥前后通腔型式和盲腔型式的DeBakey Ⅲ型主动脉夹层个性化模型,利用计算流体力学的方法,在生理流动条件下进行流固耦合数值模拟。结果搭桥后假腔的血液流动速度、压力和血管壁位移分别平均下降38.86%、15.347 kPa和39.46%。结论搭桥手术是一种在特定情况下治疗DeBakey Ⅲ型主动脉夹层的有效手术方式,具有很好的临床应用前景。     

腔内隔绝术治疗Stanford B型夹层动脉瘤

目的 探讨腔内隔绝术EVGE治疗Stanford B型夹层动脉瘤的价值及应用经验。方法采用国产人工覆膜支架治疗Stanford B型夹层动脉瘤9例。经核磁共振（MRI）、主动脉造影明确瘤体和夹层破口位置及大小,标记破口位置。准确选定覆膜支架型移植物,DSA监控下将支架导入瘤腔及裂口位置,完全封闭破口,使真、假腔隔绝。结果破口全部封闭成功,支架没有移位、狭窄等并发症。术后超声和螺旋CT检查假腔内有血栓形成。9例患者均康复出院。结论EVGE是一种治疗Stanford B型夹层动脉瘤的有效方法,早期结果满意,中远期效果还有待进一步观察。     

Features of Debakey III aortic dissection after endovascular graft exclusion: evaluation with DSCT angiography

The purpose of this study was to evaluate the prothesis and vascular features of Debakey III aortic dissection by DSCT angiography after endovascular graft exclusion. We performed a retrospective analysis of 39 Debakey III aortic dissection patients who underwent DSCT angiography after endovascular graft exclusion. After the operations in this study, all the 39 patients had no stent fracture and migration, 15 among all the 39 had endoleaks (type I 12 patients, type II 2 patients, 1 patient had no reason), 17 had large amount of thrombosis in false lumen, and 1 had false lumen outside the stent absorbed completely. While before the operations, 15 patients had abnormal renal perfusion pre-operation, and 9 of them had recovered after the operations. And the nearer located to the initial exclusive place, the more obviously the aortic remodeling occurred. In conclusion, DSCT angiography can accurately evaluate the prosthesis and anatomic-pathologic features of Debakey III aortic dissection after endovascular graft exclusion.     

腔内隔绝术治疗Stanford B型主动脉夹层23例临床分析

目的探讨Stanford B型主动脉夹层动脉瘤腔内隔绝术治疗的手术指征、术前评估方法、手术操作技巧、并发症及防治原则；观察近、中期临床疗效。方法自2003年3月～2006年1月，对23例Stanford B型主动脉夹层动脉瘤患者行腔内隔绝术治疗，笔者对临床资料进行回顾性分析。术前采用CT血管造影（CTA）或磁共振血管造影（MRA）对主动脉夹层动脉瘤进行评估，术中在数字减影血管造影（DSA）监视下经股动脉将移植物导入胸主动脉封闭夹层裂口，术后行影像学及症状学随访观察。结果术中成功释放移植物22例，术后即刻DSA造影显示18例近段破口完全被封闭，动脉瘤消失，4例发生内漏，其中2例再次置入支架后内漏消失。术后2例患者发生腹主动脉夹层，其中1例再次行腔内隔绝术。1例患者发生肠系膜动脉栓塞引起肠坏死而死亡。22例患者术后无心、肺、肾功能衰竭及截瘫等并发症，术后生命体征平稳，切口愈合，出院，术后经过CTA及症状学随访显示无严重并发症，生活质量明显提高。结论腔内隔绝术是一种创伤小、恢复快的新方法，近、中期随访结果表明该技术安全、有效。     

镍钛合金材料自膨胀式Wingspan支架置入症状性颅内动脉狭窄血管13例1年随访

背景：Gateway-WingSpan支架系统是2005年通过美国FDA认证,用于治疗症状性颅内动脉狭窄的镍钛合金自膨胀式支架,2007年在中国获得批准正式应用。 目的：进一步验证镍钛合金材料自膨胀式Wingspan支架置入治疗症状性脑动脉狭窄的近期疗效及安全性。 方法：对13例症状性脑动脉狭窄患者在Gateway球囊预扩下行Wingspan支架置入,狭窄病变18处,其中颈内动脉海绵窦段狭窄4处,大脑中动脉水平段狭窄11处,椎动脉末段狭窄2处,基底动脉下段狭窄1处。狭窄长度5~15 mm,平均狭窄(85.3±10.0)%。 结果与结论：支架置入成功率100%,置入后即刻造影显示残余狭窄在(30.5±12.0)%;随访12个月,未发生新发卒中或短暂性脑缺血发作,影像学检查显示均无再狭窄发生。13例均未出现与支架有关的动脉夹层、动脉内膜撕裂及急性支架内血栓形成等。均无支架的移位、断裂。支架置入后3 d内出现低血压 1例,皮下血肿1例,经治疗后症状均消失。结果显示镍钛合金材料自膨胀式Wingspan支架置入治疗症状性脑动脉狭窄比较安全,短期疗效较好。     

Hybrid endovascular repair of thoracic aortic aneurysm in a patient with Behçet's disease following right to left carotid-carotid bypass grafting

Endovascular repair of inflammatory aortic aneurysms has been reported as an alternative to open surgical treatment. In selective cases, adjunctive bypass surgery may be required to provide an adequate landing zone. We report a case of endovascular repair of an inflammatory aortic aneurysm in a patient with Behçet''s disease using a carotid-carotid bypass graft to provide an adequate landing zone. A 45-yr-old man with a voice change was referred to our hospital with the diagnosis of saccular aneurysm of the distal aortic arch resulting from vasculitis. Computed tomography showed a thoracic aortic aneurysm with thrombosis. Right to left carotid-carotid bypass grafting was performed. After 8 days, the patient underwent an endovascular stent graft placement distal to the origin of the innominate artery. The patient was discharged with medication and without postoperative complications after 5 days. Hybrid endovascular treatment may be suitable a complementary modality for repairing inflammatory aortic aneurysms.     

胸主动脉腔内修复术中应用体外开窗技术重建左锁骨下动脉的临床分析

目的 探讨体外开窗技术在胸主动脉腔内修复术(TEVAR)中重建左锁骨下动脉(LSA)的方法和疗效。方法 回顾性分析2016年1月—2018年12月南京鼓楼医院和徐州市中心医院血管外科应用体外开窗技术在TEVAR中重建LSA的67例患者的临床资料,其中男51例、女16例,年龄41～76(63±5)岁。67例中,B型主动脉夹层50例、胸主动脉瘤11例、壁间血肿4例、主动脉溃疡2例。观察患者TEVAR后的内漏发生率,主体和分支支架的位置、完整性和通畅性,以及患者手术相关死亡率。结果 67例患者中,有66例成功采用体外开窗技术重建LSA,技术成功率达98.5%;另1例因术中对位不准确转为烟囱技术重建LSA,术后均获随访(3~48个月)。术后即刻造影提示存在少量Ⅰ型内漏3例,未予处理,术后3个月复查主动脉CT血管造影(CTA))提示内漏消失;2例患者术后出现左上肢乏力,其中1例伴头晕,均在随访过程中逐渐恢复,无肢体缺血坏死。随访中所有患者分支支架及主体支架均通畅并保持着良好的完整性,无主动脉覆膜支架移位、内漏等并发症,无手术相关死亡患者。结论 体外开窗技术为TEVAR中重建LSA提供了技术支持,方法简单有效,短、中期随访结果满意。     

覆膜支架治疗主动脉夹层的有限元分析

目的利用有限元方法模拟覆膜支架植入治疗主动脉夹层的过程,通过观察覆膜支架在血管不同位置处释放对血管壁上的应力分布情况,分析覆膜支架植入后血管出现新发破口的生物力学机制。方法根据主动脉的计算机断层血管造影影像数据,进行图像分割和三维重建,建立具有病人特异性的主动脉夹层的三维几何模型;根据文献数据,给定主动脉夹层壁厚和材料属性;利用CAD软件设计出不同几何参数的覆膜支架环;利用有限元分析软件模拟覆膜支架的释放过程。结果当覆膜支架处于稳定状态时,血管最大Von Mises应力与覆膜支架的释放位置有关;血管壁上的最大Von Mises应力点分布在裸支架及第1节细小镍钛合金环接触处,该作用力的长期存在可能是这个部位出现新发破口的原因。结论覆膜支架的释放位置对主动脉上的最大Von Mises应力分布影响较弱,但对主动脉上的Von Mises应力影响较为明显。研究结果对临床上覆膜支架释放位置的选择具有指导意义。     

Safety and Efficacy of a Novel,Fenestrated Aortic Arch Stent Graft with a Preloaded Catheter for Supraaortic Arch Vessels: An Experimental Study in Swine

Thoracic endovascular aortic repair (TEVAR) shows limitations in cases in which the aortic pathology involves the aortic arch. The study aims were to test a fenestrated aortic arch stent graft (FASG) with a preloaded catheter for the supraaortic arch vessels and to perform a preclinical study in swine to evaluate the safety and efficacy of this device. Six FASGs with 1 preloaded catheter and 5 FASGs with 2 preloaded catheters were advanced through the iliac artery in 11 swines. The presence of endoleaks and the patency and deformity of the grafts were examined with computed tomography (CT) at 4 weeks postoperatively. A postmortem examination was performed at 8 weeks. The mean procedure time for the one and two FASG groups was 30.2 (27.9-34.5) min and 43.1 (39.2-53.7) min. The mean time for the selection of the carotid artery was 4.8 (4.2-5.5) min and 6.2 (4.6-9.4) min. Major adverse event was observed in one of 11 pigs. One pig died at 4 weeks likely because of the effects of the high dose of ketamine, while the remaining 10 pigs survived 8-week. For both the one and two FASG groups, no endoleaks, no disconnection, no occlusion of the stent grafts were observed in the CT findings and the postmortem gross findings. The procedure with the FASG could be performed safely in a relatively short procedure time and involved an easy technique. The FASG is found to be safe and convenient in this preclinical study with swine.

Graphical Abstract

相似文献   

Endovascular and open repair for blunt aortic injury, treated in one clinical institution in Brazil: a case series

OBJECTIVE:

The objective of this retrospective study is to analyze and compare the results of conventional surgical repair and endovascular treatment of blunt aortic injury over the past 8 years.

METHODS:

Twenty‐eight patients (25 male; mean age, 35 years) were treated for blunt aortic injury between April 2001 and March 2009 in a university hospital in Brazil. Twenty‐six patients were included in the study: five were treated with operative repair (OR) and 21 with endovascular treatment (TEVAR). Two patients were excluded from analysis: one was managed conservatively, and one was treated with endovascular treatment for chronic dissection related to aortic trauma.

RESULTS:

Mean age was lower in the OR group than in the endovascular treatment group (17.8 vs. 38 years, P  =  .003). There was one death in the OR group and four deaths in the endovascular treatment group. Mean follow‐up for the overall group was 33.6 months, with 48.7 months (range 8‐83 months) for the OR group, and 29.8 months (range 2‐91 months) for the TEVAR group. Mean time elapsed from injury to repair was 23.4 hours (range 8‐48 h, median 20 h) for the OR group and 30.3 hours (range 2‐240 h, median 18 h) for the TEVAR group (P  =  .374). The duration of surgery was shorter in the endovascular treatment group (142 versus 237 minutes; P  =  .005). There were no significant differences with respect to the number of postoperative days requiring mechanical ventilation, duration of ICU stay or duration of hospital stay.

CONCLUSION:

In this retrospective analysis, endovascular treatment was a safe method for repair of blunt aortic trauma, with immediate and midterm results that were comparable to those results obtained with operative repair. No complications from the stent graft were identified during follow‐up. Nevertheless, long‐term follow‐up is necessary to confirm the effectiveness of this treatment.     

周围动脉瘤的外科和介入治疗

目的：总结周围动脉瘤的诊断、外科和介入治疗体会。方法：20例周围动脉瘤患者，2例行腔内修复治疗，18例行外科手术治疗，后者中损伤动脉管壁裂口直接修补3例，动脉瘤切除自体大隐静脉移植11例、人造血管移植3例，股深动脉假性动脉瘤切除及动静脉瘘结扎1例；1例合并髂动脉瘤和腹主动脉瘤者同时行髂动脉瘤和腹主动脉瘤切除人工血管移植术，1例合并下肢缺血患者行胭动脉切开取栓，1例并发小腿骨筋膜室综合征者行切开减压术。结果i2例腔内修复治疗者一期治愈出院。18例手术患者，16例一期治愈出院；1例出现远端肢体缺血行动脉切开取栓后痊愈出院，另1例小腿骨筋膜切开减压者行二期植皮，并遗留部分腓总神经缺血症状。随访17例，随访时间4个月～5年（平均15个月），均未发现肢体远端明显缺血症状和动脉瘤复发。结论：周围动脉瘤选择恰当的治疗方法均可获得良好的疗效，腔内修复治疗周围动脉瘤是安全可行的。