Application of occluders in endovascular repair of aortic aneurysms

Since Parodi et all reported the first successful case of endovascular treatment for abdominal aortic aneurysm （AAA） in 1991, the endovascular repair has become an important option for the surgical treatment of aortic aneurysms.2-4 The occluder is a newly-developed device introduced intraluminally to block the blood flow in certain arteries. It was mainly adopted by cardiologists in occluding the ventricular septal defect （VSD） and atrial septal defect （ASD）.5-6 Afterwards, vascular surgeons found it could also be used in endovascular repair of aortic aneurysms, especially when the aorto-uni-iliac （AUI） stent-grafts were implanted.7 Herein we present 6 patients with AAA, who were treated with endovascular deployment of AUI stent-grafts combined with a newly- designed occluder.     

Fenestrated endovascular aortic repair for juxtarenal abdominal aortic aneurysm

Background Endovascular stent-graft with fenestration can improve proximal sealing in patients with juxtarenal abdominal aortic aneurysm (JAAA).The purpose of this study was to describe our primary exp...     

胸主动脉夹层动脉瘤腔内隔绝术中内漏的处理对策

目的：探讨胸主动脉夹层动脉瘤（TAD）腔内隔绝术（EVGE）中内漏的评估、处理和预防方法。方法：对116例接受EVGE的Stanford B型TAD患术中出现的内漏采单纯球囊扩张、增加延伸移植物（cuff）封堵和促凝的方法进行处理。结果：术中出现中即时内漏17例（14.65%，17／116),10例采用球囊扩张。8例有效（内漏量减少），无治愈病例；10例采用cuff，均有效，治愈7例；4例采用促凝处理，有效、治愈各1例。术中处理后带漏9例（7.76%,9/116）。内漏组死亡2例（10.50%），非内漏组死亡2例（2％）。结论：对于TAD患，单纯球囊扩张对EVGE术中内漏尤其近端内漏的治疗效果并非最佳，cuff是最有效的治疗方式。     

近端锚定区不足的主动脉夹层的腔内修复术

Background  Sufficient length of the proximal landing zone (PLZ) is the key for a successful thoracic endovascular aortic repair (TEVAR) of an aortic lesion. The aim of this research was to investigate the safety, feasibility, efficacy, and problems of endovascular repair for aortic dissection with insufficient PLZ.

Methods  The clinical data between August 2005 and February 2010 from patients with insufficient PLZ for endovascular repair of aortic dissection were retrospectively reviewed. According to the classification proposed by Ishimaru, aortic zone 0 was involved in 3 cases, zone 1 in 10 cases, and zone 2 in 11 cases. A hybrid surgical procedure of supraortic debranching and revascularization, directly coverage the orifice of left subclavian artery, or a left common carotid artery chimney graft technique were performed to obtain an adequate proximal aortic landing zone.

Results  There was no significant difference in risk factors and diameter of the PLZ between Zone 0, Zone 1, and Zone 2. But the length of the PLZ was significantly different in the three groups (P <0.01). There was no significant difference in technical and clinical success rate between the groups.

Conclusions  The procedure for extending an insufficient PLZ for endovascular repair for aortic arch pathology is feasible and relatively safe. The applicability of TEVAR in such aortic disorders may be expanded.

     

胸主动脉夹层动脉瘤腔内隔绝术中移植物释放困难的对策

目的：探讨胸主动脉夹层动脉瘤（TAD）腔内隔绝术（EVGE）中移植物（SG）释放困难的解决方法。方法：总结我院4年来对TAD进行EVGE术中遇到SG释放困难的病例，采用强力后撤、导鞘预后撤技术、导鞘闭合技术、旋转技术、贯穿导丝牵张技术等各种方法对输送器前进困难、导鞘后撤困难和SG展开后输送器退出困难等情况进行处理。结果：释放困难病例共11例，5例释放时输送器外导鞘后撤困难，经过强力后撤、贯穿导丝牵张技术和导鞘预后撤技术成功将SG释放；3例SG展开后输送器退出困难，应用导鞘闭合技术、旋转技术和贯穿导丝牵张技术后导鞘成功退出；2例携载延伸SG的输送器无法到达预定部位，放弃操作1例，另1例经贯穿导丝牵张技术导引成功。还有1例输送器携载SG进入主动脉弓时导致裂口扩大，随即转传统手术。结论：灵活采用多种技术有助于解决胸主动脉瘤EVGE中SG释放困难的问题。     

低风险肾下腹主动脉瘤腔内治疗与开腹手术临床分析

目的:比较低风险肾下腹主动脉瘤腔内治疗与开腹手术的治疗效果。方法:回顾性分析42例低风险肾下腹主动脉瘤手术的临床资料。比较腔内治疗组(17例)与开腹手术组(25例)患者手术情况、并发症及治疗费用。结果:腔内治疗组患者在手术时间、ICU时间、术后住院时间、术中出血量上均优于开腹手术组患者(P<0.05),差异具有统计学意义。腔内治疗组患者在30 d围手术期死亡率及手术相关并发症上均少于开腹手术组患者,但差异无统计学意义(P>0.05)。住院费用、1年内门诊随诊费用腔内治疗组明显高于开腹手术组(P<0.05),差异具有统计学意义。结论:对低风险肾下腹主动脉瘤患者,腔内治疗具备微创和术后恢复快的优势,但在降低围手术期的死亡率和并发症发生率上没有明显优势且治疗费用昂贵。结合中国国情,建议对于低风险肾下腹主动脉瘤患者采用传统开腹手术方式进行治疗。     

Stanford B型主动脉夹层腔内修复的发展现状

主动脉夹层(AD)是临床常见的灾难性主动脉疾病,其自然预后极差。随着介入治疗技术与相关材料学的发展,胸主动脉腔内修复术(TEVAR)已作为复杂型Stanford B型主动脉夹层(cTBAD)的首选治疗方式,得到了大量开展,随之也产生了许多新的手术方式。本文结合相关文献,对TEVAR的各手术方式进行阐述,并对各种方式的术后动脉重塑情况进行综述,力求对动脉重塑技术的现状进行全面评估。     

胸主动脉夹层动脉瘤腔内隔绝术中左锁骨下动脉的处置

目的：探讨腔内隔绝术治疗Stanford B型胸主动脉夹层动脉瘤时左锁骨下动脉开口的处理原则。方法：对116例接受腔内隔绝术治疗的Stanford B型胸主动脉夹层动脉瘤患者进行回顾性分析。结果：116例患者中62例左锁骨下动脉开口受到干扰，其中2例完全遮蔽，19例有临床症状，而术前行颈外动脉－椎动脉旁路者，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引起左侧椎动脉的急性严重缺血造成严重的并发症，术前应根据夹层破口与左锁骨下动脉开口的距离，选择性实施左锁骨外动脉－左椎动脉旁路术。     

胸主动脉腔内修复术治疗慢性B型主动脉夹层中期疗效分析

目的：评价慢性B型主动脉夹层(chronic type B aortic dissection,cTBD)行胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)的安全性和可行性。方法回顾性分析2011年1月-2013年12月本院行TEVAR的25例cTBD患者临床资料。根据随访结果和影像学资料评估患者临床转归和动脉重塑情况。结果手术成功率100%,术后30 d内无死亡病例,中位随访时间28.9(26.4~35.2)个月,1年生存率100%,2年和3年生存率均为95.2%(95%CI：86.1%~100%);支架覆盖动脉段动脉重塑较好,支架以远动脉段累积动脉扩张发生率30%~45%。结论 TEVAR治疗cTBD的成功率和早、中期生存率高,但支架以远动脉重塑水平差。行TEVAR治疗的cTBD患者,术后需密切影像学随访。     

促红细胞生成素在胸主动脉夹层动脉瘤腔内隔绝术中的应用

目的：探讨促红细胞生成素在Stanford B型胸主动脉夹层动脉瘤（TAD)腔内隔绝术中应用的临床意义和安全性。方法：20例Stanford B型TAD患者随机分成2组，给药组（10例）术前3d开始使用重组人促红细胞生成素（rhEPO）1万U／d，皮下给药，连续应用10d;对照组（10例）不给予rhEPO，其他处理同给药组。用药前，术后第1、3、7、14天观察患者红细胞及其相关指标的变化。结果：两组患者手术后血红蛋白、红细胞产较手术前明显下降，分别于术后第3天和第1天降至最低值，但给药组较对照组回升加快，至手术后第14天时2项指标均显著高于对照组，并恢复至术前水平；而两组患者血小板计数（仅手术后第3天均较术前明显降低）及血压术后虽有下降趋势，但无统计学差异，两组间也无显著性差异。用药期间未发现明显的与药物相关的不良反应。结论：术前应用rhEPO进行人红细胞动员，可明显减轻患者术后失血和贫血程度。     

胸主动脉夹层动脉瘤腔内隔绝术出现远端反流的识别和处理

目的：探讨胸主动脉夹层动脉瘤（TAD）腔内隔绝术（EVGE）中远端反流的评估、预防和处理方法。方法：术中出现的远端反流采用球囊扩张、远端移植物（SG）封堵和促凝等方法进行处理。结果：术中即时反流发现率和术后Ⅱ期反流发现率均为3.45%；术中Ⅰ期治愈率为75%。近、远期病死率为零。结论：应加强远端反流的术中评估，术中未发现远端裂口者不能肯定无均端反流存在。远端裂口隔绝是有效治疗方法，其他如假腔内灌注、外科手术甚至单纯旷置也可酌情采用。     

“烟囱”技术在主动脉弓病变腔内修复术中的应用

目的：探讨“烟囱”技术在主动脉弓病变腔内修复术中应用的方法及疗效。方法：回顾性统计2010年8月 至2014年8月应用“烟囱”技术处理主动脉弓病变的25例患者的方法、结果和术后并发症等。结果：本组25例主动脉 弓病变腔内修复技术中应用了“烟囱”技术,男性18例,女性7例,年龄38~78(65±5.8)岁。针对左颈总动脉的“烟 囱”技术5例,针对左锁骨下动脉的“烟囱”技术20例。25 例患者均获得技术成功。3例术后即刻造影提示少量I型内 漏,未处理,术后1个月复查内漏消失;2例患者出现左上肢乏力,其中1例伴头晕,随访过程中逐渐恢复,无肢体缺 血坏死。所有“烟囱”支架均通畅,无主动脉覆膜支架移位、内漏等并发症。结论：“烟囱”技术为近端锚定区不 足的主动脉弓部病变提供了完全腔内微创治疗的方法,短期随访结果满意。     

腔内隔绝术治疗胸主动脉夹层动脉瘤对血压和肾功能的影响

目的：通过对Stanford B型胸主动脉夹层动脉瘤腔内隔绝术前后患者血压和肾功能变化的观察，初步探讨此术式对患者血压和肾功能的影响及其可能机制。方法：共观察111例。以平卧位右上肢肱动脉无创血压为标准，术前和术后2周、3个月进行观察。术前、术后1周内每日、术后1个月检查患者血尿素氮和肌酐。测量患者术前、术后降主动脉真腔内径、肾动脉内径，了解肾脏真、假腔供血情况。结果：术前并存高血压82例，术后高血压改善34例（41.55）。术前肾功能正常者94例，术后肾功能无明显变化；术前肾功能异常者17例，术后出现肾功能异常一过性加重。术后肾动脉内径增大2例，高血压均明显改善，肾功能无明显改善。术后肾动脉恢复真腔供血9例中，6例高血压改善，肾功能均无明显改善。术后主动脉真腔明显增粗11例，7例高血压改善，结论：手术对患者血压的影响主要为在原有高血压基础上的改善，术后肾脏血供的改善、主动脉真腔增粗，血流阻力降低，可能是改善高血压的机制。手术对患者肾功能影响较小，主要依赖于患者本身肾功能情况。     

破裂腹主动脉瘤腔内修复与开放手术效果的比较

目的:比较破裂腹主动脉瘤（rAAA）开放手术（OR）与腔内治疗（EVAR）的治疗效果。方法:回顾性分析确诊rAAA并采取OR或EVAR治疗患者的临床资料。比较两组患者及其中游离破裂患者术前指标及合并症、术中指标、围术期死亡率、术后并发症、术后住院天数及生存率等。结果:共61例rAAA 患者,男性50例,女性11例,年龄37～86岁,平均（69.74±9.22）岁。OR组36例,EVAR组25例。两组在年龄、性别、合并症及血肌酐方面无显著性差异（P＞0.05）,而在术前血流动力学稳定性方面存在显著性差异（P <0.05）。OR组与EVAR组围术期死亡率,术后30 d、6个月及12个月生存率均无显著性差异（P＞0.05）;OR组与EVAR组在术中出血量[（2116.67±1655.52）、（339.58±786.29） mL],术中输血量[ (1413.33±978.29) 、（416.67±562.35） mL],手术时长[（279.33±66.87） min 、（161.46±82.81) min]及ICU天数[5.0（IQR:2.0～6.0）,1.0（IQR:0.0～2.0）] 方面存在显著性差异（P <0.001）。其中两组间游离破裂患者各指标均无显著性差异（P >0.05）。结论:EVAR在解剖结构合适、指征明确的患者中的应用,可显著改善预后并具有微创优势,同时在血流动力学不稳定患者中疗效不亚于OR,故EVAR可作为rAAA治疗的一线手段;而OR在解剖结构不适用于EVAR等病例中仍发挥着不可替代的作用。     

快速起搏用于胸主动脉覆膜支架精确释放的临床随机对照研究

目的 比较快速人工心脏起搏与硝普钠在胸主动脉腔内修复治疗中的安全性、有效性及对移植物定位准确性的影响.方法 经广东省人民医院伦理委员会批准,研究入选2007年9月至2009年2月在广东省人民医院心内科因胸主动脉疾病择期行胸主动脉腔内修复治疗(TEVAR)的197例患者(夹层175例,动脉瘤22例).随机分为硝普钠组(n=98)和快速人工心脏起搏组(n=99),在腔内修复治疗术中分别应用上述两种方法以助移植物的准确定位与释放.比较两组的血流动力学指标、移植物定位及释放准确性、手术时间、手术前后肾功能和神经认识功能变化以及内漏和截/偏瘫发生率.结果快速人工心脏起搏组所有患者均成功植入右室起搏电极,并成功实施快速人工心脏起搏.快速人工心脏起搏组的主动脉压(mm Hg,1 mm Hg=0.133 kPa)明显低于硝普钠组[(47±5)比(82±7) mm Hg,P=0.003],其血压恢复时间[(9±2)s比(481±107)s,P<0.01]及手术时间[(94±16)min比(103±24)min,P<0.01]均明显短于硝普钠组,并且快速起博组移植物定位及释放准确性明显高于硝普钠组[(2±1)mm比(4±3)mm,P<0.01].两组患者术前、术后的肾功能及神经认知功能和内漏、截/偏瘫发生率差异无统计学意义.结论 与硝普钠相比,快速人工心脏起博可安全应用于TEVAR,缩短手术时间,还有助于移植物的准确定位与释放.

Abstract：

Objective To compare the safety, efficacy and their impact on stent graft positioning between rapid artificial cardiac pacing induced hypotension and sodium nitroprusside induced hypotension during thoracic endovascular aortic repair( TEVAR). Methods From September 2007 to February 2009,a randomized controlled trial as approved by the Ethics Committee of our hospital was conducted in 197 patients undergoing elective thoracic endovascular aortic repair of thoracic aortic dissection(n=175) or aneurysm(n=22).The patients were randomized into sodium nitroprusside group(n=98) and rapid artificial cardiac pacing group(n=99).During the localization and deployment of stent graft,hypotension was induced by intravenous sodium nitroprusside or rapid artificial cardiac pacing.Hemodynamics, landing precision (deviation from planned placement site), duration of procedure, renal function, neurocognitive function, incidence of endoleaks and paraplegia/hemiplegia were compared. Results Rapid artificial cardiac pacing was conducted without technical difficulty in all 99 patients. The level of hypotension (mm Hg, 1 mm Hg=0.133 kPa) was most pronounced in the rapid artificial cardiac pacing group (47±5 vs 82±7, P=0.003. Once rapid pacing ceased, blood pressure recovered more quickly to the prepacing levels in the rapid artificial cardiac pacing group [(9±2)s vs (481±107)s,P<0.01]. And the duration of procedure was also shorter in the rapid artificial cardiac pacing group [(94±16)min vs (103±24)min, P<0.01]. Moreover, precise positioning and deployment was observed in rapid artificial cardiac pacing group versus to the sodium nitroprusside group(P<0.01).There was no difference in renal function and neurocognitive function before and after the procedure in both groups.There was no difference in the incidences of endoleaks and paraplegia/hemiplegia between different groups(P>0.05). Conclusion As compared with sodium nitroprusside,rapid artificial cardiac pacing is safer in thoracic endovascular aortic repair.It shortens the endovascular procedure and enables more precise positioning and deployment of stent graft.     

Totally percutaneous thoracic endovascular aortic repair with the preclosing technique: a case-control study

Background  The conventional thoracic endovascular aortic repair (TEVAR) involves groin incisions under general or epidural anesthesia. As technology moves towards less invasive procedures, a total percutaneous approach is desirable. In this study, we describe a Preclosing technique and investigate its safety and efficacy for femoral access sites management, and evaluate its advantages as compared to those of traditional surgical cutdown approaches.

Methods  The Preclosing technique involves two or multiple 6 F Perclose Proglide devices deployed in the femoral artery before upsizing to a 20–25 F sheath. The sutures were secured to close the arteriotomy at the end of the procedure. The medical records of patients who underwent thoracic endovascular aortic repairs using the Preclosing technique between December 2009 and November 2010 (group A) were compared with those using surgical femoral cutdown from January 2008 to November 2009 (group B). Outcome measures included rates of technical success, early complications, anesthesia method, procedure time, cardiac care unit (CCU) stay, time from procedure to discharge, hospital stay, procedure expense, hospital cost.

Results  Between the two groups, there were no significant differences in baseline characteristics, in the endograft models or profiles. The technical success rate was 100.0% (85/85) in group A vs. 97.4% (147/151) in group B (P <0.05). There was no access-related mortality in both groups. Compared with group B, the incidence of early complications were fewer in group A, 9.4% (8/85) vs. 22.5% (34/151) (P <0.01). Local anesthesia with conscious sedation was used more often in group A, 68.2% (58/85) vs. 51.7% (78/151) in group B (P <0.01). The procedure duration was shorter, (96±33) minutes in group A vs. (127±41) minutes in group B (P <0.01). The length of the CCU stay, the duration from procedure to discharge, and the hospital stay were both reduced in group A, (117.3±88.3) hours, (7.5±5.3) days and (15.3±6.8) days vs. (132.7±115.5) hours, (10.5±5.0) days and (19.5±7.8) days in group B (P <0.01). The procedure cost was RMB (109 000±30 000) Yuan in group A vs. RMB (108 000±25 000) Yuan in group B (P=NS). The hospital cost was RMB  (130 000±35 000) Yuan in group A vs. RMB (128 000±33 000) Yuan in group B (P=NS).

Conclusions  Total percutaneous TEAVR with the Preclosing technique is safe and effective with meticulous technique and appropriate patient selection. The Preclosing technique decreases access-related complications, depends less on general anesthesia and the surgeon’s cooperation, saves procedure time and shortens the CCU/hospital stay. With these advantages, the use of two percutaneous closure devices increases the hospital cost only slightly.

     

破裂腹主动脉瘤腔内治疗与手术治疗效果比较

目的:比较破裂腹主动脉瘤（rAAA）腔内治疗（EVAR）与开放手术（OSR）的治疗情况。方法:回顾性分析分别采取开放手术或腔内治疗的rAAA患者临床资料。比较两组术前一般情况、围手术期死亡率及并发症发生率、术后死亡率、术后住院时间等。结果:rAAA患者共35例,其中男28例,女7例,年龄37～84岁,平均(68.37±10.04)岁。 OSR 23例、 EVAR 12例。 两组在年龄、性别、合并症及术前血流动力学稳定性方面无显著性差异（P＞0.05）。OSR组与EVAR组的死亡率依次为:手术期17.4%（4/23）、0（0/12）（P=0.275）,术后30 d死亡率30.4%（7/23）、0（0/12）（P=0.070）,术后6个月34.8%（8/23）、0.0%（0/12）（P=0.032）,术后12个月45.0%（9/20）、0（0/8）（P=0.029）;两组术后住院天数中位数分别是:OSR 17.0 (IQR:14.0～27.0),EVAR 11.0 (IQR:7.0～16.0) (P=0.024)。结论:腔内治疗可作为rAAA的一线治疗手段,但应根据解剖条件进行手术方式的选择 。单臂支架型血管（AUI）是控制rAAA出血的快速、有效方式。EVAR术后必需加强对腹腔间隔室综合征的观察与处理。     

Endovascular aneurysm repair as a mean of treatment for ruptured abdominal aortic aneurysms

The metamorphosis of abdominal aortic aneurysm (AAA) repair from open surgical to endovascular means has evolved substantially over the past 2 decades.Today,endovascular abdominal aneurysm repair (EVAR)is considered as the first choice of therapy for treatment of infrarenal AAA in patients with favorable morphology.Furthermore,in "real world" clinical scenarios,with increasing physician experience and ability,the indications of EVAR have expanded from treatment of elective to emergent aneurysms and from favorable morphology to sometimes complex and unfavorable anatomy,particularly in high-risk patients.1-4 When considering these endovascular techniques for treating ruptured AAA,one has to prepare for the challenges of streamlining patient care from the emergency room to the operating room and subsequent endovascular procedure that often requires a multidisciplinary approach and a change in paradigm and local cultures.This paper will focus on a comprehensive and standardized technical approach for treating patients presenting with ruptured AAA by endovascular means that can maximize our ability to offer this treatment of most patients and optimize outcomes.     

胸主动脉夹层动脉瘤腔内治疗中导入动脉几种处理方法的比较

目的：比较总结Stanford B型胸主动脉夹层动脉瘤（TAD）腔内隔绝术中不同导入动脉处理方法的优缺点。方法：对1998年9月至2001年12月间在本中心接受腔内隔绝术的Stanford B型胸主动脉夹层动脉瘤患者116例进行回顾性分析。11例患者采用局部肝素化加导入动脉完全阻断法，5例采用全身肝素化加导入动脉完全阻断法，99例采用全身肝素化加导入动脉部分阻断法，1例采用导入动脉吻合人工血管的方法。结果：导入动脉完全阻断的患者在下肢血流复通后血压显著下降且伴有代谢性酸中毒，其中局部肝素化的患者术后下肢并发血栓形成2例，筋膜间隙综合征2例。导入动脉部分阻断法失血量增加，但下肢并发症减少。结论：在TAD腔内隔绝术中以部分阻断法处理导入动脉既可减少术中的血压波动又避免了术后严重的下肢并发症。     

Alternative management of the left subclavian artery in thoracic endovascular aortic repair for aortic dissection: a single-center experience

Background

Since the new 2009 guidelines for left subclavian artery (LSA) management using thoracic endovascular aortic repair (TEVAR), a few studies have been published about alternative LSA management. The objective of this study was to present the follow-up results of covered or revascularized LSA during TEVAR.

Methods

From January 2010 to August 2012, 109 consecutive patients were treated with TEVAR at the Department of Vascular Surgery, Changhai Hospital, for aortic dissection extending near the LSA. After evaluating the bilateral vertebral arteries, fifty-two LSAs were covered and not revascularized (covered group), while 57 LSAs were preserved (revascularized group). Complications were stratified according to the time of occurrence after surgery.

Results

Emergency operations were more common (17.3 vs. 3.5 %, P = 0.017) and operation time was shorter (96.9 ± 16.3 vs. 135.3 ± 38.4 min, P < 0.001) in the covered group. Pulselessness and intermittent claudication of the left arm occurred in most patients in the covered group (P < 0.001). Incidence of stroke and cold shoulder feeling were higher in the covered group compared with the revascularized group (P = 0.026 and <0.001, respectively). There were five aorta-related deaths in the covered group and one in the revascularized group. Eight endoleaks were observed in the revascularized group (P = 0.006).

Conclusions

The results of this study suggest that due to occurrence of complications, LSA should be preserved or revascularized to reduce complications and to improve patients’ quality of life.