主动脉夹层动脉瘤的杂交外科治疗

目的探讨主动脉弓部破口的主动脉夹层动脉瘤的杂交外科治疗经验。方法分析应用杂交外科手术治疗38例主动脉夹层患者,按照架桥方法及术式分为：颈总动脉间架桥加腔内隔绝术19例,颈总动脉-升主动脉架桥加腔内隔绝术12例,颈总动脉-锁骨下动脉架桥加腔内隔绝术4例,腹主动脉-双侧肾动脉架桥加腔内隔绝术3例。结果所有患者夹层破口均被闭合,恢复真腔血流,住院死亡2例（成功率5.2%）,术后复查均未发生支架移位,1例原夹层破口处出现内漏,3例出现新破口,再次分别行腔内支架隔绝治愈。结论 主动脉夹层动脉瘤可通过外科手术结合腔内隔绝介入的综合外科治疗方案可以取得良好的效果,降低手术风险,提高手术治愈率。     

Bicuspid aortic valve with right-sided aortic arch aneurysm and Kommerell's diverticulum

Bicuspid aortic valve (BAV) is a common congenital cardiac malformation, frequently combined with ascending aorta dilation. However, isolated abnormalities of the aortic arch are less frequent in BAV patients. Here, we present a rare case of BAV combined with right-sided aortic arch aneurysm, aberrant left subclavian artery, and Kommerell's diverticulum, diagnosed by echocardiography and computed tomography angiography. The patient was followed-up regularly because of the life-threatening risks of aortic arch aneurysms.     

Painless aortic dissection presenting as hoarseness of voice: cardiovocal syndrome: Ortner's syndrome.

Most of the neurological manifestations of the aortic dissection are due to neuronal ischemia secondary to either extension of the dissection process into a branch artery, or compression of an artery by the false lumen of the dissecting aortic hematoma. However, the enlarging false lumen may directly compress on an adjacent nerve, causing neuronal injury resulting in neurological symptoms. This may particularly take place when a distal intimal tear does not decompress the false lumen, resulting in formation of an expanding blind pouch. About 10% of aortic dissections are painless and may present with symptoms secondary to the complications of the dissection. Although cardiovocal syndrome, or Ortner's syndrome (hoarseness of voice due to involvement of recurrent laryngeal nerve in cardiovascular diseases) has been described with aortic dissection, it has not been reported as an initial presenting feature of this disorder. This report describes the first case of painless aortic dissection presenting with hoarseness of voice, the cardiovocal syndrome. The hoarseness remained the only symptom throughout the entire course of the disease. The aortic dissection was not suspected initially. During surgical exploration, the recurrent laryngeal nerve was found compressed by the false lumen at the level of aortic arch. Aortic root replacement was performed successfully, resulting in complete resolution of the hoarseness. The neurological manifestations of aortic dissection, and the cardiovocal syndrome, are discussed.     

Mycotic aortic aneurysm in a patient with Tolosa-Hunt syndrome

Mycotic aneurysms have been associated with many clinical conditions. A tender pulsatile abdominal mass in association with fever, chills, and unrelenting back pain is suggestive of a leaking mycotic aneurysm. However, the extracranial manifestations of Tolosa-Hunt syndrome (THS) may mimic several of these symptoms. We report the case of a woman who was successfully treated with high-dose steroids for THS. Two months later, she was admitted to another hospital with rigors and unremitting back and abdominal pain. CT-guided aspiration of an L5-S1 paravertebral mass was done. The aspirate and blood cultures grew Staphylococcus aureus. Intravenous antibiotics and analgesics were administered with good relief. A month after discharge from that hospital, she was admitted to our hospital with classic signs and symptoms of a leaking mycotic aneurysm. She was treated surgically and has remained asymptomatic for 21 months. Tolosa-Hunt syndrome associated with mycotic aortic aneurysms has not been previously reported.     

Recurrent choking as a presenting feature of aortic arch aneurysm

Aortic arch aneurysm occurs more commonly in the aging population. Rapid expansion and symptomatic patients should undergo aneurysm resection regardless of size. An 87-year-old man was brought to our emergency department because of choking on food during his dinner. The patient did not have hoarseness, dysarthria, dysphagia, as well as other neurologic symptoms. He was finally found to have an aortic arch aneurysm. Swallowing is complex neuromuscular activity consisting essentially of 3 phases: oral, pharyngeal, and esophageal. The pharyngeal phase was mainly mediated by the pharyngeal plexuses of both the glossopharyngeal and vagus nerves. Uncoordinated movement of the pharyngeal muscles because of a stretch of the left vagus nerve or its plexus by an enlarging aneurysm may be the possible mechanism of choking in this patient.     

Imaging of aortic arch anomalies and associated findings

Imaging is important in the diagnosis of aortic arch disease. Echocardiography is the test of choice. It possess minimal risk, can be performed at the bedside without sedation and provides a complete evaluation of the heart and the great vessels. Cardiac magnetic resonance imaging (cMRI) is an alternative when echocardiography is limited by acoustic windows. It does not use ionizing radiation or nephrotoxic contrast. 3D reconstruction and soft tissue characterization are possible. cMRI evaluates physiology and may be an alternative to diagnostic catheterization. Longer scan times, need for sedation and the presence of implantable metal devices that may be a contraindication for cMRI are the main limiting factors. Computed tomography with angiography has very short scanning times, limiting the need for sedation. It has high spatial resolution and can evaluate physiology. Its use is limited because it uses radiation, has poor temporal resolution compared with cMRI and uses iodinated contrast. Catheterization is the test of choice, and can serve for diagnostic and therapeutic purposes.     

胸降主动脉瘤伴主动脉右弓右降手术的护理配合

目的探讨临床少见的右位主动脉弓、右位降主动脉、胸降主动脉瘤外科手术中的护理配合,以提高手术配合质量,减少手术相关并发症的发生。方法针对8例行右弓、右降胸降主动脉瘤手术的病例进行术前准备、麻醉配合、体位管理和皮肤保护、术中配合、术后交接等护理配合。结果8例患者于术后4～7h清醒,无左上肢缺血、无皮肤压伤感染等护理问题。结论术前心理护理、麻醉配合、正确的体位摆放以及充分显露术野和娴熟的手术配合是确保手术顺利进行的关键因素之一。     

Genetic variation on chromosome 16 is associated with abdominal aortic aneurysm

1. There is a familial tendency to abdominal aortic aneurysms. We have followed up a previous report of a weak association between the haptoglobin 2-1 phenotype and aortic aneurysm and investigated polymorphisms of the haptoglobin gene and neighbouring cholesterol ester transfer protein gene on the long arm of chromosome 16 in patients with atherosclerotic abdominal aortic aneurysm, patients with stenosing aortic atherosclerosis and healthy control subjects. The protein polymorphism of haptoglobin results from variant alpha-chains, alpha 1 and alpha 2, the phenotype nomenclature describing the two alpha-chains. We have also investigated whether the different haptoglobin phenotypes influence the degradation of aortic connective tissue. 2. The frequency of the haptoglobin alpha 1 allele was increased in patients with aneurysms compared with healthy control subjects (0.51 versus 0.35, P less than 0.05). Patients homozygous for the alpha 2 allele had the highest mean age at aneurysm resection. The frequency of a rare polymorphism at the cholesterol ester transfer protein locus was also increased in aneurysm patients (0.15 versus 0.05 in control subjects, P less than 0.01). These two genetic markers appear to act independently. Haptoglobins containing an alpha 1-chain accelerated two- to four-fold the degradation by elastases of aortic elastin in vitro. 3. Genetic variation in the haptoglobin and cholesterol ester transfer protein genes appears to influence dilatation of the abdominal aorta. Variation at the haptoglobin locus could have a direct effect on the degradation of elastin in atherosclerotic aorta, whereas variation at the cholesterol ester transfer protein locus could affect lipid metabolism and promote atherosclerosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Transluminal dilatation of innominate stenosis in aortic arch syndrome

Successful percutaneous transluminal dilatation of an anonyma stenosis is reported. The patient was a 40 year-old male with the aortic arch syndrome. Five years before an occlusion of the central carotid artery, as well as anonyma and left subclavian stenoses were treated by means of vascular grafts. On recurrence of the neurological symptoms, reocclusion of the right graft to the anonyma artery and subtotal stenosis of the left carotid bifurcation was noted. The anonyma stenosis was dilated by means of PTD. Haemodynamic success was demonstrated by Doppler sonography.     

主动脉瘤切除及升主动脉和主动脉弓人造血管置换手术的配合及护理

目的探讨主动脉瘤切除及升主动脉和主动脉弓置换术的手术配合及护理.方法总结3例在体外循环下行升主动脉瘤和弓部主动脉瘤切除及升主动脉和主动脉弓人造血管置换手术的台上配合及巡回护理的效果.结果本组病例均顺利完成手术,术中洗手及巡回护士配合达预期的效果,病人术后安返监护室.结论手术室护士术前必须充分了解病人的病情,熟识手术操作过程,做好术前各种准备,术中才能配合默契,有利于手术的顺利进行.     

颈动脉旁路辅助主动脉弓部病变腔内修复术的手术配合

总结颈动脉旁路辅助主动脉弓部病变腔内修复术的手术配合重点。准备好手术中需要的物品和器械;巡回护士加强术中患者生命体征的观察;器械护士做好手术中的配合,特别是当降主动脉近端或主动脉弓部主动脉瘤或动脉夹层接近或累及弓上一条或多条血管时,做好左右颈总动脉旁路外科手术与腔内修复术相结合的手术配合。     

主动脉瘤切除及升主动脉和主动脉弓人造血管置换手术的配合及护理

目的 探讨主动脉瘤切除及升主动脉和主动脉弓置换术的手术配合及护理。方法 总结3例在体外循环下行升主动脉瘤和弓部主动脉瘤切除及升主动脉和主动脉弓人造血管置换手术的台上配合及巡回护理的效果。结果 本组病例均顺利完成手术，术中洗手及巡回护士配合达预期的效果，病人术后安返监护室。结论 手术室护士术前必须充分了解病人的病情，熟识手术操作过程，做好术前各种准备，术中才能配合默契，有利于手术的顺利进行。     

Endoluminal repair of distal aortic arch aneurysms causing aorto-vocal syndrome

Purpose: We have evaluated the efficacy of endovascular repair of distal aortic arch aneurysms (DAAA) causing recurrent laryngeal nerve palsy. Material and methods: Eight patients (five male and three female) with median age of 72 years (range: 59–80) presented with left recurrent laryngeal nerve palsy associated with DAAA. All patients were considered unfit for open surgery. The median aneurysm size was 5.9 cm (range: 5–7.3). Thirteen stents were deployed: eight Gore, four Endofit and one Talent. Epidural anaesthesia was used in all patients. The left subclavian artery was covered in all and the left common carotid in three who had a preliminary right to left carotid–carotid bypass. Routine follow‐up (FU) was with computed tomography (CT) at 3–6 months and yearly thereafter. Results: Exclusion of the aneurysm sac was achieved in all patients. Thirty‐day mortality was 0%, with no paraplegia or stroke. Early complications included: rupture of the external iliac artery (one) and common femoral artery thrombectomy (one). One patient died of unknown cause at 17 months. The mean FU in the remaining seven patients was 21 months (range: 6–51). Aneurysm size decreased in five, was unchanged in one and increased in one. Three patients had improvement in voice quality postoperatively. One patient had a recurrent type 1 endoleak which was restented twice. No late deaths have occurred. Conclusion: Though technically the procedures involved were more complicated, endovascular repair of DAAA causing aorto‐vocal syndrome is safe and offers a realistic alternative to open surgery. Hoarseness of the voice can improve postoperatively and is associated with reduction in aortic sac diameter.