头臂血管成形术治疗成人主动脉弓及头臂血管发育不良

目的:总结并探索主动脉弓及头臂血管发育不良的手术治疗方式。方法:2009年2月至2011年12月,北京安贞医院大血管中心对4例主动脉弓及头臂血管发育不良的患者行主动脉弓成形术治疗,手术均采用右侧腋动脉和股动脉及右心房插管建立体外循环,在深低温停循环选择性脑灌注下进行,沿主动脉弓长轴靠近头臂血管根部横行切开主动脉弓,切口两端达正常段,再纵形剖开3枝头臂血管开口及近段(狭窄段)前壁,分别将无名动脉和左颈总动脉、左颈总动脉和左锁骨下动脉相邻血管壁连续缝合在一起,将3枝血管融合成一个共同腔的后壁,再用人工血管片作为前壁补片加宽主动脉弓及头臂血管共同腔,以完成对发育不良的主动脉弓和头臂血管的手术矫治。结果:患者术后均恢复顺利,复查结果显示主动脉弓及头臂血管形态良好,上下肢压差<20 mmHg(1 mmHg=0.133 kPa)。结论:将发育不良的头臂血管近段剖开融合成一个共同腔,再用人工血管片加宽可理想地矫正主动脉弓及头臂血管发育不良。     

三分支主动脉弓覆膜支架在Stanford A型主动脉夹层手术中的应用

目的总结三分支主动脉弓覆膜支架治疗StanfordA型主动脉夹层的临床经验。方法正中开胸,股动脉、右房插管转流,不游离主动脉弓及头臂血管,鼻温18℃,停循环,于无名动脉近端2cm部分切开升主动脉,直视下置入三分支主动脉弓覆膜支架于主动脉弓和近端降主动脉及三支头臂血管内,行左颈总动脉、右无名动脉气囊导管选择性脑灌注,吻合支架血管近端与升主动脉人工血管,恢复全身灌注。观察并发症及疗效。出院时和3个月复查CT血管造影（CTA）。结果本组无死亡,手术过程顺利,脑及右上肢停循环6-7min,左上肢及降主动脉停循环25-27min,心肌血运阻断时间81-96min,体外循环时间145-190min。术后64排CTA示1例左锁骨下动脉支架外左侧少量血流流向降主动脉,3个月时消失;术后短暂、轻度精神症状1例;二次开胸止血1例,与血管吻合无关。术后1周及3个月CTA示支架血管位置满意,各头臂血管血流通畅。结论三分支主动脉弓覆膜支架术中置人治疗A型主动脉夹层具有操作简单、并发症少、临床效果好等优点,值得临床推广应用。     

主动脉右弓右降合并Stanford B型主动脉夹层的外科治疗

目的:总结主动脉右弓右降合并Stanford B型主动脉夹层的外科治疗经验。方法:3例右位主动脉弓、右位降主动脉、迷走左锁骨下动脉(迷走左锁骨下动脉型)合并Stanford B型主动脉夹层的患者经胸部右后外切口行胸降主动脉置换术、迷走左锁骨下动脉缝扎术。结果:3例患者均痊愈出院,住院天数7～10 d,无左上肢缺血症状及神经系统并发症。结论:主动脉右弓右降合并Stanford B型主动脉夹层患者行胸降主动脉置换术方法可行,临床疗效满意,术中判断后行迷走左锁骨下动脉缝扎术,可简化手术方式,但应避免术后左上肢缺血坏死。     

Isolation of the left common carotid or left innominate artery

Isolation of the left common carotid or left innominate artery from the aortic arch is rare. A six week malformed infant with a right aortic arch had isolation of a left innominate artery and connection to the pulmonary artery by a left ductus arteriosus. A right ductus arteriosus had been ligated. Another infant with a right aortic arch and ostium primum atrial septal defect was shown to have an aberrant left subclavian artery arising from the lower descending aorta. The left common carotid artery filled retrogradely and drained into the pulmonary artery by a left ductus arteriosus. This abnormality has not been reported before.     

Isolation of the left common carotid or left innominate artery.

Isolation of the left common carotid or left innominate artery from the aortic arch is rare. A six week malformed infant with a right aortic arch had isolation of a left innominate artery and connection to the pulmonary artery by a left ductus arteriosus. A right ductus arteriosus had been ligated. Another infant with a right aortic arch and ostium primum atrial septal defect was shown to have an aberrant left subclavian artery arising from the lower descending aorta. The left common carotid artery filled retrogradely and drained into the pulmonary artery by a left ductus arteriosus. This abnormality has not been reported before.     

“象鼻”支架术治疗Stanford B型主动脉夹层胸主动脉腔内修复术后Ⅰ型内漏

目的:回顾应用支架"象鼻"术治疗Stanford B型主动脉夹层胸主动脉腔内修复术(TEVAR)术后Ⅰ型内漏的临床效果。方法:2009年3月至2013年1月,首都医科大学附属北京安贞医院,收治的Stanford B型主动脉夹层TEVAR术后Ⅰ型内漏12例患者进行回顾性分析。12例患者均为男性,平均年龄(50.2±6.2)岁,平均身高(171.92±4.98)cm,平均体质量(77.50±8.43)kg,所有患者均无相关家族遗传病史,均有高血压病史,与第一次TEVAR术间隔时间平均34.4个月。支架"象鼻"术均在全麻体外循环下进行。如漏口暴露清楚,可缝闭漏口;如置入支架裸区妨碍象鼻支架缝合,可剪除部分裸露部分金属支架或将置入支架取出;如漏口累及左锁骨下动脉开口,可将左锁骨下动脉近端缝闭,截断左锁骨下动脉,其远端与左颈总动脉行端侧吻合,建立左颈总动脉至左锁骨下动脉转流或8mm人工血管行升主动脉至左腋动脉或左锁骨下动脉转流。于之前置入的支架内置入26~30mm Microport术中支架血管,覆盖内漏破口。术后随访6~48个月,平均6.53个月。结果:12例支架"象鼻"术均为择期手术,其中7例患者漏口位置累及左锁骨下动脉,4例剪除置入支架金属裸区;1例将置入支架取出;3例术中支架血管近端吻合于左锁骨下动脉以远,8例吻合于左颈总动脉与左锁骨下动脉之间;4例同期行左颈总动脉至左锁骨下动脉转流术;2例行升主动脉-左锁骨下动脉转流术;2例行升主动脉-左腋动脉转流术;1例患者因合并二尖瓣关闭不全同期行二尖瓣置换术;1例合并迷走右锁骨下动脉的患者同期行升主动脉-右腋动脉转流术。12例患者手术时间为平均(5.92±1.14)小时,平均住院时间为(21.92±9.14)天,2例患者术后出现围术期并发症,其中1例胸骨哆开,行再次胸骨固定痊愈;1例术前肾功能不全,术后出现急性肾衰竭,经透析治疗后肾功能恢复。本组患者均顺利出院。所有患者术后内漏均消失,术后随访6~48个月,平均6.53个月,均无复发。在术后随访期间,3例患者支架远端病变需再次处理,1例患者术后7个月出现支架感染、咯血、死亡。结论:应用支架"象鼻"术治疗Stanford B型主动脉夹层TEVAR术后Ⅰ型内漏,有较好的临床疗效,但远期效果仍需进一步观察。     

Repair of right carotid artery pseudoaneurysm in a patient with hostile aortic arch through left ventricular approach

We describe the case of an 81-year-old male who presented with a rapidly expanding neck hematoma from a common carotid artery pseudoaneurysm. Percutaneous repair using the right femoral artery approach was unsuccessful due to a hostile aortic arch. Using a small left thoracotomy and antegrade left ventricular access to the ascending aorta, a covered stent was successfully delivered at the site of the pseudoaneurysm. Our case provides proof-of-principle that complex carotid interventions can be performed expediently through a left ventricular approach in patients with hostile aortic arch.     

Carotid stenting in the bovine arch.

We report our experience in stent-supported angioplasty of the left internal carotid artery in patients with anomalous origin of the left common carotid, the so-called bovine arch, in which the right brachiocephalic and left carotid share a common trunk from the aortic arch. The occurrence of the anatomic variant is discussed, and techniques of femoral, brachial, and radial approaches are described.     

Subaortic left innominate vein: radiologic findings and consideration of embryogenesis

To propose a hypothesis about the embryogenesis of the subaortic left innominate vein, the authors reviewed the radiologic features of 14 patients diagnosed with subaortic left innominate vein made by computed tomography or magnetic resonance imaging scan. The authors retrospectively analyzed the level of the aortic arch, associated aortic arch anomalies, and the presence or absence of obliteration of the prevascular space. A high aortic arch was seen in 10 patients, five with a cervical, two with a right and, one with a double aortic arch. The prevascular space was occupied by the aortic arch, the great arteries, or both in all 10 patients with a high arch. In the remaining four patients with a normal aortic arch, the prevascular space was preserved, but abnormal elongation of the aortic segment between the left common carotid artery and the left subclavian artery was seen in three. The authors postulate that precardinal anastomosis can develop in any pathway where there is the available space. In the presence of abnormal elongation of the aortic arch and resultant widening of the subaortic space, the chance of the development of a subaortic left innominate vein increases.     

Aortopulmonary Artery Fistula: Ruptured Aneurysm of the Distal Aortic Arch into the Pulmonary Artery

Aortopulmonary artery fistula is uncommon, but the clinical outcome is often lethal. A 76‐year‐old man with a history of acute thoracic aortic dissection 6 years previously was admitted with dyspnea. A chest x‐ray showed pleural effusion and pulmonary congestion. Transthoracic echocardiography revealed preserved systolic function, but continuous and abnormal flow from the distal aortic arch into the pulmonary artery (PA). Transesophageal echocardiography (TEE) in the Doppler color‐flow mode demonstrated a left‐to‐right shunt between a large distal aortic arch aneurysm and the left PA via an aortopulmonary fistula and a pressure gradient across the shunt of 56 mmHg. Contrast‐enhanced computed tomography showed that the aneurysm compressed the PA. Aortography also revealed a large distal aortic arch aneurysm and almost simultaneous contrast enhancement of the aorta and the PA. Right‐heart catheterization showed a significant increase in oxygen saturation between the right ventricle and the PA. A left‐to‐right shunt due to a distal aortic arch aneurysm rupturing into the left PA was diagnosed based on these findings. TEE was very helpful in confirming the presence and precise location of the fistula.     

微创手术致主动脉弓狭窄在小鼠心力衰竭模型制作中的应用

目的观察微创手术致主动脉弓狭窄在小鼠心力衰竭（简称心衰）模型制作中的应用效果。方法将30只小鼠随机分为假手术组6只、缩窄组24只,缩窄组经颈部切口行微创手术结扎主动脉弓狭窄手术,假手术组除不结~kgt,其他同缩窄组;术后缩窄组行左右侧颈总动脉及心脏B超检查评价模型。结果缩窄组术后死亡12只,假手术组术后无死亡。随着手术时间的延长,缩窄组右侧颈总动脉内径逐渐增大,左侧颈总动脉内径逐渐缩小,术后相同时点右侧颈总动脉流速、内径均大于左侧颈总动脉（P均〈0．05）;左心室射血分数、左心室短缩分数逐渐降低,舒张期的室间隔厚度、左心室后壁厚度、左心室校正容量和质量逐渐增加,P均〈0．05。结论微创手术致主动脉弓狭窄可成功制备小鼠心衰模型。     

Left common carotid artery arising from the pulmonary artery in a patient with DiGeorge syndrome.

A female infant, born at 33 weeks' gestation with tetralogy of Fallot, died of severe perinatal asphyxia 6 hours after birth. Necropsy disclosed two associated vascular anomalies: a right aortic arch with a left common carotid artery arising from the pulmonary artery (isolated left common carotid artery) and an aberrant left subclavian artery arising from the descending aorta. Agenesis of the thymus and parathyroid gland was also found, suggesting that the child also had DiGeorge syndrome. Origin of the left common carotid artery from the pulmonary artery is exceedingly rare. When planning surgical treatment it is important to be aware of the possibility of this anomaly occurring in association with congenital heart disease, particularly in the presence of tetralogy of Fallot, right sided aortic arch, or DiGeorge syndrome.     

Cervical origin of the right subclavian artery in aortic arch interruption: pathogenesis and significance

In 14 of 21 infant hearts (66%) with aortic arch interruption between the left common carotid and left subclavian arteries (type B of Celoria and Patton), the right subclavian artery (SA) arose anomalously. In 9 (43%) it arose from the descending aorta and in 1 heart from the right pulmonary artery (5%). In 4 hearts (19%), it arose high in the neck from the right common carotid artery as a trifurcation with the internal and external carotid arteries, an anomaly not previously reported. In these latter cases, the SA descended down the neck to enter the right arm, with the right recurrent laryngeal nerve coursing around its take-off. Anomalous origin of the right SA is common in type B aortic arch interruption, and we believe this to be the result of a strong tendency for both fourth aortic arches to disappear early in development. If involution occurs in embryos of less than 14 mm crown-rump length, before the right ductus caroticus and dorsal segment of the right sixth arch have become attenuated, 3 alternate routes are available to the embryo to form a right SA.     

Arteria lusoria: Developmental anatomy, clinical, radiological and surgical aspects

The left aortic arch with an aberrant right subclavian artery, or arteria lusoria, is the most common aortic arch anomaly, occuring in 0.5-2.5% of individuals. Four vessels arise sequentially from the aortic arch: the right common carotid artery, the left common carotid artery, the left subclavian artery and the aberrant right subclavian artery, which crosses upwards and to the right in the posterior mediastinum. It results from a disruption in the complex remodelling of the paired branchial arches, typically of the right dorsal aorta distal to the sixth cervical intersegmental artery. The diagnosis and differentiation of arch anomalies is based on findings at chest radiography in association with those at esophagography. It is usually asymptomatic. When symptomatic, it produces dysphagia lusoria or dyspnea and chronic coughing. Treatment is indicated for symptomatic relief of dysphagia lusoria and for prevention of complications due to aneurysmal dilatation.     

Interventional treatment for acute cerebral infarction with large vessel occlusion combined with aortic arch interruption: A case report

Rationale:Aortic arch interruption is a type of congenital vascular malformation that is often observed in childhood. Most children die of congestive heart failure due to rapid deterioration. Children can only survive to adulthood if they have extremely rich collateral circulation. Cases of acute cerebral infarction with large vessel occlusion receiving interventional treatment in adult patients with interrupted aortic arch have not been reported.Patient concerns:A 55-year-old man with a history of atrial fibrillation and smoking but without a family history of stroke was admitted to our hospital with a 5-hour history of left limb weakness and speech difficulties.Diagnoses:Emergency brain computed tomography showed a large cerebral infarction in the right frontal temporal parietal lobe. He was suspected to have aortic arch interruption in the early stage of endovascular interventional therapy through the femoral artery approach, and was converted to the transradial artery pathway. The aortic arch was disconnected, and the right internal carotid artery was occluded.Interventions:Considering the possibility of cardiogenic embolism, a middle catheter was used for thrombus aspiration of the right internal carotid artery. After removal of the dark red thrombus was removed, the right internal carotid artery was successfully recanalized.Outcomes:The patient recovered well after the operation. However, the patient and his family refused further treatment for aortic arch interruption. The modified Rankin Scale score was 0 at 3 months and 1 year of follow-up which meant that he recovered quite well.Lessons:Adult patients with acute cerebral infarction with large vessel occlusion are rarely complicated with aortic arch interruption, and emergency thrombectomy via the radial artery approach is feasible.     

Hypoplastic right retro-oesophageal aortic arch: similarities to interrupted aortic arch.

At echocardiography a dysmorphic neonate was found to have a hypoplastic mitral valve, left ventricle, and ascending aorta with interruption of the aortic arch between the left common carotid and the left subclavian arteries--the left subclavian artery arose from a normal sized left descending aorta. Cardiac catheterisation and subsequent necropsy confirmed this arrangement but also showed a tortuous right retro-oesophageal aortic arch. This arch was severely hypoplastic distal to the right subclavian artery. These cardiovascular anomalies occurred in the child of a family in which other members showed the velo-cardio-facial syndrome, a condition known to be associated with right aortic arch. This aortic arch arrangement may be impossible to distinguish from simple aortic interruption by echocardiography alone.     

Hypoplastic right retro-oesophageal aortic arch: similarities to interrupted aortic arch

At echocardiography a dysmorphic neonate was found to have a hypoplastic mitral valve, left ventricle, and ascending aorta with interruption of the aortic arch between the left common carotid and the left subclavian arteries--the left subclavian artery arose from a normal sized left descending aorta. Cardiac catheterisation and subsequent necropsy confirmed this arrangement but also showed a tortuous right retro-oesophageal aortic arch. This arch was severely hypoplastic distal to the right subclavian artery. These cardiovascular anomalies occurred in the child of a family in which other members showed the velo-cardio-facial syndrome, a condition known to be associated with right aortic arch. This aortic arch arrangement may be impossible to distinguish from simple aortic interruption by echocardiography alone.     

Unusual vertebral artery origins: examples and related pathology.

Anomalies of the vertebral arteries are uncommon, but important to recognize in the diagnosis and catheter based evaluation and treatment of patients suffering cerebrovascular disease. This article illustrates our experience with such anomalies. These include the vertebral artery arising as the fourth and most distal branch of the aortic arch, as a right subclavian artery branch arising distal to the right thyrocervical trunk, as a right common carotid artery branch in a patient with an aberrant right subclavian artery, and a case of left vertebral artery proximal duplication, with both aortic and left subclavian vertebral arteries present in the same patient; the latter join to form a single distal cervical vertebral artery.     

Unusual complication of aortic dissections: intimo–intimal intussusception

Angiography with a pre-diagnosis of acute coronary syndrome was performed in a 76-year-old female patient presenting to another hospital with symptoms of chest pain and syncope. Upon determination of type III aortic dissection, the patient was referred to our clinic. On CT angiography, the ascending aortic diameter was 57 mm and no dissection flap was observed. There was a filling defect suggestive of intimo–intimal intussusception at the level of the aortic arch, occlusion of the left arteria carotid communis, and a double-channel aorta extending from the left subclavian artery to the iliac artery. On transoesophageal echocardiography, the ascending aorta was seen to be larger than normal and no dissection flap was observed. There were findings suggestive of haematoma and intimo–intimal intussusception at the proximal part of the aortic arch. The dissection flap causing occlusion in the vascular structures was resected. Supracoronary graft replacement of the ascending aorta was performed. Transoesophageal echocardiography is an invasive investigative method with high sensitivity and specificity for the diagnosis of intimo–intimal intussusception.     

Transesophageal and transpharyngeal ultrasound demonstration of reversed diastolic flow in aortic arch branches and neck vessels in severe aortic regurgitation

In the current study, we describe an adult patient with torrential aortic regurgitation due to an aortic dissection flap interfering with aortic cusp motion, in whom a transesophageal echocardiogram with the probe positioned in the upper esophagus and transpharyngeal ultrasound examination demonstrated prominent reversed flow throughout diastole in the left subclavian, left vertebral, left common carotid, and left internal carotid arteries. Another unique finding was the demonstration of aortic valve leaflets held in the fully opened position in diastole by the dissection flap as it prolapsed into the left ventricular outflow tract, dramatically documenting the mechanism of torrential aortic regurgitation in this patient.