国产覆膜支架治疗DeBaKeyⅢ型夹层动脉瘤的疗效分析

目的总结评价国产覆膜支架腔内隔绝术治疗胸主动脉夹层动脉瘤的手术适应证、临床疗效。方法对38例DebaKeyⅢ胸主动脉夹层患者行腔内隔绝术的临床资料进行回顾性分析,术后对所有患者行CT随访,评价其临床改善程度与真假腔的变化。结果37例患者全麻下均成功进行了覆膜支架血管腔内隔绝术,共使用40个血管支架,术中造影显示夹层裂口完全封闭或内漏明显减少。3例术中出现明显的内漏,再置入1枚短支架后内漏消失;1例因置入支架后血压下降,急诊行开胸手术人工血管置换术,15d痊愈出院。其余患者未出现与夹层及手术有关的并发症。术后3～24个月随访,所有患者复查螺旋CT或64排CT,假腔内血栓形成,真腔增大,未发现内漏、瘤体扩大及支架移位。结论应用覆膜支架腔内隔绝术治疗DeBaKeyⅢ型主动脉夹层动脉瘤创伤小、安全有效、成功率高、术后恢复较好,尤为适用于老年高危患者及亚急性或慢性期的患者。     

大动脉覆膜支架置入治疗Debakey Ⅲ型主动脉夹层疗效分析

1991年Parodi等首次使用血管腔内带膜支架置入治疗腹主动脉瘤获得成功。1994年Dake等报道治疗DebakeyⅢ型主动脉夹层。我院自2003年9月应用国产覆膜支架置入治疗DebakeyⅢ型主动脉夹层,现报道如下。1资料与方法2003年9月~2005年3月我院应用国产覆膜支架置入治疗DebakeyⅢ型主动脉夹层9例。均为男性,平均年龄67岁。9例患者合并高血压病,4例合并冠心病,呼吸功能不全1例,心功能(NYHA)Ⅰ级8例,Ⅱ级1例。本组患者所有覆膜支架全部为Aegis微创医疗器械(上海)有限公司产品。直径32~42 mm,长度100 mm。本组全部经多排螺旋CT检查,主动脉夹层破口…     

主动脉全弓置换及支架象鼻手术治疗De Bakey Ⅰ型主动脉夹层(附2例报告)

对2例De Bakey Ⅰ型主动脉夹层患者行主动脉全弓置换及支架象鼻手术.术后患者心功能良好,人造血管通畅.术后4个月彩超和MRI示支架远端主动脉真腔扩张良好,假腔内血栓充填.     

12例胸主动脉瘤的外科治疗

目的报告12例胸主动脉瘤的外科治疗经验。方法对我院自1998年4月至2003年8月完成的12例胸主动脉瘤外科治疗方面的经验进行总结。5例动脉硬化性升主动脉瘤和2例马凡综合征施行Bentall手术,5例夹层动脉瘤行升主动脉置换。结果术后早期死亡1例,死亡率8.3%,死亡原因术后吻合口出血。术后并发症:呼吸衰竭1例,纵隔感染合并胸骨哆开1例,上消化道穿孔1例,均经积极治疗后痊愈。随访8个月～6年(平均2.57年),心功能恢复至Ⅰ级9例,Ⅱ级2例。结论采用不同术式治疗胸主动脉瘤可取得良好效果。手术关键在于处理好主动脉夹层和吻合口的出血以及在冠状动脉重建过程中避免出现冠状动脉扭曲和吻合口漏血以及张力。     

马凡综合征主动脉根部瘤的外科治疗

目的总结马凡综合征主动脉根部瘤的外科治疗经验。方法2002年1月至2006年12月,手术治疗马凡综合征主动脉根部瘤34例,年龄16～54(29.5±4.1)岁。其中合并急性I型主动脉夹层(DeBakey分型)7例,急性Ⅱ型主动脉夹层2例,慢性Ⅱ型主动脉夹层2例。术前心功能分级(NYHA)Ⅱ级17例,Ⅲ级15例,Ⅳ级2例。共行Bentall手术27例,Bentall及右半弓置换1例,Bentall及全弓置换加“象鼻”手术6例,同期行二尖瓣成形术6例,胸骨翻转1例。结果全组术后死亡1例,死亡率2.9%。33例随访1个月至5年,2例接受二次手术,其余恢复良好,心功能I～Ⅱ级,无晚期死亡。结论Bentall手术是治疗马凡综合征主动脉根部瘤的首选方法,合并I型主动脉夹层的病例应行Bentall及全弓置换加支架“象鼻”手术。     

主动脉全弓置换及支架象鼻手术治疗De Bakey I型主动脉夹层（附2例报告）

对2例De Bakey I型主动脉夹层患者行主动脉全弓置换及支架象鼻手术。术后患者心功能良好，人造血管通畅。术后4个月彩超和MRI示支架远端主动脉真腔扩张良好，假腔内血栓充填。     

三分支支架血管在急性A型主动脉夹层全主动脉弓重建术中的应用

目的探讨应用三分支支架血管进行急性A型主动脉夹层全主动脉弓重建的可行性。方法对3例急性A型主动脉夹层需全主动脉弓重建的患者实施术中直视下三分支支架血管置入。当鼻咽温度降至23℃时,停止下半身灌注,于无名动脉近端横断升主动脉,经此切口将三分支支架血管置入主动脉弓和降主动脉真腔内,并将其分支支架血管依次置入左锁骨下动脉、左颈总动脉和无名动脉。将主干支架血管近端与无名动脉近端的升主动脉切口重建后与替换近端升主动脉的人造血管端端吻合。结果3例患者术中顺利地置入三分支支架血管。术后无并发症,均痊愈出院。术后电子束CT检查结果示：主干支架血管及其分支支架血管通畅,三分支支架血管均无扭曲,三分支支架血管置入部位的主动脉夹层假腔闭合。结论应用三分支支架血管直视置入进行急性A型主动脉夹层患者的全主动脉弓重建是可行的。这种方法避免于常规全主动脉弓替换术中的主动脉弓三分支血管吻合和左锁骨下动脉远端较深部位的远端人造血管一降主动脉的吻合,从而简化了全主动脉弓的重建,并提高了手术的安全性。     

手术治疗主动脉瘤33例临床分析

目的总结手术治疗主动脉瘤的经验。方法 33例主动脉瘤患者,7例采用深低温停循环（DHCA）选择性脑灌注技术行升主动脉及全弓替换、支架＂象鼻＂手术;行非体外循环全弓替换术、升主动脉包裹术、Bentall手术同期行深低温停循环半弓替换手术、降主动脉支架置入加室间隔缺损修补术以及经升主动脉插管灌注、DHCA全弓替换加支架＂象鼻＂手术各1例;行短支架人工血管置入术以及经腋动脉和股动脉插管灌注、升主动脉与次全弓人工血管替换术各2例。13例行Bentall手术,4例行部分胸降主动脉替换术。结果早期死亡3例,病死率为9.1%,并发症发生率15.2%,30例患者顺利康复出院。结论 根据病变及分型选择合理手术方式是手术治疗主动脉瘤的关键。     

29例主动脉夹层动脉瘤治疗分析

目的总结29例主动脉夹层动脉瘤外科治疗经验。方法29例患者中,DeBakey分型,Ⅰ型16例,Ⅱ型4例,Ⅲ型9例。21例手术治疗,其中6例行Bentall术,2例行Wheat术,5例行升主动脉置换(同时主动脉瓣成形4例),1例行胸主动脉置换,7例置入支撑型人工血管;8例不接受手术。结果手术死亡2例,其中1例为胸主动脉置换术后并发吻合口出血死亡,1例为支撑型人工血管置入后内漏瘤破裂猝死。非手术8例中,4例死亡,4例转慢性化趋稳定出院。结论对主动脉夹层动脉瘤应积极手术,Ⅰ、Ⅱ型可急诊手术,Ⅲ型可置入支撑型人工血管。早诊断,快速急诊手术是抢救成功的关键。     

胸主动脉置换并血管内支架植入治疗主动脉夹层

目的总结主动脉夹层行人造血管置换同时植入血管内支架的外科经验。方法急性DeBakeyⅠ型主动脉夹层1例,破口在升主动脉,行升主动脉并全弓置换同时,术中于降主动脉置入血管内支架;慢性DeBakeyⅢ型主动脉夹层2例,均为介入无法完成者,破口均在降主动脉起始部、左锁骨下动脉下方,行近段降主动脉置换同时术中于远段降主动脉置入血管内支架。术后2周及3个月复查主动脉螺旋CT,了解胸腹主动脉、人造血管及血管内支架情况。结果所有病人手术成功,体外循环时间98(38～207)min。Ⅰ型夹层阻断升主动脉136min,选择性脑灌注33min,Ⅲ型夹层阻断主动脉23min、下半身停循环时间22～28min。术后恢复顺利,痊愈出院。术后2周及3个月复查CT示人造血管血流通畅,血管内支架无内瘘及移位,支架远端主动脉真腔扩大、假腔明显缩小。结论对于病变广泛、多发破口的复杂主动脉夹层,行近端动脉夹层切除、人造血管置换同时在远端植入血管内支架,是一种安全、有效、经济的手术方法。     

升主动脉瘤合并主动脉瓣关闭不全的外科治疗

目的：回顾性总结自１９９１年１２月至１９９９年５月期间,３３例升主动脉瘤伴主动脉瓣关闭不全外科治疗的经验。方法：３３例升主动脉瘤中,１例为真性动脉瘤。３２例为夹层动脉瘤。夹层动脉瘤按ＤｅＢａｋｅｙ分型法,Ｉ型８例,ＩＩ型２４例,均伴主动脉关闭不全,均行Ｂｅｎｔａｌｌ手术,１０例合并二、三尖瓣关闭不全,做二、三尖瓣整形手术。１例合并冠心病,做内乳动脉与前降支搭桥术,结果：手术死亡率为６．０％（２／３３）,２例分别死于感染性心内膜为和吻合不可控制性渗血,２例有严重脑部并发症,随访时间１～５５个月,远期死亡２例,均系错迷窒息死亡,其余２９例心功能明显改善,眩动脉瘤无复发。结论：（１）升主动脉瘤合并主动脉瓣关闭不全行Ｂｅｎｔａｌｌ手术,采用良好的心肌保护方法,注意吻合技术防止出血,可以取得良好的手术效果。（２）对Ｄ     

Prolapse of the "floppy" aortic valve as a cause of aortic regurgitation. A clinico-morphologic study

A clinico-pathologic study was performed in 25 patients undergoing aortic valve replacement because of regurgitation, caused by myxoid degeneration of the valve leaflets. Associated cardiac anomalies were floppy mitral valve (2 cases), floppy mitral valve and idiopathic hypertrophic subaortic stenosis (1), left atrial myxoma (1), and aortic coarctation at the isthmus (1). Three patients died (2 immediately and 1 on the 30th postoperative day). Pathological studies of the explanted valves showed deformities characterized by redundant thin leaflets which appeared soft and gelatinous. On histologic examination the fibrous layer of the leaflets was seen to be infiltrated by myxomatous tissue. Echocardiography showed the aortic root to be dilated in 13 patients and normal in the others. In those with normal aortic root, the histological examination of aortic wall disclosed minimal cystic medial necrosis in two cases. In contrast, more severe forms of cystic medial necrosis were evident in all patients having a dilated aortic root. Aortic valve replacement was performed in all cases. It was accompanied by a Bentall procedure (1 case), repair of ascending aorta dissection (2), replacement of the ascending aorta (1), mitral valve replacement (2), mitral valve replacement and apico-ascending aorta conduit (1) and excision of a left atrial myxoma (1). Our experience suggests that prolapse of the aortic valve due to floppy leaflets is a common degenerative disease which is generally associated with noninflammatory aortic root degeneration. This, together with aortic root dilatation, contributes to valve insufficiency. Nevertheless, the disease, when isolated (with normal aortic root), is liable in itself to produce aortic regurgitation. The need for early diagnosis is stressed, so as to be able to perform valve replacement.     

Causes of reoperations and their outcomes in patients with the Marfan's syndrome after correction of the ascending aorta aneurysm and aortic insufficiency

Aim of the study was to elucidate causes of repeat operations and their outcomes in patients with the Marfan's syndrome. Between December 1972 and January 2009 60 patients with Marfan's syndrome were operated for aneurysm of the ascending aorta and aortic insufficiency. All patients were subjected to ascending aorta and aortic valve replacement with valve containing conduit. Five of 60 patients (8.3%) were subjected to 7 repeat operations (2 patients were reoperated twice). Causes of repeat interventions were: conduit dysfunction (n=3), abdominal aortic aneurysm (n=3), mitral valve prolapse (n=1). Three patients died: 2 during surgery because of impaired conduit function, one - in 1 year after repeat operation of mitral valve replacement for mitral valve prolapse with pronounced mitral insufficiency. In all cases cause of death was progressive heart failure. As an example a case of a female patient who had been subjected to repetitive surgeries because of malfunctioning conduit is presented in this paper. Main reason for reoperations was the Marfan's syndrome itself. Progression of this disease might continue after operation, alteration of the aortic wall promote dissection in regions not subjected to prosthetics. Application of prostheses especially designed for replacement of the ascending aorta excludes such causes of reoperations and death as disruption of old sutured of two parts conduits.     

升主动脉瘤的外科治疗

目的总结升主动脉瘤的临床诊断和外科治疗经验。方法自2003年3月至2008年11月,20例升主动脉瘤患者中马凡综合征11例、升主动脉瘤伴主动脉瓣关闭不全3例、单纯升主动脉瘤3例、急性夹层动脉瘤伴主动脉瓣关闭不全2例、升主动脉瘤伴主动脉瓣关闭不全并感染性心内膜炎1例。行单纯Bentall手术10例、Bentall手术加右半弓人工血管置换2例、Wheat手术4例、Cabrol手术1例、David手术1例、主动脉瓣置换加主动脉弓置换加象鼻手术1例、主动脉瓣置换术加升主动脉成形术1例。结果全组无手术死亡和术后严重并发症发生。结论早期诊断、精细的手术操作技巧、据病情选择合适的手术方式,是改善升主动脉根部瘤患者预后的关键。     

Images in cardiovascular medicine: prosthetic aortic valve and conduit dehiscence with large periconduit cavity, ascending aortic aneurysm and severe mitral regurgitation

Prosthetic aortic valve and conduit dehiscence with periconduitcavity and ascending aortic aneurysm is an uncommon complicationof aortic root surgery. It is usually recognizable at echocardiographydue to an abnormal position of the prosthetic valve and conduitin relation to the native aortic annulus in conjunction withan abnormal echolucent periconduit space that fills with colorflow. Mitral regurgitation is an unusual complication of thiscondition. We present a patient with severe mitral regurgitation secondaryto prosthetic aortic valve and conduit dehiscence with a largepericonduit cavity and aneurysm of the intervalvular fibrosa.The mechanism of mitral regurgitation is secondary to functionalinvolvement of the anterior mitral valve leaflet and intervalvularfibrosa with anterior mitral leaflet restriction in conjunctionwith mild left ventricular remodeling. Significant mitral regurgitationpersisted post resection of the periconduit cavity and aorticvalve replacement, requiring mitral valve replacement. This case study reports a new mechanism of mitral regurgitationin the setting of prosthetic aortic valve and conduit dehiscence.     

白塞病并发升主动脉瘤及主动脉瓣关闭不全的外科治疗

目的总结白塞病所致升主动脉瘤和主动脉瓣关闭不全的外科治疗效果,探讨相关手术方式和解决方法。方法回顾性分析两例白塞病所致升主动脉瘤和主动脉瓣关闭不全患者的手术治疗,其中1例为外院行主动脉瓣置换后来我院行改良Bentall手术,另1例在我院实施主动脉瓣置换术,主动脉根部夹层动脉瘤成形,二尖瓣、三尖瓣成形术。结果两名患者均痊愈出院。结论白塞病致主动脉瓣关闭不全如单纯行瓣膜置换,术后人工瓣膜脱落的发生率较高,主动脉根部替换手术方式是解决问题的根本方法。     

改良Cabrol分流治疗主动脉夹层手术后出血27例

目的报道采用改良Cabrol分流治疗27例Cabrol手术和Bentall手术主动脉夹层术后出血的经验。方法采用主动脉瘤壁包裹带瓣管道的后壁,加用整块长方形自体心包与瘤袋壁对接缝合,自体心包包裹主动脉远端吻合口和主动脉根部,靠近主动脉根部的自体心包缝合成1cm直径的心包管道与右心耳切口相吻合或采用8mm直径的Gore-tex管道将心包切口与右心耳切口吻合将漏血引入右房进行分流,形成漏血自体回输。结果27例出血顺利停止,止血满意。术后7～10d行心脏血管超声检查见带瓣管道周围无残留液平,分流管道内分流信号消失,分流管道已自行闭合。结论自体心包与瘤袋壁组合而成的改良Cabrol分流,避免了单纯瘤袋壁包裹带瓣管道造成的瘤袋壁的撕裂,同时避免了瘤袋壁内因漏血而造成的过高张力压迫冠状动脉及形成假性动脉瘤的可能,止血顺利满意。     

Composite graft with coronary button reimplantation: Procedure of choice for aortic root replacement

Reconstitution of coronary flow in aortic root replacement has generally been accomplished by (1) the Bentall (inclusion) technique, (2) the Cabrol (graft) technique, or (3) the direct reimplantation of coronary artery buttons (button technique). The inclusion and graft techniques have at times required supplementation by a Cabrol fistula from the peri-graft space to the right atrium for control of bleeding. Our experience over an 8-year period comprises 33 composite graft replacements of the aortic root (24 male, 9 female, ages 16–79). Twenty-seven patients had aneurysm (annuloaortic ectasia), 5 had acute dissection, and 1 had advanced endocarditis. The Bentall technique was used in 7 patients, the graft technique in 7, and the button technique in 19. Five were reoperations and in an additional 5 patients, therapeutic coronary bypass or valve replacement needed to be performed. Hospital mortality was 4/33 (12.1%). Actuarial overall survival 1 year after the operation was 84.8%. Complications related to aortic root replacement occurred only in patients not operated with the button technique and included persistence of the Cabrol fistula requiring reexploration in a patient done by the graft technique, saphenous vein graft stenosis in a patient done by the graft technique, and postoperative bleeding in 3 patients done with the Bentall (2 patients) and the graft (1 patient) technique. In late follow-up, survival free of complications related to the aortic replacement was 94.7% in patients done with the button technique and 57.1% in patients done with the other techniques (p<0.02). This early and late technical experience suggests that the button technique is effective and obviates problems inherent in other procedures (bleeding in Bentall, stenosis in the graft technique, and persistent aortic-to-right atrial fistula with the Cabrol shunt). As no foreign material or saphenous graft is required in the direct button anastomosis, it is expected that the good early results will be durable in the long term. We have adopted the button technique as the procedure of choice for coronary reconstitution in composite graft replacement of the aortic root.     

主动脉夹层动脉瘤的外科治疗

目的 :总结 1992年 6月至 2 0 0 2年 6月对 2 5例主动脉夹层动脉瘤病人的外科治疗经验。方法 :采用Cabrol手术 10例 ,Bentall手术 7例 ,升主动脉与腹主动脉搭桥转流手术 6例 ,升主动脉与双髂总动脉搭桥转流结合动脉内膜开窗手术 1例 ,升主动脉夹层缝闭加主动脉瓣成形术 1例。结果 :2 4例生存 ,1例Bentall手术左冠状动脉吻合口出血而死亡。结论 :主动脉夹层病人 ,手术中当冠状动脉开口直接缝合于人工血管有困难时 ,采用Cabrol手术 ,使吻合口无张力而且对合严密 ,避免了冠状动脉开口周围内膜撕脱和吻合口漏血。对于DeBakeyⅢ型的病人 ,采用升主动脉与腹主动脉或双髂总动脉搭桥转流术结合动脉内膜开窗术 ,治疗效果满意。对于手术中无法止血的主动脉漏血和左心室漏血 ,采用瘤袋或自体心包包裹漏血区 ,然后与右心房进行搭桥吻合 ,将漏血引入右心房而达到止血目的。