主动脉夹层TEVAR术后远端破口的临床分型及手术时机的选择

目的 探讨主动脉夹层TEVAR术后远端破口的治疗方法.方法 对新疆维吾尔自治区人民医院血管外科2006年1月-2012年4月168例行TEVAR的Stamford B型主动脉夹层患者的病例资料进行同顾性分析,根据远端破口位置的不同将其分为4型:Ⅰ型:破口位于支架尾部;Ⅱ型:破口位于胸腹主动脉,距离内脏动脉较近或累及内脏动脉;Ⅲ型:破口位于肾下腹主动脉,破口未累及内脏动脉;Ⅳ型:破口位于髂动脉.据此分型标准,对主动脉夹层TEVAR术后发生远端破口的82例患者制定相应的治疗策略并决定手术时机.结果 有82例患者支架远端仍有破口,临床分型为Ⅰ型:12例出现支架尾部破口,均行支架远端破口腔内隔绝术;Ⅱ型:47例破口位于腹主动脉并累计内脏动脉,经随访,其中4例在随访中发现假腔持续扩大或伴有症状,行“杂交”手术,即先行内脏动脉重建(髂动脉-双肾动脉,髂动脉-肠系膜上动脉,髂动脉-腹腔干人工血管搭桥术),二期行胸腹主动脉腔内隔绝术.43例患者随访发现假腔无扩大,目前继续随访.Ⅲ型:13例破口位于肾下腹主动脉,均行腔内隔绝术.Ⅳ型:10例破口位于髂动脉,均行腔内隔绝术.术后围手术期无死亡.82例患者获得随访,随访时间10 ～36个月,平均随访时间(25.6±8.4)个月,在随访过程中未发现并发症.结论 对于TEVAR术后远端破口,应根据个体情况,结合临床分型选择适宜的手术时机和手术方式,从而达到满意的治疗效果.     

Stanford B型主动脉夹层远端破口的初步临床探讨

目的 探索性提出Stanford B型主动脉夹层远端破口的腔内修复原则.方法 新疆维吾尔自治区人民医院血管外科2013年1月-2015年1月收治的101例Stanford B型主动脉夹层患者,按照不同的处理原则将患者分为两组:(1)序贯处理组57例:采取由近至远的原则腔内修复主动脉破口(如不处理内脏动脉处破口,亦不处理其远端破口);(2)非序贯处理组44例:不按照由近至远的原则腔内修复主动脉破口(不处理累及内脏动脉破口,其余远端破口行腔内修复).分别对两组患者术后腹腔干处主动脉径直径增长率、不适主诉发病率、假腔血栓化发病率进行统计分析.结果 两组患者术后腹腔干处主动脉直径增长率有明显差异(P＜0.05),序贯组低于非序贯组;不适主诉发病率及假腔血栓化比例均可见明显差异(P＜0.05),序贯组优于非序贯组.结论 经过初步临床探讨,我们得出在处理Stanford B型主动脉夹层远端破口时,序贯处理优于非序贯处理.     

Stanford B型主动脉夹层远端破口处理原则的对比研究

目的 探讨Stanford B型主动脉夹层远端破口的处理原则.方法 按照不同的处理原则将Stanford B型主动脉夹层合并远端破口的患者分为两组：原则处理组：采取由近至远的原则,腔内修复远端破口,如不处理内脏动脉处破口,则也不处理其远侧破口;非原则处理组：不处理累及内脏动脉的破口,其余远端破口行腔内修复.分别对其术后不适主诉（胸背部、腰背部疼痛）发生情况、术后支架远端再破口发生情况及假腔变化情况进行分析.结果 共纳入符合标准的患者53例,其中原则处理组37例,非原则处理组16例,两组术后不适主诉发生情况及术后支架远端再破口发生情况差异无明显统计学意义（P＞0.05）,两组术后假腔变化情况差异有统计学意义（P＜0.05）.结论 原则处理组的患者预后优于非原则处理组,对于Stanford B型主动脉夹层远端多破口应按照由近至远的顺序行腔内修复,如不处理内脏动脉处破口,则也应不处理其远侧破口.     

腔内技术二期隔绝Stanford B型主动脉夹层远端破口并重建腹主动脉内脏分支

目的观察腔内技术二期隔绝Stanford B型主动脉夹层(AD)远端破口并重建腹主动脉内脏分支的效果。方法回顾性分析12例接受体外预开窗技术二期手术隔绝Stanford B型AD远端破口并重建内脏分支患者资料,记录手术成功率及术后并发症,以主动脉CT血管造影(CTA)随访评估疗效。结果12例手术均成功,技术成功率100%。术后2例股动脉穿刺点血肿,3例肺部感染,均经保守治疗后好转。随访1~23个月,中位随访时间15个月,未见脑梗死、心肌梗死、截瘫、脏器缺血等严重并发症及死亡;复查主动脉CTA示AD破口隔绝良好,假腔内血栓形成,无内漏、新发破口及分支支架闭塞等。结论腔内技术可有效隔绝Stanford B型AD远端破口并重建腹主动脉内脏分支。     

腔内修复术治疗多破口Stanford B型胸主动脉夹层的临床研究

目的 分析多破口Stanford B型胸主动脉夹层的临床特征,探讨胸主动脉腔内修复术处理该病的临床方式.方法 回顾性分析2011年2月-2015年5月因多破口(≥2个破口)Stanford B型胸主动脉夹层在广州军区武汉总医院心胸外科接收TEVAR治疗患者的病例资料,除近心端第一破口外,使用外科方式处理远端夹层破口为处理组,否则为非处理组.比较两组术后6个月内胸背疼痛发病率、远端夹层进展情况、假腔变化情况、远端破口获益情况.结果 检索出符合条件的病例67例,所有腔内修复术均获成功,无严重并发症发生病例,术后6个月内无死亡病例.处理组7例,非处理组60例.TEVAR后两组胸背疼痛发病率、远端夹层进展发病率差异无统计学意义(P＞0.05),处理组夹层假腔较非处理组明显变小(差异有统计学意义,P＜0.05),非处理组19例患者通过夹层远端破口的血流供应腹腔内脏动脉.结论 TEVAR是治疗多破口Stanford B型胸主动脉夹层有效的手术方式,远端破口应根据Stanford B型胸主动脉夹层特点进行个性化处理或尽量不处理.     

Gore C-TAG分段释放联合潜望镜技术处理B型主动脉夹层远端破口

目的 探讨胸主动脉覆膜支架分段释放技术联合"潜望镜"技术在Stanford B型主动脉夹层腔内修复术后远端破口处理中的临床应用价值.方法 回顾性分析2019～2020年5例Stanford B型主动脉夹层腔内修复术后胸主动脉远端假腔扩张患者的临床资料.结果 5例患者均为男性.主动脉CTA影像资料显示内脏区主动脉存在夹层...     

原发逆行性Stanford A型夹层外科治疗分析

Stanford分型是临床应用较为广泛的主动脉夹层分型方法之一.只要夹层累及升主动脉即为Stanford A型主动脉夹层;如果原发破口位于降主动脉而夹层逆向撕裂累及升主动脉,即原发逆行性Stanford A型夹层(primary retrogmde type A thoracic aortic dissection,PRTAD). 2008年3月至2009年3月我们共收治了6例PRTAD患者,现将治疗经验报告如下.     

Stanford B型主动脉夹层远端破口的处理

胸主动脉腔内修复(Thoracic endovascular aneurysm repair,TEVAR)降低了Stanford B型主动脉夹层患者围手术期病死率,已成为一线治疗方案,但术后远端破口的问题,往往制约了患者远期生存率[1].尽管TEVAR一期封堵了主动脉第一破口,但IRAD注册研究TEVAR术后主动脉扩张发病率为62.7％[2].TEVAR最初目的是防止夹层破裂和内脏及肢体缺血,临床终点由TEVAR后主动脉重塑所决定,因为远端破口直接影响主动脉重塑和破裂事件的发生,所以远端破口是TEVAR术后需要关注的问题[3].本文旨在探讨Stanford B型主动脉夹层远端破口的处理方法,以远端破口处理的必要性、远端破口的整体解决方案、远端破口的局部解决方案3个方向为论点,结合本中心研究和既往临床资料分别论述.     

孕产妇合并主动脉夹层的麻醉管理

正主动脉夹层在临床上一般按Stanford分型分为A型与B型夹层。A型夹层累及升主动脉,主要以手术治疗为主;B型夹层主要累及左锁骨下动脉以远胸腹主动脉,以主动脉腔内覆膜支架介入治疗为主。孕产妇主动脉夹层的发生几率极低,如不及时诊断,恰当处理,极易发生夹层破裂并猝死。近年来我院为10例妊娠合并主动脉夹层的孕产妇实施了大血管手术和/或产科手术,现将麻醉处理报道如下。资料与方法     

Stanford B型主动脉夹层胸主动脉腔内修复术术后内脏动脉血供改善情况分析

目的探讨Stanford B型主动脉夹层患者覆膜支架腔内修复术后受累内脏动脉血供改善情况。方法回顾性分析绵阳市中心医院2013年1月至2014年3月35例Stanford B型主动脉夹层患者行胸主动脉腔内修复术(TEVAR)的临床资料,其中男30例、女5例,年龄45~82(62.5±10.0)岁。35例共140支腹部主要内脏动脉(腹腔干、肠系膜上动脉、双肾动脉)中79支血流受影响,其中完全真腔供血但狭窄36支,真假腔供血18支,假腔供血18支,无供血7支。分析腹部主要内脏动脉供血情况的改变情况。结果全组手术均成功,无死亡病例;手术时间97.8(68~147)min,住ICU时间12~34 h,住院时间10~21 d。术后无脑梗塞、急性肾功能衰竭、夹层破裂、支架移位等并发症发生。受累血管血流情况均有不同程度改善。结论 TEVAR治疗Stanford B型主动脉夹层能成功封堵夹层破口,改善腹部主要内脏动脉血供情况,杜绝或有效减少动脉血运减少和内脏缺血并发症发生。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.