Hybrid技术应用于Stanford B型主动脉夹层的近期疗效

目的探讨腔内隔绝术联合血管旁路移植术（Hybird技术）治疗破口位于弓部的StanfordB型主动脉夹层（AD）近期疗效。方法选择武汉亚洲心脏病医院2008年8月至2012年6月收治的StanfordB型AD37例,均采取腔内隔绝术,并在其术前行血管旁路移植术。其中男33例,女4例,年龄36-71（51．84±9．21）岁。主动脉夹层第一破口距左颈总动脉或左锁骨下动脉开口处均小于15mm。27例行右颈总动脉-左颈总动脉旁路移植术,2例行右颈总动脉一右锁骨下动脉旁路移植术,6例行左颈总动脉-左锁骨下动脉移植术,2例行左颈总动脉-左腋动脉移植术（左锁骨下动脉开口及近端均被夹层血肿挤压）。术后立即转人介入导管室行腔内隔绝术。共置入带膜支架42枚（双支架5例,其中4例应用带膜支架加裸金属支架）。结果（1）37例行血管旁路移植术及腔内隔绝术均顺利。术后8—24（17．97±3．88）d出院。其中1例院内死亡,近期死亡1例（随访证实出院后当日死亡,等同于近期）。其余病例均无内漏、截瘫、内脏器官缺血、脑部缺血和左上肢缺血症状,随访30d,均恢复良好。（2）术后11例出现发热,排除感染因素,考虑为腔内隔绝术后综合征,经对症处理后恢复。2例因人工血管吻合口出血再次行吻合术。2例新出现肾功能不全,分析为对比剂肾病,经治疗后恢复。术后有5例仍有胸背痛症状,复查主动脉增强CT无内漏出血,治疗后均好转出院。结论腔内隔绝术联合血管旁路移植术治疗累及主动脉弓的StanfordB型主动脉夹层是一种创伤小、疗效好的治疗方法。     

锁骨下动脉窃血综合征及其外科治疗

１９８０年１２月以来，收治９名锁骨下动脉窃血综合征患者，均以脑缺血及上肢缺血为主要症状。７例做了动脉造影检查，５例行人工血管移植术，１例锁骨下动脉窃血综合征是由颈肋压迫所致，做了颈肋切除术；手术治疗６例，效果良好。在讨论中，作者指出：动脉粥样硬化、大动脉炎为锁骨下动脉窃血综合征的主要病因，颈肋压迫也可为病因之一。人工血管转流术（尤其是腋─腋动脉人工血管转流术）是常用有效的手术方法。     

糖尿病性下肢缺血的外科治疗

目的 探讨糖尿病下肢缺血的外科治疗方法。方法 78例2型糖尿病(T2DM)患者合并下肢动脉缺血的95条肢体进行了外科手术治疗，其中动脉旁路移植术76条下肢，占80％。主要方式为股动脉-腘动脉人工血管旁路移植-单支小腿动脉自体血管旁路移植术(23．2％)和腘动脉-小腿动脉旁路移植术(21．0％)；15例患者16条下肢截肢处理，占16．8％；自体骨髓干细胞移植3例3条患肢，占3．1％。结果 75例91条下肢的移植血管在出院时均保持通畅，通畅率为100％；3例(4条下肢)于术后死亡，围手术期病死率为3．8％，手术成功率为96．2％。术后踝肱指数(ABI)为0．86～1．12，平均0．94。自体骨髓干细胞移植的3例患者，均达到避免截肢或降低截肢平面的目的。出院时足部创面愈合率39．2％。结论 糖尿病性下肢缺血可以通过外科治疗，如下肢远端动脉旁路移植、腔内血管成型术、自体骨髓干细胞移植及适当平面的截肢等方法而获得较好的疗效，外科治疗不仅可以挽救肢体或降低截肢平面，而且可为足部创面的愈合提供较好的营养环境，有利于创面的愈合和提高生活质量。     

下肢远端动脉旁路移植治疗糖尿病下肢缺血

目的探讨治疗糖尿病下肢缺血动脉旁路移植的方法和疗效。方法从2000年7月至2004年7月，应用下肢远端动脉旁路移植手术治疗了82例2型糖尿病病人的96条下肢。主要方式为股动脉-胭动脉人工血管＋小腿动脉自体血管旁路移植术31条（32．3％），胭动脉-小腿动脉旁路移植22条（22．9％），髂动脉支架＋股动脉-胭动脉人工血管＋小腿动脉自体血管旁路移植术12条（12．5％），股动脉-小腿动脉旁路移植10条（10．4％）。结果82例中，3例全麻手术病人（4条下肢）于术后死亡，病死率为3．7％；手术成功率为96．3％，总有效率为93．7％；救肢成功率为98．9％；足部创面愈合率37．3％。76例患者（96．2％）被随访，平均随访时间为13．5个月，移植血管通畅率为92．2％；死亡率为3．9％；总有效率为87．6％；截肢率为4．5％，保肢率为95．5％。93．8％（30／32）下肢创面分别于出院2～10个月（平均6个月）后愈合。结论糖尿病下肢缺血行远端动脉旁路移植手术，可以使大多数患者得到有效治疗，从而挽救肢体或降低截肢平面。     

血管旁路术结合支架植入术治疗高龄主髂动脉硬化闭塞症

主髂动脉硬化闭塞症（又称Lefiche综合症）是腹主动脉下段或双侧髂动脉闭塞造成下肢和盆腔缺血的一个综合征。严重者不仅下肢和盆腔器官功能障碍，还会造成下肢缺血性坏疽。人工血管旁路移植术是治疗Lefiche综合症最理想的方法。而主髂动脉硬化闭塞症其发病多数在高龄病人、合并有多种疾病的基础上，所以单纯人工血管旁路移植术的治疗危险性极大。本文对我院收治的7例高龄主髂动脉硬化闭塞症的病人采介入支架结合血管旁路术治疗取得良好的效果。     

腹主动脉瘤患者的围术期护理

1998年以来，我院共收治腹主动脉瘤患者15例。均行手术切除并人工血管移植术。术后均痊愈出院。现将围术期护理体会介绍如下。临床资料：本组15例中。男11例，女4例；年龄47～78岁。均为肾下腹主动脉瘤。均在全麻或硬膜外麻醉下行经腹腹主动脉瘤切除并人工血管移植术。人工血管材料为聚四氟乙烯，远端直径9mm。近端直径18mm。     

不用放大镜行内乳动脉傍路移植术(连续175例的临床和血管造影分析)

目前有两种建立冠状动脉傍路移植术的手术方法——自体大隐静脉主动脉-冠状动脉傍路移植术和将内乳动脉缝于阻塞远段冠状动脉的内乳动脉移植术。内乳动脉移植术适用于冠状动脉太小而不能接受自体静脉移植以及患静脉曲张或大隐静脉缺失的病人。此外,从内乳动脉移植血管的早期通畅率来看,此法可以考虑作为首选的手术方法。作者等至今已对175例患者施行了不用高倍放大镜的内乳动脉移植术,其中许多病人系在接受一支或多支大隐静脉傍路移植术的同时,并行内乳动脉移植术。     

42例主动脉缩窄的诊断及治疗

目的总结主动脉缩窄的诊断及外科治疗经验。方法对42例主动脉缩窄患者的临床资料作回顾性分析。结果术前证实主动脉缩窄的检查方法分别为主动脉逆行造影13例、CT大血管成像9例、磁共振大血管成像8例、心脏彩超检查12例。治疗采用人工血管补片成形术19例、自体心包补片成形术7例、锁骨下动脉与胸降主动脉旁路移植术5例、左锁骨下动脉与胸降主动脉吻合术3例、胸升—降主动脉旁路移植术2例、缩窄段远近端人工血管旁路移植术4例、缩窄段纵切横缝吻合2例。患者均顺利康复,无严重并发症发生。结论主动脉缩窄的术前诊断需行血管造影、血管成像及心脏超声检查。用个性化手术方案治疗可有效提高本病的治愈率,减少并发症的发生。     

糖尿病下肢缺血外科治疗方法的选择

糖尿病下肢缺血外科治疗有三种方法可供临床选择：第一是下肢动脉旁路移植术，创伤较大，对患者身体素质要求较高；第二是下肢动脉腔内介入治疗，是一种微创的方法，适应证较广；第三是自体干细胞移植，特别适应于体质差和无下肢动脉流出道或流出道差的患者。大动脉（腹主动脉、髂动脉）病变：血管腔内介入或动脉旁路移植或二者同时应用；中等动脉（股动脉、胭动脉）病变：介入或动脉旁路移植或二者同时应用，或者自体干细胞移植；小动脉（小腿动脉或足部动脉）病变：介入或动脉旁路移植或二者同时应用，或者自体干细胞移植。临床上应根据病变部位和患者具体情况选择合适的治疗方法。     

大动脉炎累及冠状动脉的特点和外科治疗

目的:探讨大动脉炎累及冠状动脉的特点和外科治疗.方法:共手术治疗6例冠状动脉开口狭窄或闭塞的患者,其中5例行冠状动脉旁路移植术,1例直接扩大冠状动脉开口;同期行升主动脉-腹主动脉人工血管转流术1例,Bentall主动脉根部替换术2例,Cabrol主动脉根部替换术和二尖瓣替换术1例.结果:无手术死亡.发生围术期心肌梗死和低心排综合征1例.结论:大动脉炎累及冠状动脉的同时,常合并主动脉及其分支的狭窄,也常同时合并升主动脉壁增厚、扩张和(或)主动脉瓣关闭不全等,明显增加了同期手术的难度.由于锁骨下动脉常受累,乳内动脉不适于作为旁路移植材料.     

Endovascular stent-graft repair of acute thoracic aortic dissection--early clinical experiences

BACKGROUND: Standard treatment of acute thoracic aortic dissection type B is the medical therapy used for most patients, according to Stanford. Surgical therapy involves a high mortality rate and is reserved for patients with complicated dissections. We report from four patients with acute thoracic aortic dissection, treated endoluminally by stent-graft implantation. METHODS: Four patients with complicated acute thoracic aortic dissections type B were treated endoluminally by transfemoral stent-graft implantation. Preoperative evaluation was performed with spiral-computed tomography and calibrated aortography. The Talent stent-graft system (Metronic) was used in all patients. RESULTS: The primary entry tear could be sealed successfully and complete thrombosis of the false thoracic aortic lumen was obtained in all cases. In one patient, transposition of the left subclavian artery was performed, in two patients the stent-grafts had to be placed across the origin of the left subclavian artery. No severe intra- or postoperative complications occurred. CONCLUSION: Endoluminal treatment of acute thoracic aortic dissection seems to be a less invasive and effective therapy. Long-term results for this method are necessary.     

下肢动脉硬化性闭塞症多节段复杂病变的杂交手术治疗

目的:探讨下肢动脉硬化闭塞症(ASO)多节段复杂病变的治疗手段及临床疗效。方法:采用杂交手术治疗ASO多节段复杂病变,患者21例,切开股总动脉行髂动脉Fogarty导管取栓术+髂动脉血管腔内成形术(PTA)+支架(STENT)2例,髂动脉PTA+STENT+股总动脉内膜切除术(TEA)4例,髂动脉PTA+STENT+股总动脉TEA+股动脉Fogarty导管取栓术1例,髂动脉PTA+STENT+股总动脉TEA+股腘动脉人造血管旁路移植术1例,髂动脉PTA+STENT+股总动脉TEA+股浅动脉PTA+STENT2例,髂动脉PTA+STENT+股总动脉TEA+膝下动脉PTA2例,髂动脉PTA+STENT+股总动脉TEA+股深动脉扩大成形术2例,股总股浅动脉TEA+股浅动脉PTA+STENT3例,股浅动脉TEA+腘动脉PTA+膝下动脉PTA3例,先行膝下动脉远端流出道的PTA治疗,而后同期进行股腘动脉人造血管移植术1例。结果:手术成功率为100%,未出现严重并发症,踝肱指数(ABI)复查由0.31升至0.66(正常值0.53～0.91)。分别于术后3,6,9个月及12个月进行Ⅰ期临床评估及彩色多普勒超声检查,1例11个月死于急性心肌梗死,2例再狭窄,1年通畅率90%(18/20)。结论:杂交手术治疗多节段复杂病变的下肢动脉硬化闭塞症患者安全、创伤小及通畅率高。     

带膜内支架治疗胸主动脉瘤

目的 探寻治疗胸主动脉瘤的新术式。方法 10例胸主动脉瘤病例，其中7例行单纯带膜血管内支架(stent-graft)治疗，3例夹层破裂(De Bakey I)患者行象鼻手术加带膜血管内支架置入术。结果 7例带膜血管内支架治疗组，5例成功，1例失败，1例术后死亡；3例夹层破裂手术病例均成功，恢复顺利，无并发症。结论带膜血管内支架为治疗胸降主动脉瘤的一种有效可靠方法；象鼻手术结合带膜内支架是治疗De BakeyI型的新方式，可降低手术并发症及术后病死率。     

Therapeutic approach to the unilateral occlusive iliac artery disease. Preliminary results

BACKGROUND: The different therapeutic approaches to unilateral occlusive iliac artery disease are analyzed. METHODS: In the period from September 1999 to September 2001, a total of 43 patients (38 males and 5 females) has been treated for unilateral iliac artery occlusive disease. Thirty-four cases (79%) underwent an endovascular procedure, and the remaining 9 cases (21%) had a surgical intervention. Endovascular techniques included 11 cases of percutaneous transluminal angioplasty (PTA) of common iliac artery (25.6% of whole series), 5 PTA of external iliac artery (11.6%), 8 PTA+stenting of common iliac artery (18.6%) and 10 PTA+stenting of external iliac artery (23.2%). In 9 cases a surgical revascularization was performed: 6 patients underwent a femoro-femoral cross-over bypass (14%); 2 cases were treated with aorto-bifemoral reconstruction (4.7%) and one patient was operated with ilio-femoral graft (2.3 %). RESULTS: The analysis of the follow-up of our series showed, in the group of 34 patients treated with endovascular procedures, successful results were obtained in 79.4% (27 cases); in the 9 patients operated with surgical revascularization the success rate was 88.9% (8 cases ); failure rate was 20.6% for endovascular procedures and 11.1% for surgical interventions. CONCLUSIONS: The conclusion is drawn that endovascular approach (PTA, stenting) is usually the procedure of choice in the treatment of unilateral well localised lesions of the iliac artery. Conventional surgical intervention is effective for revascularizing an extensive involvement of the iliac segment or in case of bilateral disease.     

下肢髂股动脉慢性完全性闭塞病变的腔内治疗经验

目的:总结下肢髂股动脉慢性完全性闭塞病变的介入治疗经验和临床疗效,探讨并发症的防治。方法:回顾性分析143例髂股动脉完全性闭塞的血管造影和介入治疗资料,行经球囊扩张或置入支架治疗。结果:143例患者共165条肢体行介入治疗,158条肢体获成功,成功率96.5%。结论:髂股动脉慢性完全闭塞的球囊扩张和支架植入是一种安全和微创的治疗技术。     

盐酸沙格雷酯对糖尿病伴膝下动脉病变球囊扩张成形术后疗效的影响

目的:观察盐酸沙格雷酯对糖尿病膝下动脉病变,球囊扩张成形术(PTA)后再狭窄的疗效。方法:选择我科2007年4月至2011年8月收治2型糖尿病合并重症下肢缺血患者46例,男性21例,女性25例,年龄49～93岁,平均73.03岁。所有患者均为单纯膝下3支动脉病变。按随机数字表法将入选患者按1∶1的比例随机分为对照组(拜阿斯匹林)和治疗组(拜阿司匹林联合盐酸沙格雷酯),每组23例。PTA术后基础治疗两组一致,治疗组加用盐酸沙格雷酯片(安步乐克,100 mg,每日3次,日本三菱制药),治疗时间为6个月。疗效观察时间为PTA治疗前、治疗后3个月、6个月。观察项目为静息痛缓解、溃疡愈合、术后成功开通血管通畅及再狭窄的情况,将静息痛完全缓解,或者溃疡愈合评为疗效显著。结果:糖尿病性膝下动脉病变PTA术后,治疗组的症状改善及疗效优于对照组。结论:盐酸沙格雷酯对糖尿病膝下血管病变PTA治疗后,再狭窄的预防、缺血症状的改善有较好的作用。     

Percutaneous angioplasty of stenoses of bypass grafts or of bypass graft anastomotic sites

Forty patients who had stenoses of coronary artery bypass grafts or stenoses of the proximal or distal coronary insertion sites were treated with percutaneous transluminal angioplasty (PTA). PTA was successful in 78% of the patients. Mean stenoses were diminished from 86% to 34% in luminal diameter. One patient needed emergency coronary artery bypass grafting. There were no deaths associated with PTA. Follow-up angiography showed continued patency in asymptomatic patients, whereas in all but 1 patient with recurrent symptoms restenosis had developed at the PTA site. In 38% of patients restenosis developed after successful PTA; the highest restenosis rate was after PTA of aorta/graft anastomoses or proximal graft stenoses. In conclusion, PTA is a successful, low risk alternative to repeat coronary artery bypass grafting, although the restenosis rates at some PTA sites are high.     

Prevertebral lesions of the subclavian artery: long-term results of reconstructive surgery and percutaneous angioplasty

Short and long-term results were compared after reconstructive surgery and percutaneous transluminal angioplasty (PTA) of aortic arch trunks and subclavian arteries in 2 groups of patients (10 after dilatation and 12 after surgery). The technique used for treatment was selected as a function of distribution of lesions, their number and their appearance. Gruntzig's method was applied for PTA, while surgery consisted of either reimplantation of subclavian arteries into the main carotid artery or prosthetic by-pass procedures. Immediate and long-term (mean: 14 months) review examinations were by Doppler velocimetry and digital subtraction angiography. Thromboembolic complications secondary to PTA were not observed and there were no cases of recurrence of stenosis in the 10 patients after follow up for 13 months. Complications after surgery were one case of recurrence of stenosis requiring a repeat operation after 20 months, one case of thrombosis of carotid-axillary shunt after 19 months and one case of repeat surgery for lymphorrhea. Long-term results were very good in this series of 12 patients. It is difficult to compare results of the two techniques, patients treated by surgery having multiple lesions requiring combined procedures, and the number of cases treated being too low. However, PTA appears to be effective therapy for localized, non-ulcerated stenosis, and surgery for long or ulcerated stenosis, complete thrombosis and multiple lesions of aortic arch trunks justifying associated procedures.     

主动脉腔内修复术治疗75例DeBakey Ⅲ型主动脉夹层

目的 总结主动脉腔内修复术(EVAR)治疗DeBakey Ⅲ型主动脉夹层适应证的选择、临床疗效以及探讨并发症的防治原则.方法 2002年12月至2007年6月采用TALENT带膜支架施行EVAR治疗75例DeBakeyⅢ型主动脉夹层患者,男65例,女10例,平均年龄54.4±12.6(29～83)岁.1例29岁女性病因考虑为埃-当综合征,2例年青男性分别继发于原发性醛固酮增多症和外伤车祸.全部患者均经螺旋CT或磁共振血管造影检查确诊.全身麻醉下经股动脉置入带膜血管内支架,封堵原发破口,重复造影检查.结果 75例患者共置入81枚带膜支架.其中2例因近端破口接近左锁骨下动脉,先行颈总动脉-锁骨下动脉旁路移植术,再置入支架,支架近段覆盖左锁骨下动脉.25例支架置入后出现明显内漏,20例予球囊扩张,6例置入1枚短支架后内漏消失.支架置入技术成功率为100％.1例埃-当综合征女性患者术中出现股动脉、髂外动脉、髂总动脉广泛血管撕裂,失血性休克,经抢救好转恢复.2例术后早期死于夹层破裂.术后随访1～24个月,2例(包括1例埃-当综合征患者)术后半年发生猝死,1例术后1年复查CT发现支架远端出现破口,经外科手术治疗后恢复良好;其余存活者复查螺旋CT示假腔径缩小并见腔内血栓形成,真腔径增大,无瘤体破裂、内漏及支架移位等并发症发生.结论 EVAR治疗DeBakeyⅢ型主动脉夹层具有技术可靠、创伤小、术后恢复快、成功率高等优点,尤其适用于不能耐受传统开胸手术的老年高危患者.而对于年轻的主动脉夹层患者要注意排除埃-当综合征等遗传性疾病,用EVAR治疗埃-当综合征的血管并发症,目前尚未见报道,其手术并发症及疗效有待进一步观察.     

胸主动脉病变腔内修复术中“烟囱”技术的应用

目的:探讨胸主动脉病变腔内支架修复术"烟囱"技术的临床应用。方法:对2009年12月至2012年12月间,44例经"烟囱"技术治疗的胸主动脉病变患者临床资料,适应证及手术实施要点进行回顾性分析。结果:44例患者中,男性35例,女性9例,年龄49～76岁,平均(64.2±12.71)岁;其中胸主动脉瘤12例,Stanford B型胸主动脉夹层32例。44例胸主动脉病变患者因病变近端锚定区不足行左锁骨下动脉支架植入术即"烟囱"技术。所有患者手术均成功,最长随访时间12个月,无不良并发症发生。结论:腔内支架修复术"烟囱"技术扩展了胸主动脉病变腔内修复术的适应证范围,提高了治疗成功率,使更多的胸主动脉病变患者可以受益于这一微创、安全、有效的治疗方法。远期疗效尚需要进一步随访和观察。