胸主动脉瘤和主动脉夹层的腔内治疗

本文综述了近年来应用支架型人工血管治疗胸主动脉瘤和主动脉夹层的主要进展，认为该术式是手术等传统治疗方法的有效替代之一，但还存在一些亟待解决的问题。     

胸主动脉瘤外科综合治疗

目的 总结2001年5月～2005年5月我院对223例各类胸主动脉瘤行介入腔内隔绝、“杂交手术”等综合外科治疗的经验,探讨手术方法的选择和手术新技术的应用。方法 单纯Bentall手术83例,单纯升主动脉置换17例,David手术3例,Wheat手术7例,Bentall及右半弓人工血管置换术12例,全弓人工血管置换联合象鼻或改良象鼻手术10例,“杂交手术”（Bentall手术＋全弓置换＋介入腔内隔绝）8例,降主动脉人工血管置换术4例,降主动脉及左半弓人工血管置换术3例,腔内覆膜支架介入治疗降主动脉夹层动脉瘤76例。急诊手术98例,同期行冠状动脉旁路移植术6例（包括“杂交手术”＋冠状动脉旁路移植术1例）。结果 手术死亡9例：1例Ⅰ型夹层动脉瘤术后死于大面积脑出血;2例Bentall手术后呼吸功能衰竭合并肺部感染,分别在术后7、12 d死亡;1例急性肝功能衰竭,经人工肝,血浆置换治疗未好转术后3 d死亡;2例分别于术后8、14 d死于多脏器功能衰竭;2例分别于术后4、6 d死于心脏功能衰竭;1例术后3 d脑梗塞家属放弃治疗。76例腔内隔绝术即时操作成功率100%,即夹层裂口完全封闭,恢复真腔血流,动脉假腔不再显影。214例随访4～52个月,（27±18）个月,3个月内无死亡。1例Bentall术后8个月因突发心律紊乱死亡;1例Bentall及右半弓人工血管置换术后12个月因脑栓塞死亡;1例马凡综合征行Bentall术后6个月出现降主动脉夹层动脉瘤,再次行胸降主动脉置换和肋间血管移植痊愈。结论 早期根据病变部位、程度采用包括经导管植入支架、杂交手术等综合外科治疗可以简化手术操作、提高手术安全性、降低胸主动脉瘤手术病死率。深低温停循环联合右锁骨下动脉插管选择性脑灌注是一种简便易行有效的脑保护方法。     

胸主动脉瘤及主动脉夹层外科治疗进展

胸主动脉瘤及主动脉夹层病情凶险，死亡率和病残率均很高。近几年在保留和不保留主动脉瓣的主动脉根重建术治疗升主动脉瘤，弓部主动脉瘤切除与脑保护，胸主动脉瘤或胸腹主动脉瘤切除与脊髓保护，以及主动脉腔内支架移植术等方面取得了较大的进展。手术死亡率已从31．4％下降至3．3％－4．8％。胸主动脉瘤，特别是主动脉夹层系一全身性主动脉病变，近年来手术疗效有所改善，但远期复发率和再手术率仍较高。主动脉内支架移植与外科手术结合应用，对复杂的伴有降主动脉病变的A型主动脉夹层治疗，可能是一种安全而有效的方法。     

复杂主动脉夹层及胸主动脉瘤的腔内治疗

目的总结复杂主动脉夹层(AD)及胸主动脉瘤(TAA)腔内隔绝术的治疗经验。方法共76例行腔内治疗的复杂AD及TAA病例,其中行单纯腔内隔绝术52例,结合烟囱技术的腔内隔绝术6例;结合支架近端开槽的腔内隔绝术5例;颈部杂交手术13例。结果围手术期死亡2例,其中1例患者术后4小时死于心跳骤停,1例杂交手术患者术后死于脑血管意外。51例得到随访,随访时间3个月至9年,平均18个月,1例TAA杂交手术患者人工血管全段闭塞,但患者无任何神经系统症状。2例患者分别在术后3个月及1年出现支架远端破口再行腔内隔绝术。1例AD患者术后6个月时出现支架近端新破口。在随访期死于肺癌和冠心病各1例。结论结合覆盖左锁骨下动脉、烟囱技术、开槽技术及颈部血管搭桥的腔内隔绝术,可提高复杂AD及TAA的疗效,降低并发症。     

Stanford A型主动脉夹层的外科治疗

目的总结A型主动脉夹层的外科治疗经验。方法回顾分析手术治疗68例StanfordA型主动脉夹层患者的临床资料。其中急性主动脉夹层45例,慢性主动脉夹层23例。采用中低温体外循环53例,深低温停循环(DHCA)和上腔静脉逆行灌注脑保护11例,DHCA加选择性脑灌注4例。急诊手术39例(其中紧急手术19例),择期手术29例。术式为升主动脉置换术7例,升主动脉加右半弓置换术6例,升主动脉加全弓置换术3例,升主动脉加全弓置换加术中支架置入术4例,Bentall手术34例,改良的Wheat术12例,同时行主动脉瓣成形术2例、二尖瓣成形1例。结果全组死亡5例(7%),其中急诊手术3例,急诊手术病死率8%(3/39);择期手术2例,择期手术病死率7%(2/29)。共随访58例,随访率92%(58/63),随访时间(37±22)个月(5~77个月),死亡4例,累积1,3和5年的生存率分别是100%,95%和86%。结论StanfordA型夹层的手术方式应根据内膜破口位置决定,正确的手术指征、技巧和脑保护是手术成功的关键。     

外科治疗DeBakey Ⅲ型主动脉夹层动脉瘤17例

2000年1月至2004年12月我们对17例DeBakeyⅢ型主动脉夹层动脉瘤病人进行了手术治疗,现总结报道如下.     

主动脉夹层动脉瘤的外科治疗

回顾性地对１９９０～１９９５年收治的６１例主动脉夹层动脉瘤资料进行分析，探讨其手术治疗原则及治疗效果。其中ＤｅＢａｋｅｙⅠ、Ⅱ型３１例，Ⅲ型３０例。手术治疗４１例，非手术２０例，非手术２０例中１０例在等待手术期间因室颤和心衰死亡５例，突发夹层瘤破裂死亡５例；另外１０例中，２例动脉瘤破裂包裹保守治疗，２例因肾功能严重受损未手术，６例不接受手术出院。非手术组住院死亡率为５０％。手术治疗４１例中ＤｅＢａｋｅｙⅠ、Ⅱ型手术２３例，２０例行Ｂｅｎｔａｌｌ术，３例行Ｗｈｅａｔ术，手术死亡３例，手术死亡率１３％，术后５年死亡率为２０％。ＤｅＢａｋｅｙⅢ型手术１８例，手术死亡２例，死亡率１１．１％，５年死亡率为１２％。故作者认为，主动脉夹层动脉瘤病人应积极手术治疗，ＤｅＢａｋｅｙⅠ、Ⅱ型急性期应手术治疗，Ⅲ型如果无不可控制的高血压、无不能制止的疼痛、瘤体扩大不明显，或有重要脏器缺血受累外，应先严密监测、控制血压，做必要检查后择期手术。     

A型主动脉夹层动脉瘤的外科治疗

目的　总结 1996年 1月至 2 0 0 2年 8月收治的 34例 A型主动脉夹层动脉瘤的外科治疗经验。　方法　应用 Bentall手术 19例 ,升主动脉人工血管置换术 7例 ,升主动脉人工血管置换加主动脉瓣成形术 (Trusler's法 )5例 ,分别行升主动脉人工血管置换及主动脉瓣置换术 (Wheat术 ) 2例 ,升主动脉、主动脉弓人工血管置换术 1例。结果　手术死亡 6例 ,死亡率 17.6 %。其中慢性主动脉夹层动脉瘤死亡 3例 ,急性夹层动脉瘤死亡 3例。随访 2 0例 ,随访率 71.4 %。随访时间 2～ 4 6个月 ,平均 2 4 .7个月 ,1例术后 3个月猝死 (原因不明 ) ,1例术后 6个月死于心内膜炎。18例存活患者情况良好。　结论　应根据夹层动脉瘤的部位及范围采用不同的手术方式 ,保留主动脉瓣的升主动脉人工血管置换术治疗该病效果较好 ,准确可靠的吻合技术、保留瘤壁的完整性 ,将使手术更为安全。     

Bentall手术治疗胸主动脉瘤和主动脉夹层54例

胸主动脉瘤和主动脉夹层临床上较常见,其病情凶险,病变血管随时可能突然破裂导致患者死亡。Bentall手术是治疗胸主动脉瘤或主动脉夹层的经典手术。2007年10月至2010年10月我科采用Bentall手术治疗54例胸主动脉瘤或主动脉夹层患者,现总结其临床经验。1临床资料与方法1.1一般资料本组共54例,男41例,女13例;年龄18~63岁,平均年龄43.8岁。     

腔内修复术治疗胸主动脉夹层动脉瘤

目的 探讨应用支架人工血管行腔内修复术治疗胸主动脉夹层动脉瘤的临床效果.方法 回顾性分析采用腔内修复术治疗胸主动脉夹层动脉瘤32例患者的临床资料.男26例,女6例;平均年龄61岁.术前根据CTA结果 确诊,并对病变部位及解剖条件进行评估.手术在DSA监控下进行,全麻或局麻,应用Telent 8例(美敦力公司),国产支架24例(2例上海微创,22例北京裕恒佳).结果 7例破口距左锁骨下动脉开口＜1.0 cm,3例将覆膜支架跨过左锁骨下动脉开口将其封闭后,夹层动脉瘤消失,无上肢及脑缺血症状.治愈31例,死亡1例.31例夹层动脉瘤患者随访3～56个月均健在,其中5例CTA复查有内漏存在.结论 EVAR手术为夹层动脉瘤的治疗开辟了一个新的方法 ,具有比传统手术并发症少、病死率低等优点.在Stanford B型夹层动脉瘤的治疗中,EVAR可代替传统的开胸手术.     

Thoracic aortic aneurysm associated with congenital bicuspid aortic valve.

Congenital bicuspid aortic valve is a relatively rare malformation. It is reported that the presence of this anomaly predisposes the patient to development of true aortic aneurysms or dissecting aortic aneurysms. Between 1981 and August 1997, 25 patients with an aneurysm of the thoracic aorta associated with congenital bicuspid aortic valve underwent surgical treatment at the authors' institution. There were 20 males and five females. The age of the patients ranged from 27 to 74 years (mean 53 years). There were 18 patients with true ascending aortic aneurysms (of which 10 presented with annulo-aortic ectasia) and seven with dissecting aortic aneurysms (four with DeBakey type I dissection, two with type II and one with type IIIb). These 25 patients constituted 2.6% (25/973) of all cases of surgical operations for aneurysms in the thoracic aorta. Aortic valve dysfunction was noted in 20 patients. The authors performed a valved conduit operation in nine patients, aortic valve replacement and wrapping of the ascending aorta in six, graft replacement of the ascending aorta in five, graft replacement of the ascending aorta and aortic arch in four, and graft replacement of the descending aorta in one. No hospital deaths occurred in the authors' patients. Pathological examination of surgical specimens of the aortic wall showed cystic medial necrosis in 11 patients and mucoid degeneration in nine. In patients with congenital bicuspid aortic valve, attention should be paid to aneurysmal dilatation and aortic dissection as complications in addition to valve dysfunction.     

Secondary procedures after endovascular aortic aneurysm repair

PURPOSE: The purpose of this study was to evaluate the incidence, distribution, and indications of secondary procedures after endovascular aortic aneurysm repair (EAR). METHODS: At a single institution, 179 patients underwent EAR with four different endografts (AneuRx, n = 117; Zenith, n = 49; Ancure, n = 12; and Talent, n = 1). The vascular section database was queried for patients who needed secondary procedures after the original EAR. The mean time from EAR to the termination of the study was 27.0 +/- 16.7 months. Type I or III endoleaks were treated aggressively. Type II endoleaks were treated only in the presence of aneurysm expansion. RESULTS: Thirty-five (35/179; 19.6%) secondary procedures were performed in 32 patients. Indications for secondary procedures included 14 limb occlusions or stenoses (40.0%), 13 endoleaks (37.1%), six endograft migrations (17.1%), one delayed aneurysm rupture (2.8%), and one device malfunction (2.8%). Seven of the 10 early (<90 days) limb failures (70%) occurred within the first 60 patients. At that time, a protocol with aggressive external iliac artery evaluation was adopted. In the next 125 patients, the rate of early limb occlusion or stenosis was 2.4% (P =.025, with Fisher exact test). Distribution of secondary procedures included 23 endoluminal interventions (65.7%; angioplasty +/- stent placement, thrombolysis, endocuff placement, embolization), eight traditional peripheral procedures (22.9%; femoral-femoral bypass, thrombectomy), two laparoscopic interventions (5.7%; inferior mesenteric artery ligation), and two laparotomies (5.7%; delayed conversions). Interventions for limb occlusion or stenosis occurred earliest (3.5 +/- 5.4 months; P <.05, with analysis of variance), followed by treatment of endoleaks (14.3 +/- 12.9 months) and migration (27.5 +/- 10.4 months). The one delayed rupture occurred at 15.3 months. CONCLUSION: Secondary procedures after EAR are common. Reinterventions can be grouped temporally on the basis of indication. Treatment for limb ischemia is predominately early (>/=3 months), whereas treatment for endoleaks occurs at approximately 1 year and interventions for migration predominate after 2 years.     

Thoracic aortic aneurysm associated with pseudocoarctation of the aorta

Pseudocoarctation is a rare anomaly in the descending thoracic aorta. A 44-year-old man experienced sudden onset of back pain for 5 days prior to admission. Computed tomography showed kinking and stenosis in the distal aortic arch with a distal aneurysm. The patient underwent emergency surgery, with a diagnosis of impending rupture. The aneurysm was lobular with a very thin wall. Pseudocoarctation is rare and most often is asymptomatic. However, the aneurysm should be treated surgically, and the area of stenosis resected.     

Long-term surgical outcomes of aortic arch aneurysm

Between January 1990 and October 2001, arch replacement was performed in 99 patients with aortic arch aneurysm at Omiya Medical Center. For brain protection during surgery, antegrade selective cerebral perfusion was performed. There were 11 (11.1%) hospital death, and causes were heart failure (3), pneumonia (2), respiratory failure (1), mediastinitis (1), cerebral infarction (1), sepsis (1), myocardial infarction (1), and bleeding (1). During follow-up, 24 patients died, and causes were pneumonia (4), malignancy (3), heart failure (2), cerebral infarction (2), rupture of residual aneurysm (2), asthma (1), myocardial infarction (1), sepsis (1), multiple organ failure (1), traffic accident (1), and unknown (6). Postoperative survival was 75.2% at 3 years, 61.5% at 5 years, and 35.3% at 8 years. Event free ratio was 71.8% at 3 years, 58.6% at 5 years, and 30.8% at 8 years. Surgery of the aortic arch using selective cerebral perfusion is a safe and demonstrated acceptable short- and long-term outcomes.     

不同手术方式行全胸腹主动脉替换的临床研究

目的 比较手术治疗的效果,探讨不同手术方式行全胸腹主动脉替换术的适应证和具体手术方法,明确常温非体外循环下全胸腹主动脉替换的可行性和安全性.方法 2009年2月到2011年5月,46例CrawfordⅡ型胸腹主动脉瘤(thoracoabdominal aortic aneurysm,TAAA)患者行全胸腹主动脉替换术(total thoracoabdominal aortic aneurysm repair,tTAAAR).根据术式不同,分为深低温停循环tTAAAR(A)组15例和常温非体外循环tTAAAR(B)组31例.计数资料采用精确概率的x2检验和计数资料经正态性检验后采用t检验等统计学方法,比较了患者的术前、术中和术后ICU治疗情况以及围术期病死率、并发症发生率等.结果 A组和B组术后早期死亡(26.67％对3.20％,P=0.033)和一过性脑功能障碍发生率(33.30％对3.30％,P=0.018)差异有统计学意义.两组手术时间(P＜0.0001)、降主动脉阻断时间(P ＜0.0001),输注红细胞(P=0.013)差异亦有统计学意义.术前情况、内脏缺血时间、脊髓缺血时间、ICU治疗时间、带气管插管时间、脊髓损伤、肾功能不全等差异无统计学意义,P＞0.05.结论 常温非体外循环全胸腹主动脉替换术安全、可靠.适应证为可在常温下建立降主动脉到髂动脉旁路循环的胸腹主动脉动脉瘤.肋间动脉重建是重要的脊髓保护手段.