腔内隔绝术治疗主动脉夹层动脉瘤107例分析

目的 探讨应用覆膜支架腔内隔绝术治疗主动脉夹层动脉瘤的方法和效果.方法 对107例(男88例,女19例,年龄28～83岁)主动脉夹层动脉瘤腔内隔绝术患者的临床资料进行回顾性分析.术前采用CT血管成像(computerized tomography angiography,CTA)、经胸心脏超声(transthoracic echocardiography,TTE)、磁共振血管成像(magnetic resonance aniography,MRA)等技术对主动脉夹层动脉瘤进行评估.术中穿刺左肱动脉行主动脉造影了解破口的位置及撕裂的范围,在数字减影血管造影(digital subtraction angiography,DSA)监视下经股动脉将覆膜支架送入胸降主动脉封闭夹层破口.结果 107例成功进行了主动脉夹层动脉瘤腔内隔绝术.术后主动脉造影证实夹层裂口完全封闭或内漏明显减少,无中转开胸手术.术后随访1～48个月,术后1个月3例死亡.104例行CTA复查,术后3个月,所有患者内膜破裂口封闭,胸降主动脉真腔扩大,假腔内血栓形成,支架位置、形态正常.术后6个月,1例再发生升主动脉夹层,置入一枚支架后后假腔消失.术后1年,主动脉均未见病变.结论 覆膜支架腔内隔绝术是治疗主动脉夹层动脉瘤的安全、有效的方法,近期疗效好.手术死亡率和并发症发生率低,手术成功率和生存率高.     

胸主动脉夹层动脉瘤的外科治疗——手术适应证手术方法的选择及疗效

目的 :探讨胸主动脉夹层动脉瘤外科治疗的手术适应证及手术方法的选择和疗效。方法 :1982年 5月至 2 0 0 2年 6月 ,治疗各类胸主动脉夹层动脉瘤 4 2 7例 ,其中DeBakeyⅠ型 116例 ,Ⅱ型 133例 ,Ⅲ型 178例 ,平均年龄 2 7 5± 10 7(2 3～ 74 )岁 ,体重 72 5± 13 2 (5 2～ 12 0 )kg。手术方法包括 :改良Bentall手术 176例 ,Bentall及右半弓人工血管置换 1例 ;Wheat手术 2 0例 ,Wheat及右半弓人工血管置换 4例 ;升主动脉人工血管置换 2 1例 ,升主动脉及全弓人工血管置换 10例 ,升主动脉及右半弓人工血管置换 4例 ,升主动脉置换及弓部破口修补 3例 ,升主动脉置换及主动脉瓣成型 3例 ;全弓部人工血管置换 7例 ;降主动脉置换 4 1例 ,降主动脉及左半弓人工血管置换 2例 ,降主动脉补片成型 12 9例 ;腔内覆膜支架介入治疗降主动脉夹层动脉瘤 6例。其中急诊手术 5 4例。全组病人升主动脉手术采用股动脉及右房插管全心转流 ,弓部手术采用深低温停循环加上腔静脉脑逆灌 ,降主动脉采用左上肺静脉及股动脉插管左心转流的方法。结果 :手术死亡 4 3例 ,死亡率 10 1% ;与手术相关的并发症包括 :术后心律失常 7例 ,脑功能障碍 5例 ,脊髓损伤影响下肢活动 5例 ,感染引起胸骨裂开 4例 ,术后出血而 2次开胸 8例 ,肾功能衰?     

支架型人工血管介入治疗主动脉夹层动脉瘤及主动脉穿透溃疡30例报告

目的探讨支架型人工血管介入治疗主动脉夹层动脉瘤和主动脉穿透溃疡的可行性及疗效。方法2001年6月至2004年3月,行支架型人工血管治疗主动脉夹层动脉瘤及主动脉穿透溃疡30例。男性24例,女性6例。平均年龄(523±119)岁。25例主动脉夹层动脉瘤中,慢性TypeB23例,急性TypeB1例,TypeA1例。主动脉穿透溃疡5例。术后随诊1～32个月。结果30例支架型人工血管均成功植入。5例有近端内漏,1例术中发生升主动脉夹层,2例分别在术后1d、7d发生升主动脉夹层。术后30d内死亡2例。术后30d内死亡率为67%。1例术后20个月因近端内漏接受第2次支架型人工血管植入术。术后随诊1～32个月,无死亡,亦无支架移位、狭窄等并发症。结论支架型人工血管是治疗主动脉夹层动脉瘤和主动脉穿透溃疡的有效方法,中远期效果还有待进一步观察。     

合并迷走右锁骨下动脉的B型主动脉夹层的治疗体验

目的:总结术中支架人工血管植入术或胸主动脉腔内修复术治疗合并迷走右锁骨下动脉的B型主动脉夹层的初步经验。方法:2010年8月至2017年8月,我中心共收治合并迷走右锁骨下动脉的B型主动脉夹层17例,其中术中支架人工血管植入术7例,胸主动脉腔内修复术10例。结果:术中支架组和腔内修复组均无患者围术期死亡。术中支架组有1例患者术后7d发生胸骨哆开行清创术。腔内修复组无围术期并发症。术中支架组随访13~85个月,平均(54.86±27.01)个月,腔内修复组随访(12~89)个月,平均(51.10±24.71)个月。随访期间两组无死亡病例。结论:合并迷走右锁骨下动脉的B型主动脉夹层应根据不同的解剖特点和合并病变,选择术中支架人工血管植入术或胸主动脉腔内修复术。     

急性期Standford B型主动脉夹层腔内修复术后早、中期随访结果

目的 评价急性期StanfordB型胸主动脉夹层(TAD)腔内修复术后早、中期手术效果.方法 2009年11月至2012年6月完成80例急性期Stanford B型胸主动脉夹层腔内修复术,手术在发病72 h内完成.手术前行胸腹主动脉夹层强化CT检查,在DSA手术室全麻下切开股动脉进行支架置入术,出院前进行CTA检查,手术后半年至一年内复查CTA.结果 14例患者手术后失去随访.5例术后造影提示有Ⅰ型内漏,4例1年内复查消失或造影剂溢出量明显减少,1例手术后仍有明显Ⅰ型内漏,1年后接受再次支架手术成功.其余支架安装后造影显示破口封闭,无内漏.住院期间死亡2例,1例为高龄患者降主动脉破裂,1例为夹层逆行撕裂至升主动脉后破裂.住院期间发生严重低氧血症8例,急性肾功能不全6例,均经治疗后恢复.结论 急性期Stanford B型胸主动脉夹层进行腔内修复术,术后早期并发症发生率高,中期效果理想.     

“杂交”手术治疗弓部主动脉夹层的疗效评价

目的:评价人工血管旁路移植术结合腔内隔绝术的“杂交”手术用于主动脉弓部夹层动脉瘤的治疗效果。方法:对12例破口位于主动脉弓部的主动脉夹层动脉瘤患者进行了人工血管旁路移植术+腔内隔绝术的“杂交”手术治疗。评价该方法围手术期死亡率、并发症以及术后桥血管通畅率,进行了6~48(28±11)个月的随访观察。结果:全组1例死亡,原因为等待二期腔内手术期间发生动脉瘤破裂。1例患者因并发医源性升主动脉夹层而改行全主动脉弓置换+支架植入术,随访中1例患者出现90%人工血管狭窄,1例患者出现轻度I型内漏,经18月观察无明显变化,其余患者生存良好,未出现截瘫及其他严重并发症。结论:本文所指的“杂交”手术治疗主动脉弓部夹层动脉瘤具有良好效果。     

胸主动脉钝性外伤的腔内修复治疗

目的 探讨腔内修复技术在治疗胸主动脉钝性外伤中的可行性和安全性.方法 回顾分析2010年2月至2013年12月期间7例胸主动脉钝性外伤患者的临床资料.术前CTA及术中造影评估病变,回顾术中技术成功率,死亡及截瘫等主要并发症的发生率.术后CTA随访明确有无内漏、支架移位等情况.结果 所有创伤都累及主动脉峡部,包括Stanford B型夹层1例、降主动脉假性动脉瘤6例.全部患者均接受覆膜支架腔内修复治疗,其中1例先行左-右锁骨下动脉转流术.术中6例部分或全部覆盖左锁骨下动脉开口.所有手术患者均获得技术成功,无死亡及截瘫发生.术后随访时间2～28个月,无左上肢缺血症状及神经系统并发症,支架无内漏及移位.结论 腔内修复治疗胸主动脉夹层安全、有效,可行性高.     

Stanford A型夹层动脉瘤112例手术治疗体会

目的 提高Stanford A型夹层动脉瘤的治疗水平.方法 对112例Stanford A型夹层动脉瘤患者根据升主动脉受累部位分别采用直接升主动脉人造血管置换或David、Bentall 、Carbrol、 Wheat手术,主动脉弓部受累者置入带分支人工血管,胸降主动脉受累者同时行"象鼻"或"支架象鼻"手术.结果 110例手术顺利,术中出血200～1 600 ml,共植入人工血管123条;术中死亡2例.术后出现并发症22例,死亡3例.本组康复出院107例,术后2 a内复查无移植物感染、栓塞狭窄,均能行轻度体力劳动,心功能Ⅰ级85例,Ⅱ级22例.结论 手术是治疗Stanford A型夹层动脉瘤首选治疗方法,应根据累及部位选择不同术式,预防术中出血、缩短体外循环时间是手术成功的关键.     

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。     

腔内血管支架植入治疗胸主动脉夹层

目的：总结腔内血管支架植入治疗主动脉夹层临床经验。方法：胸主动脉夹层5例,男3例,女2例,平均年龄(53.5±4.5)岁。经多排 CT 增强扫描或磁共振成像确诊。切开右侧股动脉,植入腔内血管带膜支架,封堵原发破口。植入后重复造影检查。随访行胸部 X 线平片与多排螺旋 CT 检查。结果：支架植入均成功,术后即刻造影5例均无内漏。降主动脉及腹主动脉真腔均明显扩大,远端降主动脉及分支供血均有明显改善。术后3月随访,降主动脉及腹主动脉真腔扩大,近端夹层动脉瘤消失。结论：腔内血管带膜支架植入治疗胸主动脉夹层近期疗效满意。     

Underlying aortic pathology and clinical health status determine success of endovascular stent-grafting for descending thoracic aortic disease.

Despite advances in medical and surgical treatment, acute as well as chronic diseases of the thoracic aorta are still associated with a high mortality. For the descending thoracic aorta, endovascular stent-graft placement competes with surgical therapy for clinical outcome. From July 1999 till December 2004, a total of 84 patients (64 +/- 14 years) with aortic disease of the descending thoracic aorta were treated. Nine patients had acute (AAD) and 35 chronic aortic dissection (AD), 16 had thoracic aortic aneurysms (TAA), 21 had penetrating aortic ulcer (PAU), and 3 patients had traumatic dissection (trans). Initial clinical status was assessed using the American Society of Anesthesiologists (ASA) classification. Fifty-three patients were in class 2, 16 in class 3, 8 in class 4, and 7 in class 5. Stent-graft placement was performed in the cardiac catheterization laboratory with the patient under general anesthesia. Technical success was obtained in 81/84 patients (96%). Within 30 days, seven patients (8%) died, four of them due to aortic rupture. In 14 patients, additional stent-grafts had to be implanted due to type I endovascular leakage (n = 5) or additional entry site adding up to a total of 107 implanted stent-grafts. During a follow-up period of 21 +/- 18 months, 17 additional patients died (22%). In 10 patients, death was disease- or procedure-related (13%). This long-term mortality depended on the underlying disease and was highest in the group with TAA (45%) followed by AAD (38%) and AD (18%). Patients in ASA class 4 and 5 had a significantly worse outcome. No aortic-related death occurred among patients with PAU or traumatic transsections. Overall, there was only one transient neurological deficit. Endovascular stent-graft placement has acceptable results in the treatment of patients with disease of the descending thoracic aorta. The outcome strongly depends on the underlying aortic pathology and the clinical health status of the patients. Randomized trials are necessary in order to establish the exact value of this new therapeutic option.     

Endovascular stent grafting of descending thoracic aortic aneurysms

The treatment of descending thoracic aortic aneurysms using endovascular stents is one of the more recent advances in treatment and is receiving increasing attention as it is a less invasive alternative to open surgical repair. Although the technology is still primitive, significant improvements have lately been made in the design and deployment of the endovascular stent-grafts. Aortic stent-grafts were used initially to exclude abdominal, and later thoracic, aortic true and false aneurysms. These prostheses have been increasingly used to treat aneurysms, dissections, and traumatic ruptures of the descending thoracic aorta with good early and mid-term outcomes. Although the long-term outcome of patients with aneurysms of the descending thoracic aorta after stent graft implantation has not been investigated, continued refinement of the endovascular approaches has decreased the need for conventional open thoracic aortic aneurysm repair, especially in patients who are at a high risk for standard surgery because of advanced age or the presence of comorbid diseases. The placement of endoluminal stent-grafts to exclude the dissected or ruptured site of thoracic aortic aneurysms is a technically feasible and relatively safe procedure. With the rapid development of endovascular approaches, the treatment of the descending thoracic aortic aneurysms might alter even more, but an extended follow-up is necessary to determine the longer term outcome. Historical perspectives, advantages, device considerations, complications, and current perspectives of the endovascular stent grafting of the descending thoracic aortic aneurysms are elaborated on.     

Expanding false lumen in the abdominal aorta 5 years after endovascular repair of a type B aortic dissection: successful exclusion of 3 distal re-entry sites.

PURPOSE: To report endovascular treatment of an expanding aneurysmal false lumen several years after successful stent-graft deployment in the descending thoracic aorta for type B aortic dissection. CASE REPORT: A 54-year-old woman who had a stent-graft placed at the entry site of a type B aortic dissection 5 years prior presented with abdominal discomfort and palpable abdominal mass. Successful remodeling of the thoracic aorta was demonstrated by computed tomography; however, a false lumen aneurysm in the abdominal aorta had expanded from 4.8 to 6.5 cm and caused symptoms. She was successfully treated with 3 additional stent-grafts at 3 re-entry sites. Six months after the procedure, the false lumen aneurysm was completely excluded. CONCLUSIONS: Endovascular repair of the re-entry sites can prevent further expansion of false lumen aneurysm, which occurs in some patients with type B dissection treated with stent-grafts.     

Stent-grafts in patients with marfan syndrome.

PURPOSE: To explore the safety and feasibility of stent-graft placement in the dissected descending thoracic aorta of patients with Marfan syndrome. METHODS: Six consecutive patients (4 men; mean age 33+/-15 years, range 24-61) with Marfan syndrome were offered endovascular repair for dissection after previous aortic root repair in 5 and solitary type B dissection in 1. RESULTS: Transluminal placement of customized Talent stent-grafts was technically successful in all patients, with no 30-day or 1-year intervention-related mortality. Complete abolition of the dissection and reconstruction of the entire dissected aorta was documented in 2 patients. Over a mean 51+/-22-month follow-up (range 12-74), elective conversion to surgical repair was necessary in 2 patients at 22 and 43 months after stent-graft implantation. In a third patient, conversion to surgery is being considered at 74 months after stent-grafting. One patient died suddenly 12 months after endovascular repair. CONCLUSIONS: Nonsurgical reconstruction of postsurgical distal aortic dissection in patients with Marfan syndrome is feasible and technically successful. Stent-graft placement may either avoid or bridge to repeat surgery of distal aortic dissections after previous aortic root repair. Technical expertise and close postinterventional surveillance appear mandatory and may limit the procedure to centers of competence for aortic diseases.     

Type A dissection following endovascular thoracic aortic stent-graft repair.

PURPOSE: To describe our experience with endovascular stent-graft repairs in the thoracic aorta focusing on the secondary complication of type A dissection. METHODS: Between January 1996 and April 2004, 73 patients were treated for traumatic thoracic aortic rupture (n=15), type B dissection (n=22), or atherosclerotic descending thoracic aortic aneurysms (TAA, n=36). A retrospective review of the records found 5 (6.8%) patients (3 men; median age 64 years, range 43-87) who experienced a type A dissection at a median 20 days (range 2-124) after thoracic stent-graft repair for 3 type B dissections, 1 TAA, and a late type I endoleak that appeared 28 months after initial stent-graft repair of a traumatic dissection. RESULTS: In 3 patients (2 dissections, 1 endoleak), a tear in the aortic wall at the proximal stent-graft was responsible for a retrograde type A dissection. Underlying disease was the cause of the type A dissection in the 2 other patients (1 dissection, 1 TAA) and was unrelated to the stent-grafts. Three patients underwent open surgery at 3, 26, and 124 days after stent-graft placement; 2 procedures were successful, but the third patient died 3 months later due to multiorgan failure. Two type A dissections were untreated: one patient died from cardiac tamponade 14 days after successful stent-graft exclusion of the type I endoleak; the other patient refused further treatment and survived. The procedure-related mortality following acute retrograde type A dissection was 40%. CONCLUSIONS: Endovascular stent-graft repair of the thoracic aorta is associated with lower morbidity and mortality rates than surgical repair, although potentially lethal complications, acute or delayed, may occur.     

Endovascular treatment for dissection of the descending aorta

Surgery for acute ischaemia complicating dissection of the descending aorta is associated with high mortality. We used an endovascular fenestration approach (scissor technique) to treat seven of 12 patients with ischaemic complications of descending aortic dissection; the remaining five patients were treated by stent implantation. Four of the 12 patients died (two in the fenestration group and two in the stenting group) in the days after the procedure. The remaining eight were symptom-free a mean of 9.4 (SD 8) months later. We suggest that the fenestration approach is a promising addition to endovascular treatment for patients with ischaemic complications of descending aortic dissection.     

Self-Expanding Endovascular Stent-Graft Implant for Treatment of Descending Aortic Diseases

Abstract Background: Aneurysms and dissections involving the descending thoracic aorta and the distal portion of the aortic arch are difficult to resolve surgically. The introduction of endovascular self-expanding stent-grafts has simplified the operation. Given the complications associated with their peripheral placement, we explored the feasibility of surgical insertion. Methods: Thirteen patients underwent surgical insertion of a stent-graft into the aortic arch via longitudinal aortotomy. Six patients had aneurysms (ruptured in two, and seven dissections (acute in two, ruptured in one). Five patients also underwent associated procedures including aortic valve replacement (one), ascending aorta replacement (two), arch replacement (one), and coronary artery bypass (one). Results: There was one intraoperative death due to ascending aortic dissection, and two hospital deaths due to multiple complications. Of ten patients discharged, one died 3 months postoperatively. The remaining survivors are well, and imaging studies confirmed adequate correction of the aortic disease. Conclusions: The use of this technique simplifies the operation and treatment of particular cases of aortic disease. The observed morbidity and mortality are due to factors independent of the technique.     

Short term outcome of thoracic endovascular aortic repair in patients with thoracic aortic diseases

Aim and background

Open surgical repair for thoracic aortic diseases is associated with a high perioperative mortality and morbidity. Most of type B aortic dissections are uncomplicated and are medically treated which carries a high mortality rate. Thoracic endovascular aortic repair is the first-line therapy for isolated aneurysms of the descending aorta and complicated type B aortic dissection. The aim of this study is to test the safety of early thoracic endovascular aortic repair in patients with uncomplicated type B aortic dissection and patients with thoracic aortic aneurysms.

急性Stanford B型主动脉夹层腔内修复治疗的疗效评价

目的:评价腔内修复术（TEVAR）治疗急性Stanford B型主动脉夹层的中、远期疗效。方法: 2001年12月～2009年6月,对急性Stanford B型主动脉夹层进行血管腔内支架植入治疗患者288（男237,女51）例,年龄21～79（平均51.2）岁。局部或全身麻醉,在 X线透视下将支架型人工血管经股动脉放置在主动脉夹层第1裂口位置,实现腔内修复。应用多排CT等技术进行38个月（6～102月）的随访,观察假腔血栓形成情况、有无内漏、血流动力学变化、移植物位置及形态、内脏动脉供血等情况,评估该方法的安全性及有效性。结果: 全组患者无移植物错放、移位、瘤体破裂、中转手术和截瘫等并发症。围术期死亡6例,分别为:腹腔脏器缺血/再灌注损伤2例、升主动脉逆行夹层1例、夹层破裂1例、心肌梗死1例及死亡原因不明1例。住院期间并发症发生率25.3%,包括术后即刻内漏、发热、肾功能不全、切口感染、肺炎、神经系统并发症、心功能不全、左肱动脉假性动脉瘤、截肢等。随访中共有7例死亡(2.4%),4例患者行二次TEVAR术后治愈。Kaplan-Meier生存曲线显示5年累积生存率达96%。结论: TEVAR术是治疗急性Stanford B型主动脉夹层的一种有效方法,中期疗效满意,患者远期生存状况良好。     

Treatment of thoracic aortic disease using endovascular stent-grafts: from therapeutic indications to possible complications

Thoracic endovascular aortic repair (TEVAR) is a minimally invasive technique which is increasingly used in different thoracic aortic pathologies such as aortic aneurysm, complicated type B aortic dissection, aortic trauma, intramural hematoma and penetrating aortic ulcer. In this paper we discuss the main indications for endovascular stent-grafts in the treatment of thoracic aortic disease, based on three cases in which this procedure was used for three different conditions: degenerative aneurysm, complicated type B dissection and post-traumatic injury. These case reports add to the evidence that TEVAR is a safe and feasible therapeutic alternative in selected patients with thoracic aortic disease, improving aortic remodeling, with relatively low morbidity and mortality. The main complications and difficulties related to the procedure are also discussed.