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腔内隔绝术治疗Stanford B型主动脉夹层--116例临床分析

目的 探讨腔内隔绝术(EVGE)治疗Stanford B型主动脉夹层动脉瘤的手术指征、术前评估方法、手术操作技巧、并发症防治原则及临床应用前景. 方法 对自1998年9月至2001年12月间施行的116例Stanford B型胸主动脉夹层动脉瘤EVGE进行了回顾性研究.术前CT血管造影(CTA)或磁共振血管造影(MRA)显示:夹层动脉瘤最大直径平均66.2±18.1mm,72例患者表现为单一夹层裂口,44例表现为多裂口.经股动脉或髂动脉将移植物导入胸主动脉封闭夹层裂口,手术在数字剪影血管造影(DSA)监视下完成. 结果 术中移植物成功释放115例,72例单一夹层裂口患者中62例使用单一移植物,8例使用2个移植物,2例使用3个移植物,6例手术结束时残存I型内漏;44例多夹层裂口者,18例使用2个移植物同时封闭不同部位夹层裂口,26例远端夹层裂口旷置,1例中转开胸手术.平均随访时间15.4±11.2个月,围手术期死亡6例,其余病例术后无心、肺、肾功能衰竭及截瘫等严重并发症;术后11个月猝死1例,2例分别于术后14个月和24个月再发Stanford A型胸主动脉夹层而行Bentall手术,其余患者未出现与夹层及手术相关的并发症. 结论 EVGE治疗Stanford B型主动脉夹层动脉瘤是一种创伤小、恢复快的新方法,短期的随访结果表明该技术安全、有效.内漏是该方法的主要并发症,并可能导致术后患者死亡,远期疗效有待继续随访.

VASCULAR BYPASS GRAFTING COMBINED WITH ENDOVASCULAR AORTIC REPAIR FOR TREATMENT OFAORTIC DILATATION DISEASE

Objective To summarize the cl inical experience of vascular bypass grafting combined with endovascularaortic repair (EVAR) for aortic dilatation disease. Methods Between January 2008 and August 2011, 12 patients with aorticdilatation disease were treated with vascular bypass grafting combined with EVAR. Of 12 patients, 11 were male and 1 wasfemale, aged 47-81 years (mean, 65.9 years). All cases were diagnosed through computed tomography angiography (CTA),including 1 case of Stanford type A dissection, 5 cases of Stanford type B dissection, 4 cases of aortic arch aneurysm, and 2 casesof abdominal aortic aneurysm. Eight patients received neck artery bypass grafting before EVAR, and 4 patients underwentfemoral artery bypass grafting after EVAR. Results After operation, pulmonary infection occurred in 3 patients, renalinsufficiency in 2 patients, cerebral infarction in 1 case, decreased hemoglobin and platelets in 7 cases, and poor healing of groinwound in 1 case. Eleven patients were followed up 3-42 months, with an average of 18.6 months. In 1 case undergoing EVARof the thoracic and abdominal aorta, EVAR was performed again because new aneurysms formed at 6 months after operation,and the patient achieved good recovery after 3 months. CTA showed reduced false lumen, thrombosis formation, no endoleak,no deformation or displacement of stent, and anastomotic patency of artificial blood vessels in the other patients at 3, 6, and12 months after operation. Conclusion Vascular bypass grafting combined with EVAR can expand the indications forendovascular repair. It not only provides sufficient anchoring area, but also ensures the blood supply to vital organs, simplifiesthe surgical procedure, and reduces the difficulty of endovascular treatment.

Management of Endoleak after Endovascular Exclusion for Aortic Dissection

腔内隔绝术（endovascular exclusion, EVE）最早用于治疗腹主动脉瘤，1994年Dake报道将其用于B型主动脉夹层（aortic dissection, AD）的治疗，国内自1998年开展。在EVE治疗AD的10余年历史中，内漏的预防和处理始终是一个备受关注的问题，现结合笔者的经验讨论AD术后内漏相关的问题。......

创伤性主动脉夹层并发肾功能衰竭一例

Advances in surgical indications and morphological rupture-risk assessment of abdominal aortic aneurysms

ObjectiveThis paper aimed to summarize the new progress in surgical indications regarding as maximum diameter from evidence-based medical evidence and morphological rupture-risk assessment of abdominal aortic aneurysms (AAA) and its clinical application value.MethodThe rupture-risk and its mechanism of AAA in specific population and morphological characteristics were reviewed.ResultsAsymptomatic patients in specific subgroups may also benefit from AAA repair by lowering the intervention threshold. Besides the maximum diameter of aneurysm, other morphological factors, such as the true geometric shape, the wall thickness, and mural thrombus also had important predictive value for AAA rupture risk.ConclusionRupture-risk assessment based on the actual individual situation of AAA patients can further facilitate the clinical diagnosis and treatment.

覆膜支架腔内隔绝术治疗Stanford B型主动脉夹层

目的　总结采用覆膜支架腔内隔绝术治疗Stanford B型主动脉夹层的临床经验。 方法　2008年8月至2012年10月安庆市立医院对26例Stanford B型主动脉夹层患者行覆膜支架腔内隔绝术治疗，男21例，女5例；年龄（52.4±10.3）岁。术后定期复查CT血管成像。 结果　所有患者支架释放全部成功，无死亡、中转开胸和截瘫。术后发现支架覆盖腹腔干及肠系膜上动脉1例，急诊行旁路移植术；多发性脑梗塞1例，轻度Ⅰ型内漏2例，未予特殊处理；股动脉狭窄3例，其中1例严重狭窄者行大隐静脉移植术，2例中度狭窄者给予保守治疗。随访22例，随访时间（23.5±15.9）个月。随访期间CT血管成像显示所有患者支架无移位，主动脉真腔较术前明显扩大，假腔血栓形成。 结论　覆膜支架腔内隔绝术创伤小、效果佳、并发症少，是治疗Stanford B型主动脉夹层的有效方法。

Improvement of Visceral Arterial Blood Supply after Thoracic Endovascular Aortic Repair for Stanford Type B Aortic Dissection

ObjectiveTo investigate the improvement of visceral arterial blood supply after thoracic endovascular aortic repair (TEVAR) for patients with Stanford type B aortic dissection (AD). MethodsWe retrospectively analyzed clinical data of 35 patients with Stanford type B AD undergoing TEVAR in Mianyang Central Hospital from January 2013 to March 2014. There were 30 male and 5 female patients with their age of 45-82(62.5±10.0) years. Among the 140 main visceral arteries (celiac artery, superior mesenteric artery, left and right renal arteries) of the 35 patients, blood supply of 79 arteries were compromised, including 36 arteries with stenosis and blood supply via the true lumen, 18 arteries with blood supply via both true and false lumen, 18 arteries with blood supply via the false lumen, and 7 arteries without blood supply. Improvement of blood supply of main visceral arteries was analyzed. ResultsAll the operations were successfully performed without in-hospital death. Operation time was 97.8 (68-147) minutes, length of ICU stay was 12-34 h, and length of hospital stay was 10-21 days. None of the patients had cerebral infarction, acute renal failure, AD rupture or stent migration after TEVAR. Blood supply of the compromised visceral arteries showed improvement in various degrees. ConclusionFor the treatment of Stanford type B AD, TEVAR can not only successfully block the rupture of AD, but also improve blood supply of main visceral arteries, avoid or reduce the complications resulting from compromised visceral arterial blood supply and visceral ischemia.

Clinical Analysis on Perioperative Death of Endovascular Repair for Acute Aortic Dissection

Objective　To analyze the reasons for the perioperative death of endovascular repair of acute aortic dissection （AD）. Methods　The clinical data of 176 patients with acute AD and received endovascular repair from July 2001 to October 2012 were analyzed retrospectively. Results　Among 176 patients with acute AD， 8 patients died during perioperatively， received endovascular repair in 1-5 days after admission （mean 2.4 d）， and all of them admitted before 2008. Two cases were type A and 6 cases were type B. All cases with hypertension and 3 cases with pleural effusion. Three cases died on the day of operation， among them 2 cases occurred in 1 h after operation， the other 1 case occurred in 2 h after operation. Four cases died in 2 days after operation and 1 case died in 4 days after operation. Four cases died of rupture of the aortic dissection， 2 cases died of cerebral infarction， 1 case died of multiple organ failure， and 1 case died of gastrointestinal bleeding. Conclusion　To avoid performing endovascular repair during the acute phase and improving operation skills may help to avoid the occurrence of perioperative death.

Causes and Risk Factors of Multiple-interventions in Endovascular Repair for Aortic Dissection

ObjectiveTo assess the causes and risk factors of multiple-intervention in endovascular aortic repair (EVAR) for type B aortic dissection (TBAD). MethodsWe retrospectively analyzed the clinical data of 347 TBAD patients initially treated with EVAR in our hospital between January 1999 and December 2013. The patients were stratified into a multiple-intervention group (34 patients) and a single-intervention group (313 patients). We analyzed the differences of clinical data of the two groups. ResultsThere were 9 patients with endoleak, 10 patients with new dissection, 8 patients with incomplete thrombosis of the false lumen, 4 patients with new aneurysm, 2 patients with retrograde dissection, and 1 patient with iliac artery occlusion in the multiple-intervention group. Higher proportions of chronic dissection and smoking occurred in the multiple-intervention group (79.4% versus 50.8%, 61.8% versus 40.3%, P=0.002, 0.018, respectively). Both of the degree and proportion of hyperglycemia were higher in the multiple-intervention group (6.9±2.3 mmol/L versus 5.7±1.8 mmol/L, P=0.027; 44.1% versus 22.7%, P=0.011). There were statistical differences in oversizing rate of grafts (14.6%±3.2% versus 11.3%±2.5%, P<0.001), operation time (172 min versus 82 min, P<0.001), and blood loss (280 ml versus 100 ml, P=0.006) between the two groups. ConclusionEndoleak, new dissection, and incomplete thrombosis of the false lumen are the main causes of multiple-intervention. While in chronic phase, smoking, hyperglycemia, too big oversizing, and complicated lesion or operation are the potential risk factors.

主动脉弓部夹层动脉瘤手术治疗

目的 总结通过人工血管旁路术延长锚定距离后，腔内隔绝术（endovascular graft exclusion，EVGE）治疗主动脉弓部夹层动脉瘤的疗效。 方法 2005 年9 月－ 2007 年9 月，采用血管旁路术后二期行EVGE 治疗主动脉弓部夹层动脉瘤10 例。男9 例，女1 例；年龄33 ～ 55 岁，平均38 岁。合并高血压病8 例，尿毒症1 例。DSA 示近端破口位于左颈总动脉与左锁骨下动脉之间4 例；破口距左锁骨下动脉开口lt; 1.5 cm 且左椎动脉为优势动脉6 例，合并无名动脉瘤1 例，升主动脉及主动脉弓部壁内血肿1 例。 结果 除1 例患者由于真腔闭塞未能行EVGE 治疗外，9 例均顺利完成EVGE 治疗。术后即刻造影示Ⅰ型内漏、Ⅱ型内漏（左锁骨下动脉未结扎所致）各1 例，分别于治疗后1、3 个月经计算机X 线断层扫描血管造影术证实内漏消失。8 例破口封堵良好，1 例并发降主动脉周围血肿而失访。8 例获随访，随访时间12 ～ 36 个月，降主动脉假腔内血栓形成。 结论 人工血管旁路术延长锚定距离，不仅可扩大EVGE 的适应证，还能降低Ⅰ型内漏。