Mid-term outcomes of left subclavian artery revascularization with Castor stent graft in treatment of type B aortic dissection in left subclavian artery

BackgroundHere we analyzed mid-term data of thoracic endovascular aneurysm repair (TEVAR) surgery with Castor single-branched stent graft placement for the management of Stanford type B aortic dissection (STBAD) involving the left subclavian artery (LSA).MethodsBetween April 2014 and February 2019, 32 patients with STBAD involving a Castor single-branched stent graft were included. We analyzed their outcomes, including technical success rate (TSR), surgical duration (SD), presence of ischemia, perioperative complications, LSA patency, and survival rate (SR), using computed tomography angiography and clinical evaluation during mid-term follow-up.ResultsThe mean patient age was 54.63 ​± ​12.37 years (range, 36–83 years). The TSR was 96.88% (n ​= ​31/32). The mean SD was 87.44 ​± ​10.89 with a mean contrast volume of 125.31 ​± ​19.30 ​mL. No neurological complications or deaths occurred during the study period. The patients had a mean hospital stay of 7.84 ​± ​3.20 days. At a mean follow-up of 68.78 ​± ​11.26 months, four non-aortic deaths (12.5%) were observed. The LSA patency rate was 100% (n ​= ​28/28). There was only one case of type I endoleak immediately after surgery (3.12%) (type I from LSA). However, none of the patients experienced type II endoleaks, and there were no cases of retrograde type A aortic dissection or stent graft-driven new distal entry. Finally, all patients exhibited good LSA patency.ConclusionTEVAR using a Castor single-branched stent graft may be a highly feasible and efficient procedure for the management of STBAD involving the LSA.     

使用TEE经气管声窗检查主动脉弓分支的技术探索

目的 TEE经气管声窗(TTW)检查左颈总动脉(LCA)和左锁骨下动脉(LSA).方法 30例心脏手术患者进行了术中TEE检查.比较使用TTW前后LCA、LSA的显像阳性率.结果 TEE检查LSA和LCA的阳性率分别为97%和67%,使用TTW后,阳性率提高至100%和90%.结论 TEE可查多数患者的LSA、LCA.TTW提高了TEE检查气管插管患者LCA的阳性率(P<0.05),可帮助个别患者检查LSA,主动脉弓分支不再是TEE的盲区.     

经皮左锁骨下动脉植入药盒治疗中晚期肝癌

目的：探讨经左锁骨下动脉留置导管药盒治疗肝癌的操作方法和临床价值。方法：对15例晚期原发性肝癌、4例多发转移性肝癌采用seldinger技术经左锁骨下动脉植入药盒，留置管头端深置靶动脉内，药盒埋植在穿刺点外下方皮下，作肿瘤靶动脉内长期灌注治疗。结果：19例导管药盒系统均1次植入成功，术中无明显并发症；随访1～12个月，死亡2例、导管脱出1例、导管阻塞1例，术后病人生活质量和临床指标均有较明显改善。结论：经皮左锁骨下动脉植入式药盒操作简单易行、成功率高且创伤小；药盒的植入给以后肿瘤靶动脉内长期灌往治疗提供了方便、有效的新途径。     

Aortic valves stenosis and regurgitation: assessment with dual source computed tomography

To prospectively evaluate diagnostic accuracy of dual source computed tomography (DSCT) for evaluation of aortic stenosis (AS) and aortic regurgitation (AR) with transthoracic echocardiography (TTE) as reference. We evaluated a total of 79 patients who underwent both DSCT and TTE, 40 with aortic valve disease as assessed by TTE, and 39 matched controls. Maximum aortic valve area (AVA) in systole was planimetrically measured with DSCT, and measurements were compared with TTE, as well as maximum regurgitant orifice area (ROA) in diastole. Dimensions of the aortic root and left ventricular parameters were compared. DSCT correctly identified 30 patients with AS [sensitivity 91%, specificity 100%, positive predictive value (PPV) 100%, and negative predictive value (NPV) 94%], and 32 patients with AR (sensitivity 94%, specificity 98%, PPV 97%, and NPV 96%). A significant correlation was observed between CT planimetric size of aortic valves area and TTE (r = 0.79; P < 0.01). Bland-Altman plot demonstrates a good intermodality agreement between DSCT and TTE with a slight overestimation of AVA by DSCT (+0.14 cm²). A significant correlation was observed between CT planimetric size of ROA (0.49 cm² ± 0.40) and TTE classification of mild, moderate and severe AR (r = 0.79; P < 0.01). With receiver operating characterisitic curve analysis, discrimination between degrees of AR with DSCT was not very accurate within cutoff ROAs. A significant correlation was observed between methods in dimensions of aortic annulus (r = 0.87, P < 0.01), sinus of Valsalva (r = 0.91, P < 0.01), and ascending aorta (r = 0.92, P < 0.01), and in end-systolic volume (r = 0.82, P< 0.01), end-diastolic volume (r = 0.87, P < 0.01) and ejection fraction (r = 0.86, P < 0.01). DSCT can provide a simultaneous and accurate evaluation of the AVA, left ventricular ejection fraction and aortic root dimensions in patients with AS or AR, but measurement of ROA is not very accurate to differentiate severity of AR. DSCT can achieve an exhaustive and comprehensive preoperative assessment of patients with AS and AR.     

左前降支狭窄程度与左心室功能的相关研究

目的探讨单纯左前降支不同狭窄程度对左心室功能的影响。方法将冠状动脉造影证实为冠状动脉正常及单纯左前降支病变的714例患者,按前降支不同狭窄程度分成5组:狭窄≤25%为正常组380例,26%~50%为轻度狭窄组181例,51%~75%为中度狭窄组57例,76%~99%为重度狭窄组69例,100%为闭塞组27例。比较组间经左心室造影测定的左心室射血分数(LVEF)和左心室舒张末期压(LVEDP)。结果①LVEF:与正常组的(67.83±11.04)%比较,轻、中、重度狭窄组和闭塞组分别为(68.40±10.47)%、(65.70±11.19)%、(67.72±9.70)%和(62.41±12.02)%,仅闭塞组LVEF的下降差异有显著性(P<0.05);LVEF降低(<50%)的发生率各组间均未见差异;左前降支狭窄程度和LVEF的相关系数为0.08(P<0.05);②节段室壁运动异常:正常、轻度、中度、重度狭窄组和闭塞组患者发生节段室壁运动异常的比例分别为17.11%、24.86%、31.58%、40.58%和59.26%,呈有意义的升高(P<0.05或P<0.01)。③LVEDP:LVEDP的平均值、LVEDP升高(>12 mm Hg)的发生率、造影前后LVEDP差值在5组间差异均无显著性(P>0.05)。结论单纯前降支闭塞性病变可使LVEF下降,进行血运重建有助于改善左心室功能;但总体而言,左前降支狭窄程度与LVEF及LVEDP关联不大。     

非体外循环冠状动脉搭桥术治疗低射血分数的左主干并三支病变患者疗效分析

目的 探讨非体外循环冠状动脉搭桥术(OPCABG)治疗低左心室射血分数(LVEF)的左主干并三支病变患者的疗效.方法 2010年1- 12月我院收治低LVEF的左主干并三支病变的冠心病患者28例,均在全身麻醉下行OPCABG.分别于术前和术后3d进行血红蛋白(Hb)、血小板计数(PLT)、丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)、尿素氮(BUN)、肌酐(Cr)的检测;术后3个月行心脏超声检查记录LVEF、左心室舒张末期内径(LVED)测定值,并与术前检查结果进行比较.结果 1例因肺感染死于呼吸衰竭,剔除其数据.术前和术后3 d27例患者Hb分别为(137.94±19.40)、(111.06±12.71)g/L,PLT分别为(210.43±48.26)、(148.40±52.20)×109/L,差异均有统计学意义(t值分别为5.239、4.869,P均＜0.01);术前和术后3 dALT分别为(27.66±11.51)、(29.02±16.40) U/L,AST分别为(26.55±10.12)、(27.75±8.14) U/L,BUN分别为(6.51±1.00)、(6.88±2.53) mmol/L,Cr分别为(96.35±15.25)、(95.11±24.38) μmol/L,差异均无统计学意义(t值分别为0.335、0.882、1.625、0.803,P均＞0.05).术前及术后3个月LVEF分别为(36.23±3.41)％、(47.23±5.13)％,LVED分别为(62.23±5.93)、(58.08±5.02)mm,术后3个月LVEF较术前提高(t=6.904,P＜0.01),LVED明显缩小(=2.790,P＜0.05).结论 OPCABG治疗低LVEF的左主干并三支病变患者早期效果满意,对患者全身重要器官影响有限.但远期疗效及预后还需进一步随访分析.     

Tei指数评价冠脉旁路移植术前后左室整体心功能变化

目的应用Tei指数评价冠脉旁路移植术(CABG)前后患者整体心室功能的变化.方法34例行CABG手术的冠心病患者根据术前LVEF测值分为A组(EF正常组)和B组(EF低下组),分别于术前、术后2～4周、3个月、6个月,应用Tei指数、左室射血分数(LVEF)和二尖瓣血流图检测左室整体心功能.结果术前,A、B两组Tei指数均较正常增高,且B组显著高于A组(P＜0.01).术后,两组Tei指数均逐渐下降,与术前比较以及术后各时间点间比较差异显著(P＜0.05或0.01),且术后不同时间点两组间比较差异显著(P＜0.01).采用LVEF和二尖瓣血流图评价时,术前A、B两组间均存在显著差异(P＜0.05);术后A组LVEF较术前增高不显著(P＞0.05),但E/A较术前明显增高(P＜0.01);B组LVEF较术前明显增高(P＜0.05),E/A早期减低,术后3个月至6个月逐渐升高.结论Tei指数综合考虑心室收缩和舒张功能,能较LVEF和E/A更准确地评价CABG前后患者整体心功能的变化.     

Aberrant right retroesophageal subclavian artery causing esophageal compression

Dysphagia lusoria is present in 0.2–2.5% of the population representing the most common anomaly of the aortic arch (De Araújo et al., 2015, Int. J. Surg. Case Rep., 7, 32). It usually presents in infants, but can present at any age. Symptoms include cough, dysphagia, thoracic pain, and pulmonary infection. Barium contrast studies, CT, and MR angiography are useful studies for evaluating the condition. Dietary modification and PPI therapy are the first‐line treatments with surgical intervention reserved for those with ongoing symptoms (Janssen et al., 2000, Am. J. Gastroenterol., 95, 1411).     

胎儿双侧锁骨下动脉切面在迷走右锁骨下动脉诊断中的应用价值

目的探究胎儿双侧锁骨下动脉切面在迷走右锁骨下动脉(ARSA)诊断中的应用价值。方法选择2018年4月至2019年4月入院接受胎儿心脏超声检查的978例孕妇为研究对象,采用彩色多普勒超声诊断仪观察胎儿三血管气管切面(3-VT)和双侧锁骨下动脉切面。统计孕妇产前超声检查结果中的ARSA检出情况。结果978例胎儿中3-VT切面异常者20例,包括6例ARSA、2例主动脉弓缩窄、2例法洛氏四联症、2例永存动脉干、1例右心发育不良、1例单心室、6例永存左上腔。双侧锁骨下动脉切面ARSA检出率为0.72%(7/978),其中6例与3-VT切面诊断结果一致,1例被3-VT切面扫查漏检。结论双侧锁骨下动脉切面可清晰显示左、右锁骨下动脉及其与左、右无名静脉、气管的位置关系,有助于提高产前ARSA检出率,预防严重畸形儿出生。     

Left Ventricular Longitudinal Strain Measured by Speckle Tracking as a Predictor of the Decrease in Left Ventricular Deformation in Children with Congenital Stenosis of the Aorta or Coarctation of the Aorta

Children born with a left ventricular outflow tract obstruction (LVOTO) can present with symptoms of left ventricular (LV) failure while ejection fraction (EF) is normal. A more sensitive parameter of systolic function might be obtained with speckle tracking echocardiography, which describes ventricular longitudinal deformation in strain values. It is presumed that despite a normal or only slight decrease in ejection fraction, patients with a LVOTO demonstrate aberrations in the longitudinal deformation of the left ventricle. In addition, it is expected that after a successful intervention, longitudinal deformation returns to normal values. Standard trans-thoracic echocardiography was performed on 33 consecutive patients with a LVOTO, either an isolated aortic coarctation (AoCo) or an isolated aortic stenosis (AoSt). Before intervention a significant decrease in strain values was observed compared with the control group (N = 40), with an additional decrease in strain values in the first week after intervention (N = 16). Strain values recovered after a mean follow-up period of 42 wk (N = 9), though normal values were never reached. In addition, patients with an AoCo had a smaller decrease in strain values compared with patients with AoSt. All strain values were measured with a concomitant ejection fraction between normal limits. It is concluded that patients with a congenital LVOTO have decreased ventricular systolic function measured as strain values, whereas their ejection fraction is within the normal range. Therefore, as ejection fraction may not be an accurate measure, speckle tracking-based strain may be significant in the identification of subtle changes in longitudinal deformation and may create opportunities for patients to benefit from early treatment for heart failure.     

左锁骨下动脉急性闭塞与动脉夹层

目的通过对46例左锁骨下动脉急性闭塞患者的造影诊断和经皮腔内血管成形术治疗,探讨动脉夹层与左锁骨下动脉急性闭塞的关系、病理特点及经股动脉-肱动脉逆行双路径腔内血管支架植入术的治疗方法、疗效、适应证及并发症。方法对46例锁骨下动脉急性闭塞的患者采用经股动脉-肱动脉双路径诊断动脉夹层,采用经股动脉-肱动脉双路径腔内血管支架植入技术治疗左锁骨下动脉急性闭塞患者46例。结果造影证实左锁骨下动脉近端动脉夹层并左锁骨下动脉急性闭塞38例,降主动脉内膜下出血(DebackeyⅢ)不典型型并发左锁骨下动脉急性闭塞8例,植入支架46枚,全部成功,仅4例发生短暂左上肢缺血;支架植入后,造影证实左锁骨下动脉血流方向恢复正常、左椎动脉血流方向恢复正常;术后采用彩色多普勒超声、经颅多普勒超声(TCD)和(或)数字减影血管造影(DSA)复查随访2周至12个月,证实支架位置恒定、血流方向正常、无再狭窄。结论左锁骨下动脉近端动脉夹层、主动脉内膜下出血可引起左锁骨下动脉急性闭塞,而导致锁骨下动脉窃血综合征,经股动脉-肱动脉双路径腔内支架植入术治疗效果可靠、操作方法简单安全。     

左心室射血分数≤40%冠心病患者不同血运重建策略的比较

目的 探讨左心室射血分数(LVEF)≤40%的冠心病患者接受经皮冠状动脉介入治疗术(PCI)或冠状动脉旁路移植术(CABG)两种不同血运重建策略的效果.方法 将196例LVEF≤40%的冠心病患者分为PCI和CABG组.回顾性比较其临床资料、血运重建情况、药物治疗效果、院内及随访不良心血管事件(MACCE),并进行生存分析.结果 寿命表法示PCI组与CABG组30 d生存率(96%与94%)、1年生存率(95%与92%)、2年生存率(93%与87%)相似,并且2组COX生存曲线差异无统计学意义(P=0.249);PCI组与CABG组30 d无MACCE事件生存率(92%与92%)、1年无MACCE事件生存率(86%与88%)相似,而CABG组2年无MACCE事件生存率略高于PCI组(83%与72%),但2组COX无MACCE事件生存曲线差异无统计学意义(P=0.662).结论 LVEF≤40%患者接受PCI治疗可以取得与接受CABG治疗相似的急性期和长期生存率.     

Subclavian and pulmonary artery steal phenomenon in a patient with isolated left subclavian artery and right aortic arch

We describe a patient with an isolated left subclavian artery associated with right aortic arch, patent ductus arteriosus, and ventricular septal defect. As the isolated left subclavian artery is supplied by the left vertebral artery in which blood flows in the retrograde direction, this anomaly is usually responsible for a congenital subclavian steal phenomenon. Atrophy of the left cerebral hemisphere and inverted left vertebral arterial flow were clearly depicted by echoencephalography in this patient, whose subclavian artery was connected to the main pulmonary artery by a patent ductus arteriosus. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 2013.     

Arteria lusoria: A rare cause of chronic dysphagia

Arteria lusoria is a rare cause of dysphagia in which dysphagia due to esophageal compression. The upper GI endoscopy does not bring significant element that can orient the diagnosis. The injected thoracic CT scan remains the key examination for the diagnosis of dysphagia lusoria and to characterize the defective artery.     

Subclavian artery laceration: A serious complication of needle decompression

A 31‐year‐old woman presented with spontaneous tension pneumothorax. This was initially treated with needle decompression, which led to massive haemothorax. Treatment and methods to reduce the likelihood of this complication are discussed.     

超声在锁骨上臂丛神经阻滞定位中的应用

目的 研究锁骨上臂丛神经与其周围组织结构的毗邻关系,为超声引导下锁骨上臂丛神经阻滞的临床优化应用提供解剖学基础.方法 应用超声对200例ASAⅠ-Ⅱ级患者的左右双侧锁骨上臂丛神经进行检查,记录所有的声像图,采用二维超声影像工作站测定锁骨上臂丛神经和锁骨下动脉的中心连线与皮肤的夹角及两者中心的水平距离,皮肤到臂丛神经、锁骨下动脉、第一肋骨的距离.应用多因素线性回归分析身高、体质量、年龄等变量与锁骨上臂丛神经的距离的相关性.结果锁骨上臂丛神经和锁骨下动脉的中心连线与皮肤的夹角:左侧(45.3±17.2)°,右侧(46.3±17.6)°;锁骨上臂丛神经和锁骨下动脉的中心水平距离:左侧(0.53±0.17)cm,右侧(0.53±0.18)cm;皮肤到锁骨下动脉的距离:左侧(1.51±0.39)cm,右侧(1.46±0.39)cm;皮肤到第一肋骨的深度距离:左侧(2.23±0.40)cm,右侧(2.23±0.41)cm;皮肤到锁骨上臂丛神经的深度距离:左侧(0.97±0.29)cm,右侧(0.95±0.29)cm.所有测量数据左右两侧相比,差异均无统计学意义(P＞0.05).左、右侧皮肤到锁骨上臂丛神经的距离与身高、体质量存在相关性,其相关系数:左侧0.45,右侧0.52.结论 超声可清楚地显示锁骨上臂丛神经及其周围组织结构.在横断面声像图中,锁骨上臂丛神经主要位于锁骨下动脉的外上方.     

Use of Wave Intensity Analysis of Carotid Arteries in Identifying and Monitoring Left Ventricular Systolic Function Dynamics in Rabbits

Wave intensity analysis (WIA) of the carotid artery was conducted to determine the changes that occur in left ventricular systolic function after administration of doxorubicin in rabbits. Each randomly selected rabbit was subject to routine ultrasound, WIA of the carotid artery, cardiac catheterization and pathologic examination every week and was followed for 16 wk. The first positive peak (WI₁) of the carotid artery revealed that left ventricular systolic dysfunction occurred earlier than conventional indexes of heart function. WI₁ was highly, positively correlated with the maximum rate of rise in left ventricular pressure in cardiac catheterization (r = 0.94, p < 0.01) and moderately negatively correlated with the apoptosis index of myocardial cells, an indicator of myocardial damage (r = −0.69, p < 0.01). Ultrasound WIA of the carotid artery sensitively reflects early myocardial damage and cardiac function, and the result is highly consistent with cardiac catheterization findings and the apoptosis index of myocardial cells.     

超声心动图诊断左心室射血分数减低的左冠状动脉异常起源于肺动脉的效果分析

目的探讨左心室射血分数（LVEF）减低的左冠状动脉异常起源于肺动脉（ALCAPA）的超声心动图特点及手术效果。 方法选取2008年10月至2018年9月首都医科大学附属北京儿童医院ALCAPA患者28例，根据LVEF分为LVEF减低组（LVEF＜50%）19例和LVEF正常组（LVEF≥50%）9例，比较2组患者超声心动图表现，应用两独立样本t检验比较2组患者间超声参数的差异。手术患者（17例）分别于术后1 d、1个月、6个月、1年进行超声心动图随访，应用配对t检验与术前超声参数进行对比。 结果LVEF减低组患者LVEF为30%~48%，平均年龄5.4个月；LVEF正常组LVEF为60%~73%，平均年龄2.5岁。LVEF减低组与LVEF正常组相比，左心室舒张末期内径大［（131.95±24.24）mm/m² vs（85.67±20.26）mm/m²］，右冠状动脉内径小［（3.06±0.51）mm vs（4.01±0.62）mm］，差异具有统计学意义（t=-4.465、4.075，P均＜0.001），易形成室壁瘤。LVEF减低组中10例行手术治疗，7例超声心动图随访至术后1年；与术前相比，术后1 d开始左心室舒张末期内径逐渐回缩［（109.98±16.06）mm/m²、（99.49±12.02）mm/m²、（89.48±10.90）mm/m²、（80.03±8.09）mm/m² vs（123.26±12.40）mm/m²］，差异具有统计学意义（t=-2.668、-7.519、-5.413、-6.526，P=0.004、0.001、0.012、0.007），LVEF术后1个月开始恢复，术后6个月达正常水平［（45.50±9.57）%、（66.25±10.34）%、（67.25±4.50）% vs（38.83±7.05）%］，差异具有统计学意义（t=3.162、3.683、5.869，P=0.025、0.014、0.002）。 结论LVEF减低的ALCAPA患儿年龄小、心脏病变重，超声心动图可以准确作出诊断，但需要与心内膜弹力纤维增生症、扩张型心肌病相鉴别。ALCAPA手术治疗远期效果较好，超声心动图在术后随访中有重要作用。