胸腹主动脉瘤手术治疗中的截瘫并发症

胸腹主动脉瘤（thoracoabdominal aortic aneurysm，TAAA）是指胸主动脉和腹主动脉联合动脉瘤，按照性质可分为真性动脉瘤、假性动脉瘤和夹层动脉瘤。治疗方式主要包括传统外科手术、腔内修复术（endovascular aneurysm repair，EVAR）以及近来新兴的“杂交手术”（hybrid treatment），即联合利用传统外科手术重建脏器血管和腔内技术修复动脉瘤。传统外科手术治疗TAAA已有半个多世纪，术式历经不断改进；EVAR技术应用十余年来发展迅猛，已经历几代产品的变革。但迄今为止无论何种术式，因脊髓缺血而造成截瘫这一灾难性的并发症仍无法完全解决。     

主动脉瘤腔内隔绝术

主动脉的扩张性疾病可分为真性动脉瘤、动脉夹层（aortic dissection，AD）和假性动脉瘤。随着这类疾病发病率和检出率逐年提高，人们对它们的关注程度也不断提高。如何治疗他们，成为摆在临床医生面前的难题。1991年，Parodi率先报告了支架-人造血管复合体（直型）在腹主动脉瘤治疗中的应用，成为腔内血管治疗历史上的一个里程碑。随着医疗器械的不断发展、技术的不断完善、经验的不断积累总结，微创、安全的腔内隔绝术在主动脉扩张性疾病中的治疗中得到广泛的认可，并在全球范围内迅速推广。     

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微创技术在血管外科领域的应用导致了一个崭新的学科—腔内血管外科的诞生。1964年ＣｈａｒｌｅｓＤｏｔｔｅｒ使用同轴导管技术为1例83岁的下肢动脉硬化闭塞症导致左足溃疡合并感染并且伴有心功能不全的女性病人施行了世界首例经皮腔内血管成形术,这一微创手术的成功不仅标志着腔内血管外科技术的出现,同时也在一开始就充分体现了腔内血管外科技术安全、微创的特点。20世纪80年代以后,球囊导管血管成形术和血管支架广泛用于阻塞病的治疗。最近10年来,腔内隔绝术治疗腹主动脉瘤、胸主动脉瘤、胸主动脉夹层动脉瘤等动脉扩张病的成功是微创技…     

大动脉外科疾病的腔内治疗

发生于大动脉的外科疾病主要是真性动脉瘤、夹层动脉瘤和假性动脉瘤等动脉扩张病。早在1684年,Moore将一段金属丝导入腹主动脉瘤腔内,希望促发瘤内血栓形成。这是人类的首次大动脉腔内治疗尝试,而其真正的发展仅仅是最近20年的事。上世纪80年代中后期开始了动脉瘤腔内隔绝系统的实验研究,到1990年,Parodi成功地施行了世界上第一例腹主动脉瘤腔内隔绝术,在国内,笔者于1997年率先开展了该手术[1],并在此后迅速推广应用于胸主动脉瘤、夹层动脉瘤、假性动脉瘤和动静脉瘘等疾病的治疗。1主动脉真性动脉瘤的腔内治疗发生在主动脉的真性动脉瘤可分…     

累及分支动脉的主动脉病变腔内治疗移植物研究进展

主动脉瘤（包括胸、腹主动脉瘤和主动脉夹层动脉瘤）是一类严重威胁人类健康的动脉疾病．其治疗方式在近数十年中一直是研究焦点。随着影像学技术、材料技术的进步，主动脉瘤的治疗方式发生了巨大变化。腔内隔绝术是主动脉瘤治疗方式的重大改进，由于微创、围手术期低死亡率、低并发症率以及良好的近期效果使其得到广泛认同并迅速普及。动脉瘤的瘤颈条件是腔内隔绝治疗首要考虑的因素。以往认为．动脉瘤距锁骨下动脉和腹腔干2．3cm、距肾动脉开口1-2cm是行腔内隔绝的前提，且瘤颈不能有过大的成角和血栓形成。对于涉及分支血供的主动脉瘤（如主动脉弓动脉瘤、胸腹主动脉瘤、肾上型及累及髂内外动脉的腹主动脉瘤等）和短瘤颈的腹主动脉瘤（瘤颈长度〈10mm），采用标准的腔内移植物则会在隔绝动脉瘤的同时造成身体其他部位的缺血性改变，同时也会因开放的侧支增加术后Ⅱ型内漏的风险并影响腔内隔绝术后早期瘤囊的缩退。若在治疗中保留主要分支血供（如左锁骨下动脉、肾动脉），则腔内移植物固定不稳．会增加移位和隔绝失败的风险。如何在隔绝动脉瘤的同时保留分支血供，自然而然地成为研究的重点，也是将来腔内移植物发展的方向。     

主动脉疾病的封堵器治疗

在过去的十几年中,随着腔内技术的日益成熟,应用腔内技术治疗主动脉疾病已成为临床重要的方法。但对于一些复杂的主动脉病变,应用支架移植物既良好隔绝主动脉瘤或主动脉夹层,又保持分支动脉通畅往往十分困难,而且长期随访之后发现一些患者出现腔内治疗的并发症,甚至需要再次手术,比如主动脉夹层远端裂口部位的假腔瘤样扩张等[1]。故近年来陆续有学者提出以传统的治疗先天性心脏病的封堵器来治疗复杂的主动脉病变的想法,其应用目前主要集中于主动脉夹层和主动脉假性动脉瘤。     

腔内隔绝术治疗累及分支的主动脉弓疾病

血管腔内隔绝术（endovascular exclusion，EVE）是一种微创而安全的介入治疗技术，应用这一技术可对多种主动脉扩张性疾病进行有效的治疗，尤其适用于伴有高危因素而不宜行外科手术治疗的患者。     

主动脉疾病腔内隔绝术的热点及难点思考

主动脉疾病腔内治疗具有创伤小、恢复快、低死亡率和低并发症率等特点,已经在国内外得到广泛普及,并且随着腔内技术和腔内器具的不断发展,越来越多的主动脉疾病得到了腔内微创治疗,在技术上经历了经典的腔内隔绝术、杂交手术阶段,再到复杂腔内隔绝术阶段.从国内外临床资料来看,主动脉疾病腔内治疗术后中长期随访效果还是非常令人满意的.随着对主动脉疾病的不断认识,为了更好地适应主动脉疾病腔内治疗的需要,我们也提出了新的"3N3V"分型法.目前,累及分支动脉的主动脉疾病腔内隔绝术无疑是这个领域的热点及难点问题.     

少见的主动脉病变的腔内隔绝术：附8例报告

总结腔内隔绝术治疗少见大动脉疾病的疗效。8例少见大动脉疾病，均采用腔内隔绝术进行治疗，报告其术前，手术及术后的情况。8例大动脉疾病患者（Stanford A型主动脉夹层3例，Stanford B型主动脉夹层1（转流后）, 主动脉弓部真性动脉瘤3例，肾水平腹主动脉瘤1例）。Stanford A型主动脉夹层2例术后因并发症死亡，余患者全部存活，随访生活质量良好。腔内隔绝术治疗大动脉疾病具有创伤小，疗效可靠的优点，其远期效果尚有待近一步观察。     

胸腹主动脉瘤的外科治疗进展

胸腹主动脉瘤(TAAA)是一种累及降主动脉及腹主动脉的动脉瘤样变,自然病程病死率高,手术治疗难度大。传统的治疗方式为开放手术,随着腔内技术的发展,杂交手术和以开窗支架和分支支架为代表的腔内手术技术在TAAA治疗方面展现出了价值,新近出现的八爪鱼技术进一步完善了腔内治疗的术式选择,TAAA的微创治疗正逐步成为可能。     

"Free" and "exchangeable" or "trapped" and "non-exchangeable" water in cartilage

We repeated some of our own previous experiments, as well as some of Torzilli's recent experiments (11) on which he bases his conclusions relating to a nonexchangeable "trapped water" in cartilage. We are unable to confirm Torzilli's findings. We observed partition coefficients for 3H.HO very close to unity. That both the extrafibrillar and most of the intrafibrillar water is freely exchangeable and behaves as available water towards small solutes has been independently shown (3) for other collagenous tissues. All the different permutations of partition experiments have yielded results that are fully consistent with our original picture of the very major fraction of cartilage water being free.     

"Empty wall" and "vertical strut" signs of ACL insufficiency

We report our observation on the "empty wall" and "vertical strut" signs of anterior cruciate ligament (ACL) insufficiency. ACL tears most commonly occur in the midsubstance; arthroscopic evaluation of patients with these tears often reveals minimal evidence of previous ACL tissue along the intercondylar wall, thus giving the appearance of an "empty wall." In proximal ACL tears, the long remnant of ACL tissue may adhere to adjacent PCL tissue. Arthroscopically, one may see this vertically oriented strut of tissue, which to the casual arthroscopist may mimic a normal-appearing ACL except for orientation and tension. In addition, the "empty wall" sign will be noted because the lateral intercondylar wall becomes easily visible following ACL injury. In two separate prospective studies of 84 such patients, the combined incidence of the empty wall sign was 82%, and the incidence of the vertical strut sign was 50%. These findings should be sought for meticulously at the time of arthroscopic evaluation. The vertical strut should not be misinterpreted as an aberrantly oriented ACL or partial ACL tear.     

Spatiotemporal analysis of auditory "what" and "where" working memory

Goal-directed attention to sound identity (what) and sound location (where) has been associated with increased neural activity in ventral and dorsal brain regions, respectively. In order to ascertain when such segregation occurs, we measured event-related potentials during an n-back (n = 1, 2) working memory task for sound identity or location, where stimuli selected randomly from 3 semantic categories (human, animal, music) were presented at 3 possible virtual locations. Accuracy and reaction times were comparable in both "what" and "where" tasks, albeit worse for the 2-back than for the 1-back condition. The partial least squares analysis of scalp-recorded and source waveform data revealed domain-specific activity beginning at about 200-ms poststimulus onset, which was best expressed as changes in source activity near Heschl's gyrus, and in central medial, occipital medial, right frontal and right parietal cortex. The effect of working memory load emerged at about 400-ms poststimulus and was expressed maximally over frontocentral scalp region and in sources located in the right temporal, frontal and parietal cortices. The results show that for identical sounds, top-down effects on processing "what" and "where" information is observable at about 200 ms after sound onset and involves a widely distributed neural network.