胸主动脉腔内修复术中应用体外开窗技术重建左锁骨下动脉的临床分析

目的 探讨体外开窗技术在胸主动脉腔内修复术(TEVAR)中重建左锁骨下动脉(LSA)的方法和疗效。方法 回顾性分析2016年1月—2018年12月南京鼓楼医院和徐州市中心医院血管外科应用体外开窗技术在TEVAR中重建LSA的67例患者的临床资料,其中男51例、女16例,年龄41～76(63±5)岁。67例中,B型主动脉夹层50例、胸主动脉瘤11例、壁间血肿4例、主动脉溃疡2例。观察患者TEVAR后的内漏发生率,主体和分支支架的位置、完整性和通畅性,以及患者手术相关死亡率。结果 67例患者中,有66例成功采用体外开窗技术重建LSA,技术成功率达98.5%;另1例因术中对位不准确转为烟囱技术重建LSA,术后均获随访(3~48个月)。术后即刻造影提示存在少量Ⅰ型内漏3例,未予处理,术后3个月复查主动脉CT血管造影(CTA))提示内漏消失;2例患者术后出现左上肢乏力,其中1例伴头晕,均在随访过程中逐渐恢复,无肢体缺血坏死。随访中所有患者分支支架及主体支架均通畅并保持着良好的完整性,无主动脉覆膜支架移位、内漏等并发症,无手术相关死亡患者。结论 体外开窗技术为TEVAR中重建LSA提供了技术支持,方法简单有效,短、中期随访结果满意。     

A型主动脉夹层头臂血管的解剖学研究及临床意义

目的　对Ａ型夹层状态下的头臂血管进行解剖学测量,为人工血管的制作和完善提供数据支持,为主动脉腔内治疗和头颈部介入操作提供参考。 方法　对331例Ａ型主动脉夹层的患者行回顾性CTA三维重建,并对其分别进行形态描述,径线和角度测量。 结果　共计331例,标准型主动脉弓91.5%(303例),变异型主动脉弓8.5%(28例)。25.4%（77例）3分支开口均低于主动脉弓最高点。3分支开口分布中,IA多见于后位,而LCCA和LSA则多见于中位。IA最易被夹层累及。由IA到LSA,3分支在开口处的直径分别为（16.2±3.6）、（11.0±3.3）、（12.9±3.6）mm。3分支在距离开口2 cm处直径分别为：（12.0±3.0）、（9.0±1.9）、（9.8±2.1）mm。IA-LCCA间距平均为（10.1±5.5）mm(2.0~20.0mm)。LCCA-LSA间距平均为(14.1±5.9)mm(2.0~27.0mm)。在主动脉弓冠状面,头臂血管与主动脉弓所成角分别为（62.5±26.5）°,（57.8±23.4）°,（64.9±23.5）°。在主动脉弓横截面,头臂血管与主动脉弓所成角分别为（121.1±24.7）°,（107.3±19.4）°,（100.5±16.1）°。 结论　通过本研究得到了A型夹层状态下的头臂血管详细解剖数据,且和目前流行的人工血管设计数据并不一致,这为人工血管进一步完善提供了数据支持。     

基于叠加DRR库的胸主动脉腔内修复术中CT血管造影与X线图像配准

目的胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)已经广泛应用于胸主动脉病变的治疗,成为传统主动脉开胸手术的可靠替代方案。然而,医生在术中看不到血管形态和位置,覆膜支架容易封堵主动脉重要分支而引发严重并发症。为了帮助医生导航支架,提出并实现了一种TEVAR术前CT血管造影(computed tomographic angiography,CTA)与术中X线图像的配准算法。方法首先,对影响CTA投影形状的参数高密度采样,利用采样获得的系列投影形变,分别对CTA全图和分割的CTA骨架进行数字影像重建(digitally reconstructed radiograph,DRR),将两者叠加起来,生成叠加DRR库;然后,以爬山优化,在叠加DRR库中寻找与X线图像归一化互信息最大的DRR图像,推算出投影形变,最终实现CTA与X线图像的配准。结果采用叠加DRR库的方法,配准了1例患者的术前CTA图像与一帧术中X线图像。与归一化互相关方法以及无骨架叠加的普通DRR库方法相比较,本方法获得了更为精确的配准结果。结论基于叠加DRR库的方法能有效配准术前CTA与术中X线图像。     

1例Stanford B型主动脉夹层TEVAR术后新发破口的血流动力学分析

目的 基于血流动力学分析,探究1例B型主动脉夹层在腔内修复术（thoracic endovascular aortic repair, TEVAR）后发生新发破口的原因。方法 对1位B型主动脉夹层患者在TEVAR术后1、6、12、24月定期复查主动脉CT血管造影检查（computed tomography angiography,CTA）。基于各时期CTA影像,重建三维模型,进行形态学和血流动力学数值模拟分析。结果 相比于术后1月,术后12月真腔直径增加1.8倍,且主动脉整体扭曲度增加16.67%;术后1、6、12月,在心脏收缩期新发破口处最大血流速度分别高于支架远端锚定区平均流速69.6%、33.7%、92.1%,最大壁面剪切应力分别为平均剪切力的2.52、2.32、3.52倍;此外,最大时均壁面切应力（time-averaged wall shear stress, TAWSS）在术后1、6、12月分别为平均TAWSS的1.88、2.53、3.62倍。结论 TEVAR术后新发破口处主动脉真腔直径存在明显突变,且持续增大。导致该处主动脉血流流速加快,内膜长期承受高壁面剪切应力,进而引起新发破口。     

杂交手术治疗累及弓部的Stanford B型主动脉夹层的疗效分析

目的:探讨杂交手术在治疗累及弓部的Stanford B型主动脉夹层（TBAD）中的有效性和安全性。方法:前瞻性描述性研究。纳入2020年1月—2021年9月蚌埠医学院第一附属医院血管外科确诊为累及弓部的TBAD患者。其中男16例,女5例;年龄32~81（59.7±12.9）岁。患者均采用外科转流术和胸主动脉腔内修复术相...     

腔内隔绝术治疗Stanford B型主动脉夹层23例临床分析

目的探讨Stanford B型主动脉夹层动脉瘤腔内隔绝术治疗的手术指征、术前评估方法、手术操作技巧、并发症及防治原则；观察近、中期临床疗效。方法自2003年3月～2006年1月，对23例Stanford B型主动脉夹层动脉瘤患者行腔内隔绝术治疗，笔者对临床资料进行回顾性分析。术前采用CT血管造影（CTA）或磁共振血管造影（MRA）对主动脉夹层动脉瘤进行评估，术中在数字减影血管造影（DSA）监视下经股动脉将移植物导入胸主动脉封闭夹层裂口，术后行影像学及症状学随访观察。结果术中成功释放移植物22例，术后即刻DSA造影显示18例近段破口完全被封闭，动脉瘤消失，4例发生内漏，其中2例再次置入支架后内漏消失。术后2例患者发生腹主动脉夹层，其中1例再次行腔内隔绝术。1例患者发生肠系膜动脉栓塞引起肠坏死而死亡。22例患者术后无心、肺、肾功能衰竭及截瘫等并发症，术后生命体征平稳，切口愈合，出院，术后经过CTA及症状学随访显示无严重并发症，生活质量明显提高。结论腔内隔绝术是一种创伤小、恢复快的新方法，近、中期随访结果表明该技术安全、有效。     

累及左锁骨下动脉的主动脉夹层腔内修复术中开窗技术的研究进展

目的探讨累及左锁骨下动脉(LSA)的主动脉夹层(AD)腔内修复术中开窗技术的研究进展。方法在中国知网、万方数据、维普数据及PubMed等中、英文数据库检索2023年6月前公开发表的关于AD治疗和开窗技术的相关文献142篇, 剔除内容不符、无法获取原文、重复性研究的文章, 最终纳入48篇近期发表在较为权威期刊的文章, 总结和分析累及LSA的AD腔内开窗技术的研究进展。结果近年来开窗技术发展迅速且比较成熟, 在累及LSA的AD治疗中表现出诸多优势, 并成功应用于左椎动脉起源于主动脉弓的解剖学变异患者的治疗。但该技术存在对位困难的缺点, 术前3D打印技术的应用有效提高了预开窗技术的对位成功率。结论开窗技术是众多分支血管重建技术中的一种, 在目前AD治疗以腔内介入为主的大环境下, 凭借其创伤小、符合生理解剖结构、并发症少等优势, 加上3D打印技术的辅助, 在未来会有更大的发展空间。     

右位主动脉弓及相关结构的变异一例

中年男尸,右位主动脉弓,肉眼观察,其它体征正常。（1）右位主动脉弓：主动脉向右前上方斜升,至第2胸椎体下缘高度移行为主动脉弓。主动脉弓向上经气管前方继续向右后下方行走,沿脊柱右侧下行至第4胸椎体下缘移行为胸主动脉。头臂干缺失,右位主动脉弓从左到右直接发出左颈总动脉、右颈总动脉、右锁骨下动脉和左锁骨下动脉。左、右颈总动脉及右锁骨下动脉的口径数值分别为11．6mm、7．28mm和10．35mm。（2）左锁骨下动脉变异：于第3胸椎体及第4胸椎体上缘前面,起自主动脉弓降部,横跨第3胸椎体及第4胸椎体上缘,到脊柱的左侧几乎成直角向上走行。     

腹主动脉瘤开放手术和腔内手术治疗的近期疗效分析

目的 对比分析腹主动脉瘤开放手术(OSR)与腔内修复手术(EVAR)的近期疗效。方法 回顾性研究。纳入2008年1月—2020年12月蚌埠医学院第一附属医院血管外科接受手术治疗的腹主动脉瘤患者118例,其中男102例、女16例,年龄(70.5±9.6)岁。根据手术治疗方式的不同,分为OSR组23例和EVAR组95例。观察指标:(1)比较两组患者的年龄、性别、不良生活习惯、合并症、瘤体最大径、复杂瘤颈形态等基线资料。(2)比较两组患者手术时间、术中出血量、术后禁饮食时间、术后卧床时间、住院时间,以及术后并发症和死亡发生情况。(3)术后定期复查CT血管成像(CTA),观察有无再干预、支架内血栓形成、支架内再狭窄、移植物感染、各型内漏等发生。结果 OSR组和EVAR组的基线资料比较差异均无统计学意义(P值均＞0.05)。患者均顺利完成手术。EVAR组的手术时间、术中出血量、术后禁饮食时间、术后卧床时间、住院时间均少于OSR组,分别为(141.15±22.97) min与(242.79±29.41) min、(34.32±16.08) mL与(443.93±109.58)mL、(14.26±3.34) h与(52.25±12.05)h、(4.07±0.63) d与(6.48±0.83)d、(21.88±1.78) d与(24.44±2.44)d,差异均有统计学意义(t=17.919、17.881、14.978、15.532、4.745,P值均＜0.05);两组患者围手术期并发症发生率及死亡率比较,差异均无统计学意义(P值均＞0.05)。患者均获随访1年,除EVAR组2例出现轻微Ⅱ型内漏外,均无严重并发症发生。结论 腹主动脉瘤的OSR和EVAR均能取得良好的近期治疗效果。与OSR相比较,EVAR手术时间更短,术中出血更少,术后禁饮食、卧床及住院时间更短,术后恢复更快。     

经桡动脉穿刺椎动脉支架置人术治疗颅内动脉狭窄1例报道

目的：探讨颈动脉支架成形术（CAS）治疗高手术风险颈动脉狭窄的短期疗效和安全性.方法：采用自膨式颈动脉支架（所有患者均给予脑保护装置）治疗高手术风险颈动脉狭窄患者20例.结果：所有患者均成功置入支架.术后造影复查,所有患者颅内血管供血状况改善.术后临床症状均有缓解.20例术后随访1～18月,术后3月时出现短暂性脑缺血发作1例,无脑梗死及脑出血发生,无支架内再狭窄.结论：颈动脉支架成形术治疗高手术风险颈动脉狭窄,是一种安全、有效的方法,短期疗效肯定.     

Early outcomes of extra-thoracic debranching thoracic endovascular aortic repair for distal aortic arch disease

Thoracic endovascular aortic repair (TEVAR) combined with supra-aortic debranching is a promising approach for distal aortic arch disease, especially in high-risk patients. Most debranching TEVAR procedures for distal arch pathologies can now be performed by using extra-thoracic bypass and endovascular repair, without intra-thoracic manipulation needing sternotomy or thoracotomy. To compare the early outcomes of extra-thoracic debranching TEVAR with those of conventional arch replacement, we retrospectively reviewed data from 20 high-risk patients with distal aortic arch disease who underwent extra-thoracic debranching TEVAR and 16 patients who underwent total arch replacement from March 2009 to November 2011. Patient demographics, operative data, and outcomes in each group were evaluated and compared. The mean follow-up period was 22.4 ± 12.7 months. In the extra-thoracic debranching TEVAR group, primary technical success was achieved in all cases. One patient (5 %) died of low cardiac output syndrome within 30 days after surgery. Two patients had perioperative morbidities (10 %); both had a stroke during the procedure. No endoleak or graft migration was observed, and all bypass grafts remained patent. No patient had paraplegia, a new aortic event, or surgical site infection. In conclusion, the early outcomes of extra-thoracic debranching TEVAR in high-risk patients with distal aortic arch disease were satisfactory and encouraging, compared with conventional arch replacement. Extra-thoracic debranching TEVAR has the advantage of less invasiveness and no possibility of sternal infection.     

Thoracic Endovascular Aortic Repair with the Chimney Technique for Blunt Traumatic Pseudoaneurysm of the Aortic Arch in a No-Option Patient

A 42-year-old man was involved in a motor vehicle collision. Imaging studies revealed the presence of a post-traumatic aortic pseudo-aneurysm (about 34×26 cm) arising from the descending thoracic aorta at the level of the left subclavian artery (LSA), prone to rupture. Thoracic endovascular aneurysm repair (TEVAR) was the only feasible option due to his poor overall medical status. In this case, LSA needed to be covered in order to extend the proximal landing zone. Eventually, modified TEVAR was successfully performed by means of the chimney technique to preserve flow to the LSA and to prevent flow into the pseudoaneurysmal sac.     

395例体外循环下冠状动脉旁路移植术临床分析

目的总结分析冠状动脉旁路移植术(CABG)治疗冠心病的疗效和经验。方法 2002年1月至2012年12月我们完成CABG有395例,其中男299例,女96例,平均年龄62.3岁,均在中低温体外循环下完成手术,其中18例同期行室壁瘤切除术。结果本组平均搭桥3.2支。体外循环时间62~170 min,平均88 min,主动脉阻断时间25~102 min,平均68 min。术后机械通气时间12~72 h,平均18 h。围手术期死亡8例,死亡率2.0%,其中多器官功能衰竭6例,术后发生室颤抢救无效死亡1例,围术期急性心肌梗死1例。心功能均明显改善,195例心绞痛症状完全缓解,85例症状较前减轻。随访280例,随访时间8个月至11年,远期死亡5例,死亡原因不明。结论常规中低温体外循环下CABG是治疗冠心病安全、有效的方法。     

Stent graft treatment for thoracic and thoracoabdominal aortic disease using a unibody Z-stent that adapts to flexure

Positioning a stent graft (SG) that adapts to the anatomical shape of the aorta is important to prevent complications after SG procedures to treat aortic disease. The Gianturco Z-stent has several benefits, but its rigid structure prevents adaptation to flexure. We improved this stent and studied its ability to adapt in the clinical environment. We positioned SGs and inspected their adaptability to flexure in an aortic arch model. We examined several gap lengths and strut directions, and determined the distance generated between the stent and the aortic wall. We found that adaptation was quite satisfactory with a gap of more than 10 mm or when the struts faced the major flexure or the side of the model aorta. Based on these findings and to facilitate placement, we manufactured the unibody Z-stent with 10-mm gaps. The unibody Z-stent was applied to treat thoracic and thoracoabdominal aortic disease in seven patients. The SG was positioned from the femoral or iliac artery in five patients and from an anastomosed graft to the ascending aorta after median sternotomy and bypass of the arch branches in two patients. A minor endoleak developed in one patient. None of the other six patients developed complications or died during the procedure, although one patient died in the hospital due to cerebral infarction. The unibody Z-stent was applied as a SG that adapts to flexure of the aorta and was easy to apply. The frequency of complications was apparently decreased after clinical application of the unibody Z-stent in SG treatment for thoracic and thoracoabdominal aortic disease.     

Clampless aortic punch system for making a large-diameter access route without side-biting clamp: a preliminary study

Journal of Artificial Organs - Although thoracic endovascular aneurysm repair (TEVAR) has been getting popularity as a less-invasive procedure, the treatment of thoracic aortic aneurysm with...     

Surgical results of low-dose systemic heparinization (1 mg/kg, 100 IU/kg) in thoracic aortic operation combined with a heparin-coated cardiopulmonary bypass circuit: Is low-dose heparinization safe during deep hypothermic circulatory arrest?

Heparin-coated cardiopulmonary bypass circuits allow a reduction in the use of systemic heparin administered during cardiopulmonary bypass. This study was carried out to investigate safety during deep hypothermic circulatory arrest in this low-dose heparin group during thoracic aortic operation. Heparin-coated cardiopulmonary bypass circuits were used in 30 adult patients who underwent thoracic aortic operations that required deep hypothermic circulatory arrest. The patients were divided into two groups. Six patients received 300 IU/kg of heparin, and the remaining 24 patients received 100 IU/kg. Clinical outcomes (mortality, incidence of stroke, and transfusion volumes during operation) were examined. All devices remained functional throughout the procedures, and no systemic emboli were detected. Two deaths occurred in the high-dose heparin group, but no deaths occurred in the low-dose heparin group (P = 0.03). The percentage of patients requiring transfusion was similar in the two groups (66.7% vs. 70.8%), but the median exposure to allogenic blood products was greater in the high-dose heparin group than in the low-dose heparin group (9.8 ± 9.5 units vs. 5.5 ± 5.2 units; P = 0.09). Reduced systemic heparinization, combined with hepar-in-coated cardiopulmonary bypass circuits during deep hypothermic circulatory arrest, can be performed with acceptably low early mortality in thoracic aortic operations. Patients are not at increased risk for stroke. Received: September 28, 2000 / Accepted: April 10, 2001     

LEO+Baby单支架辅助弹簧圈栓塞前交通动脉瘤的有效性及安全性

目的评价专为小血管设计的低剖面、自膨式LEO+Baby单支架辅助弹簧圈栓塞前交通动脉瘤的有效性和安全性。方法回顾性分析应用LEO+Baby单支架辅助弹簧圈栓塞技术治疗的52例前交通动脉瘤患者的临床资料,统计患者基本信息、影像学资料、手术情况及并发症情况。结果52例前交通动脉瘤患者应用LEO+Baby支架51枚,1例患者支架导管到位困难,转开颅手术治疗,其余均操作成功,成功率为98%(51/52);术后即刻造影动脉瘤完全栓塞42例,瘤颈残留9例。术中动脉瘤破裂1例,支架内血栓形成3例,术中弹簧圈脱出1例。术后随访6~12个月,改良Rankin量表(mRS)评分为4~5分2例,2~3分5例,随访无死亡病例。46例患者术后6个月DSA复查结果显示完全栓塞率89.1%(41/46),其余5例未行DSA复查;无支架相关并发症及动脉瘤再破裂出血发生。头颅CT显示,无迟发性脑梗死、脑出血发生。结论应用LEO+Baby单支架辅助弹簧圈栓塞前交通动脉瘤操作成功率和安全性高、围术期并发症少且短期预后良好。