急性期Stanford B型主动脉夹层患者腔内修复术后主动脉重塑

【摘要】 目的 探讨急性期Stanford B型主动脉夹层（TBAD）胸主动脉腔内修复（TEVAR）术后主动脉重塑及其演变过程。方法 回顾性分析2013年6月至2018年6月单中心诊断为急性期TBAD并行TEVAR治疗的217例患者临床和影像学资料。通过RadiAnt Dicom Viewer工作站进行图像后处理，测量主动脉峡部、肺动脉分叉、膈肌、腹腔干、左肾动脉开口及腹主动脉分叉平面的真腔、假腔直径和总直径，记录假腔血栓化程度。 结果 主动脉峡部、肺动脉分叉平面真腔增大、假腔缩小，差异均有统计学意义（P＜0.05），假腔血栓化率高；膈肌、腹腔干、左肾动脉开口平面真腔增大、假腔缩小，真腔增大差异均有统计学意义（P＜0.05），假腔缩小差异均无统计学意义（P＞0.05），假腔血栓化率较高；腹主动脉分叉平面真腔增大、假腔增大，差异均无统计学意义（P＞0.05），假腔血栓化率低。各平面术后总直径较术前无明显变化，差异均无统计学意义（P＞0.05）。 结论 TEVAR术后胸降主动脉段重塑良好，真腔明显扩张，假腔明显缩小、血栓化率高。腹主动脉段重塑不良，可能与远端破口旷置有关。远端假腔直径和总直径变化不显著提示夹层可能稳定，远端破口暂无需手术处理，但严密影像学随访远端破口尚未处理患者十分重要。     

单分支型主动脉覆膜支架治疗Stanford B型主动脉夹层的临床价值

【摘要】 目的 探讨单分支型主动脉覆膜支架在Stanford B型主动脉夹层单纯腔内隔绝治疗中的临床价值。 方法 2017年7月至2018年10月采用国产CastorTM单分支型主动脉覆膜支架行单纯腔内隔绝治疗19例Stanford B型主动脉夹层患者,观察术后即时血管造影结果。术后1个月门诊随访,术后6个月复查主动脉CTA。以手术成功率、假腔消失率和分支支架通畅率为有效性终点指标,观察相应不良事件。 结果 19例患者支架均释放成功,技术成功率100%。围手术期无不良事件发生。随访期患者无死亡,4例门诊随访时出现左上肢缺血症状,经对症治疗后缓解。无严重内漏发生,分支支架通畅率100%,夹层假腔均出现血栓化,假腔直径平均缩小（10.3±1.2） mm（肺动脉分叉平面）。 结论 单分支型主动脉支架对于近端破口距左锁骨下动脉开口＜15 mm或逆撕至左锁骨下动脉根部的Stanford B型主动脉夹层,是有效的单纯腔内隔绝方法。     

单中心主动脉腔内修复术治疗Stanford B型主动脉夹层近远期疗效

目的总结应用主动脉腔内修复术治疗胸降主动脉夹层(Stanford B型)的经验并评价其近、远期疗效。方法收集2002年4月至2013年3月行主动脉腔内修复术治疗的Stanford B型主动脉夹层患者320例。行主动脉夹层腔内修复术后定期随访,评价术后1、3年死亡及并发症情况,包括内漏、脑血管事件、新发主动脉夹层、再次行主动脉腔内修复术等。结果主动脉腔内修复术操作成功率为100%。6例患者于术后死亡,对314例出院患者进行随访,1年随访率73.0%(229/314)。术后1年死亡12例(5.2%),其中,主动脉源性死亡6例,心源性死亡1例,脑源性死亡2例,肿瘤源性死亡2例,其他源性死亡1例。1年发生内漏3例,脑梗死2例,脑出血3例,新发主动脉夹层1例,再次行主动脉腔内修复术3例。3年随访率为69.4%(218/314)。术后3年死亡21例(9.6%),其中,主动脉源性死亡9例,心源性死亡2例,脑源性死亡5例,肿瘤源性死亡3例,其他源性死亡2例。3年发生内漏5例,脑梗死3例,脑出血6例,新发主动脉夹层5例,再次行主动脉腔内修复术5例。结论主动脉腔内修复术治疗Stanford B型主动脉夹层技术可行,安全性高,并发症少,1年、3年随访疗效满意,远期疗效需进一步随访观察。     

Stanford B型主动脉夹层假腔供血动脉分支对腔内治疗后假腔重塑的影响

【摘要】 目的 探讨胸主动脉腔内修复术（TEVAR）治疗Stanford B型主动脉夹层后,腹主动脉假腔供血动脉分支对远端假腔重塑的影响。 方法 单中心回顾性队列研究2005年8月至2018年8月东南大学附属中大医院采用TEVAR术治疗的56例急性和慢性Stanford B型主动脉夹层患者。通过CTA随访资料观察记录主动脉腹段假腔内血栓形成、腹主动脉内脏分支供血类型。 结果 56例患者腹主动脉分支真腔供血以假腔完全血栓形成和血栓吸收为主。腹主动脉假腔参与分支供血,包括双腔供血、完全假腔供血,假腔以部分血栓形成为主,同时有假腔通畅情况。有假腔参与分支供血合并有更多内膜破口,与假腔血栓形成呈负相关。结论 主动脉夹层TEVAR术后腹主动脉假腔供血可影响假腔血栓形成。假腔供血分支可能是假腔部分血栓形成或通畅的危险因素。     

Stanford B型主动脉夹层腔内修复术后血管重塑分析

目的 探讨Stanford B型主动脉夹层患者经胸主动脉腔内修复术(TEVAR)治疗后血管形态学转归.方法 回顾性分析51例接受TEVAR术治疗的Stanford B型主动脉夹层患者术前及术后临床及影像学资料,分析术后1个月内、1～6个月、6个月后主动脉各段真假腔内径及假腔血栓化情况.结果 TEVAR术后胸主动脉真腔扩大、假腔缩小,与术前比较差异有统计学意义(P＜0.05),腹主动脉管径真腔和假腔变化较术前无统计学差异(P＞0.05),腹部重要分支动脉血供情况较术前有所改善.结论 TEVAR术治疗Stanford B型主动脉夹层患者的近中期效果确切,但仍需要远期随访观察.     

远端破口在Stanford B型主动脉夹层预后中的研究进展北大核心CSCD

胸主动脉腔内修复术(TEVAR)是目前治疗Stanford B型主动脉夹层(TBAD)的首选术式。TEVAR主要封闭TBAD近端破口,对远端破口进行定期随访观察。鉴于远端破口的存在对夹层预后会产生不利的影响,本文介绍了远端破口的解剖学特征评估方法、远端破口对夹层预后的影响以及相关血流动力学的研究进展,在此基础上进一步综述了远端破口的介入干预方法及其远期疗效。     

带膜支架治疗Stanford B型胸主动脉夹层的疗效分析

目的分析带膜支架腔内隔绝术治疗Stanford B型胸主动脉夹层的短期和中长期疗效。方法对2005年1月至2013年12月全麻下行带膜支架治疗的183例Stanford B型胸主动脉夹层患者的资料进行回顾性分析,包括术后住院期间的临床症状、术后并发症、ICU留观时间、住院时间、30 d病死率、出院后复查支架塌陷情况、位置和形态、夹层假腔直径情况、内漏等并发症及生存率、生存质量等。结果 183例患者带膜支架腔内隔绝术手术均成功,术后平均ICU留观时间为(3.08±1.93)d,平均住院时间为(7.08±1.67)d,术后30 d病死率为1.09%;出院后定期影像学复查所有患者均无支架塌陷、移位,形态正常,未出现夹层复发、破裂和逆向撕裂,未发现长期存在的内漏。随访过程中死亡4例,其中3例诊断为脑梗死。患者5年生存率为97.82%,生存质量无明显下降。结论腔内隔绝术治疗Stanford B型胸主动脉夹层具有良好的短期疗效和稳定的中长期疗效。     

多层螺旋CT对主动脉夹层的诊断价值

目的探讨多层螺旋CT(MSCT)对主动脉夹层的诊断价值。方法回顾性分析了经手术和随访证实的21例主动脉夹层患者的MSCT表现。结果诊断符合率为100%,均能辨别真假腔;可以清楚显示主动脉分支受累及情况及显示破口位置。结论 MSCT对主动脉夹层诊断及随访有着重要的价值,是首选影像学检查方法。     

Stanford B型主动脉夹层腔内修复术治疗体会

目的:探讨腔内修复术治疗Stanford B型主动脉夹层的效果。方法:对2005-09~2010-02期间18例Stanford B型主动脉夹层患者实行血管造影和血管腔内带膜支架植入手术治疗,术后3、6、12个月行CTA检查,观察手术疗效以及有无狭窄、移位和扭曲等术后并发症。结果:无中转开胸手术。除1例再发Stanford A型夹层破裂死亡外,其余患者均顺利出院。结论:主动脉夹层腔内修复术治疗Stanford B型主动脉夹层是一种安全有效的方法,早期结果满意,中远期效果还有待观察。     

主动脉夹层的CTA表现分析

目的:探讨主动脉夹层(AD)的CTA特征性表现,分析其与血流动力学的关系。方法:回顾性分析我院经MSCT及临床证实的47例AD患者的CTA资料。结果:AD以顺向分离为主,内膜破口倾向于内壁流体力学压力最大处。内膜片显现率100%。体积:假腔真腔,密度:真腔假腔,真假腔相对位置倾向于固定。主动脉分支受累及情况呈随机分布。16例血栓形成均位于假腔,占34.0%(16/47)。结论:AD的CT血管成像后夹层分离方式、内膜破口位置、内移内膜片出现及其延伸的形态、双腔主动脉真假腔的体积、密度、相对位置等具有特征性,与其血流动力学有密切关系。     

85例Stanford B型主动脉夹层腔内修复治疗体会

目的 探讨胸主动脉腔内修复术(TEVAR)治疗Stanford B型主动脉夹层(AD)方法与疗效.方法 回顾性分析2010年1月至2016年4月采用TEVAR治疗的85例Stanford B型AD患者临床资料.85例患者均常规行左肱动脉穿刺,右侧股动脉直切口,升主动脉DSA造影明确AD破口位置、真假腔及与重要器官血管开口位置关系;置入覆膜血管内支架,封堵原发破口,升主动脉造影复查观察近端破口封闭情况及主动脉弓部分支血管、真假腔血流变化情况.结果 84例患者TEVAR手术成功,成功率100％;1例术前麻醉过程中突发AD破裂死亡.9例部分覆盖左锁骨下动脉,1例左锁骨下动脉“烟囱”支架完全封闭左颈总动脉和左锁骨下动脉,2例行无名动脉至左颈总动脉和左锁骨下动脉转流.Ⅰ型内漏2例,无住院期间死亡.术后随访3个月至3年,患者均存活,远端再发新破口2例.结论 TEVAR术治疗Stanford B型AD安全有效,严格把握手术指征、术中精细操作及加强术后院外管理是手术成功、提高远期生存率关键.     

Endovascular management of chronic type B dissecting aortic aneurysm utilizing aortic and renal stents

Over the last 10 years endovascular stent-graft placement has been increasingly used to treat complicated acute Type B thoracic aortic dissections. While studies have demonstrated the use of additional aortic stent-grafts to treat continued false lumen perfusion and case reports have detailed the use of renal artery stents to treat renal ischemia related to aortic dissection, to our knowledge the adjuvant use of renal artery stents to reduce false lumen perfusion has not been reported. We present the case of a 72-year-old male who had previously undergone endovascular repair of a complicated Type B thoracic aortic dissection and presented with an expanding false lumen in the peridiaphragmatic aorta despite coverage of the entire thoracic aorta. This was treated by closure of a right renal fenestration using a renal stent.     

Morphologic Outcome after Endovascular Treatment of Complicated Type B Aortic Dissection

PurposeTo investigate the long-term morphologic changes of the aorta after thoracic endovascular aortic repair (TEVAR) for acute complicated type B aortic dissection and to analyze whether these changes differed between DeBakey class IIIa and IIIb dissections.Materials and MethodsDuring the period 1999–2009, 58 patients with acute complicated type B aortic dissection were treated with TEVAR. Seven patients lacked follow-up data, leaving 51 patients—17 patients with DeBakey IIIa aortic dissection and 34 patients with DeBakey IIIa aortic dissection IIIb—for inclusion in the study. Computed tomography scans performed before and after TEVAR were evaluated. Maximum thoracic and abdominal aortic diameters and diameters of the true lumen and false lumen at the level of the maximum aortic diameter in the thorax and abdomen were analyzed as well as degree of thrombosis of the false lumen.ResultsThere was an overall significant reduction of the thoracic aortic diameter, increased true lumen diameter, and reduced false lumen diameter (P < .05). Total thrombosis of the false lumen, with or without reintervention, was seen in 53% of all patients, in 41% primarily and in 12% after reintervention. The IIIa group had a higher degree of total false lumen thrombosis. All patients in the IIIb group had total thrombosis of the false lumen along the stent graft.ConclusionsLong-term follow-up showed favorable aortic remodeling after TEVAR for acute complicated type B aortic dissection. Total thrombosis of the false lumen occurred more often in patients with DeBakey IIIa aortic dissection compared with patients with DeBakey IIIb aortic dissection.     

Endovascular treatment in diseases of the thoracic aorta

PURPOSE: To determine whether endovascular treatment of thoracic aorta conditions can be an effective alternative approach to surgical repair. MATERIAL AND METHODS: July 1997 to February 1999, eighteen patients (16 men and 2 women; 58.6 +/- 14.8 years) presenting with different kinds of descending aorta conditions were selected for the endovascular treatment. All patients exhibited severe comorbid pulmonary and/or cardiovascular medical conditions which increased surgical risk. All implants were performed in the operating room under fluoroscopic and TEE guidance. Clinical and imaging follow-up was performed 1, 3, 6 and 12 months later. RESULTS: The endovascular treatment was successful in 17 cases. No deaths or major complications occurred. No leakage was evident at post-procedure angiography. The patients were discharged after 6 +/- 4 days. MRI or CT study performed before hospital discharge showed aneurysms exclusion in 16 patients. In the four cases of dissection, thrombosis of the false lumen was evident since the first follow-up study. In the group of patients (11 cases) with 6 months follow-up, the diameters of stented aortic segments decreased. No late leakage was observed and thrombosis was complete in all cases. DISCUSSION: The natural history of aortic aneurysms and dissection is progressive toward dilation and aortic rupture. Surgery of descending thoracic aorta is burdened with a mortality of 8-12% in elective cases and over 50% in emergency cases or aortic dissection. The endovascular treatment of aortic conditions was introduced in clinical practice in 1991 and literature data show that it is effective, with lower mortality and morbidity rates than surgical treatment. CONCLUSION: Our results stress the feasibility and effectiveness of endovascular procedure in the treatment of complex thoracic aorta conditions even in high risk patients. Thus, endovascular treatment of thoracic aorta can be considered an effective alternative approach to conventional surgery.     

腔内修复术治疗Stanford B型主动脉夹层:单中心长期疗效分析

目的探讨胸主动脉腔内修复术(TEVAR)治疗Stanford B型主动脉夹层的长期疗效。方法回顾性搜集300例行TEVAR治疗的Stanford B型主动脉夹层患者的临床及影像学资料,分析患者短期(在院/术后30天)及长期死亡率、并发症发生率及主动脉重塑情况。结果技术成功率100%。左锁骨下动脉完全覆盖29例,烟囱支架重建左锁骨下动脉11例,烟囱支架重建左颈总动脉7例。患者在院/术后30天死亡率0.7%(2/300),并发症发生率14%(42/300)。中位随访时间35个月(6~126个月)。1、3、5年累积全因死亡率分别为2.0%、6.7%、12.8%,主动脉夹层相关死亡率分别为1.7%、4.5%、8.4%;晚期并发症发生率14.7%(44/300),胸主动脉段假腔完全血栓化率83.7%(251/300)。结论应用覆膜血管内支架行TEVAR是治疗Stanford B型夹层安全有效的方法,长期疗效令人满意。     

Elective endovascular treatment of descending thoracic aortic aneurysms and chronic dissections with stent-grafts

PURPOSE: To report our experience of endovascular stent-graft placement in patients with descending thoracic aortic dissections and aneurysms and to evaluate the feasibility, safety, and clinical outcomes of the treatment. MATERIALS AND METHODS: Stent-grafts were placed in the descending thoracic aortas of 23 patients with saccular aneurysms (n = 11) and Stanford type B chronic aortic dissections of the descending thoracic and abdominal aorta (n = 12). All stent-grafts were individually constructed of self-expandable stainless steel stents covered with polytetrafluoroethylene. Vascular access was achieved through the femoral artery in all patients. Clinical status of each patient was monitored and postoperative CT was performed within 1 month of the procedure and at 3-12-month intervals after the procedures. RESULTS: Successful exclusion of the primary entry tears of dissections and the inlets of saccular aneurysms was achieved in all but two patients with aortic dissection. The overall technical success rate was 91.3% (dissection: 10 of 12 = 83%; aneurysm: 11 of 11 = 100%). All patients in whom technical success was achieved showed complete thrombosis and significant decrease in diameter of the thoracic false lumen (preoperative: 5.3 cm +/- 0.9; postoperative: 4.3 cm +/- 0.9; P = .004) or aneurysm sac (preoperative: 5.3 cm +/- 1.7; postoperative: 2.8 cm +/- 2.5; P = .001). In addition, five patients demonstrated complete resolution of the dissected thoracic false lumen (n = 2) and aneurysm sac (n = 3). However, in all patients with aortic dissection, the abdominal aorta was not significantly changed in size (P = .302) and shape and their false lumen flows remained persistent. Immediate postoperative complications were detected in 12 patients (52%); 10 had fever, leukocytosis, and elevation of C-reactive protein, another had wound infection, and another had transient abdominal pain. Three patients died 2, 3, and 12 months after the procedure: one from septic shock, another from underlying mediastinitis, and the other from an unexplained cause. The remaining 20 patients were well after the procedure (1-9 days; mean, 3 days), without any stent-graft-related complications or discomfort (follow up period: 10-65 mo; mean: 25.1 mo +/- 15.6). The cumulative survival rate after the stent graft was 100% at 30 days and 91% at 12 months. CONCLUSIONS: For treatment of aortic dissection and saccular aneurysm of the descending thoracic aorta, endovascular stent-graft repair may be a technically feasible and effective treatment modality.     

Treatment of Stanford type B aortic dissection with stent-grafts: preliminary results

PURPOSE: To evaluate the feasibility and safety of endovascular stent-graft placement in treating Stanford type B aortic dissection. MATERIALS AND METHODS: Seven patients underwent endovascular stent-graft placement for type B aortic dissection. Five patients had acute and two had chronic dissection. In five patients, the proximal entry tear was within 2 cm of the origin of the left subclavian artery, and in two patients it was beyond this site. In three patients, the noncovered proximal portion of the stent-graft was placed across the origin of the left subclavian artery. The efficacy of the procedure was assessed at follow-up studies 3, 6, 12, and 24 months after intervention. RESULTS: The procedure was technically and clinically successful in six patients (86%). The left subclavian artery remained patent in all patients. In two patients with involvement of aortic branches, endovascular stent-graft placement restored adequate blood flow to the compromised branches. One patient was readmitted 1 month later because the dissection extended into the ascending aorta. In all but this patient, closure of the entry tear and thrombosis of the false lumen along the stent-graft were achieved. All false lumina shrank considerably. The mean follow-up time was 14 months (range, 1-25 months). CONCLUSION: Type B aortic dissections within and beyond 2 cm of the origin of the left subclavian artery can be treated safely and effectively by means of endovascular stent-graft placement.     

Treatment of chronic type B aortic dissection with endovascular stent-graft placement

A 74-year-old man with chronic aortic dissection was treated with an endovascular stent graft, fabricated from expanded polytetrafluoroethylene and a Z-stent. It was placed in the true lumen to close an entry tear. Closure was obtained immediately and thrombosis of the false lumen at the descending thoracic aorta was observed on computed tomography (CT) obtained 1 week later. No procedure-related complications developed. The patient is doing well with no adverse events including aortic rupture or aortic branch ischemia.     

Treatment of chronic aortic dissection by transluminal endovascular stent-graft placement: preliminary results.

PURPOSE: To investigate efficacy of stent-graft repair for the treatment of patients with chronic aortic dissection. MATERIALS AND METHODS: Fifteen patients with chronic aortic dissection were treated with endovascular stent-grafts. Entry tears were located in the descending thoracic aorta in all patients. The mean maximum diameter of the descending thoracic aorta was 47 mm +/- 8. The mean diameter of the true lumen at the same level was 20 mm +/- 5. The mean interval between diagnosis and stent-graft procedure was 32 months +/- 91. Stent-grafts were fabricated from expanded polytetrafluoroethylene and Z-stents. RESULTS: Stent-grafts were placed successfully in all patients. Two stent-grafts were required in one patient. Entry closure and thrombosis of the false lumen of the descending thoracic aorta were also achieved in all patients. No procedure-related complications were observed except for postimplantation syndrome, including fever and leukocytosis. The diameter of the true lumen was significantly increased (mean, 31 mm +/- 6) at the level of the descending thoracic aorta (P <.01) and the diameter of the aorta was significantly decreased (mean, 44 mm +/- 8) at the same level (P <.01). There were no deaths and no instances of aortic rupture during the subsequent average follow-up period of 24 months. Secondary stent-graft procedures were required to treat the abdominal component of dissection during follow-up in one patient. CONCLUSIONS: Stent-graft repair of chronic aortic dissection is a safe and effective method and may be an alternative to surgical graft replacement in selected patients. However, further evaluation is mandatory before this method is widely employed.