腔内修复术中应用Viabahn支架重建肠系膜下动脉——2例报告

2015年5~12月我科行主动脉腔内修复术(endovascular aortic repair,EVAR)治疗腹主动脉瘤(abdominal aortic aneurysm,AAA),同期应用Viabahn支架重建肠系膜下动脉(inferior mesenteric artery,IMA)2例。1例肾下型AAA合并双髂总动脉瘤样扩张,Riolan动脉弓形成,行EVAR治疗AAA,同期采用"烟囱"技术IMA内植入Viabahn支架成功,术后3个月随访复查CTA示支架位置良好,瘤体隔绝成功,Viabahn支架通畅。1例右侧髂总动脉巨大动脉瘤,行EVAR治疗髂总动脉瘤,髂内动脉弹簧圈栓塞,IMA内植入Viabahn支架成功,术后6个月随访复查CTA示支架位置良好,瘤体隔绝成功,Viabahn支架通畅。我们认为复杂AAA应用Viabahn支架合理重建IMA预防肠缺血,简化手术操作,近期疗效满意。     

BAI型国产覆膜支架治疗犬主动脉假性动脉瘤

目的　探讨BAI型国产覆膜支架治疗动物主动脉假性动脉瘤的可行性和有效性。方法　在 16条犬中建立腹主动脉假性动脉瘤模型 ,分为 4组 ,各 4只 ,1组为对照组 ,其余 3组为实验组。实验组 2周后行国产镍钛记忆合金覆膜支架 (BAI型 )植入术。分别于术后第 2、3、6个月时处死动物 ,处死前做CT及动脉造影。病理检查包括光镜与电镜。结果　国产覆膜支架 (BAI型 )均成功地将动脉瘤封闭 ,成功率为 10 0 %。术后死亡率为 0。覆膜支架无移位 ,无内漏。 2例出现支架内血栓栓塞 ,栓塞率 17%。其余病理检查示管腔通畅 ,覆膜内表面均已内皮化。 7条犬的腰动脉再通。结论　国产覆膜支架 (BAI型 )在犬的腹主动脉假性动脉瘤模型的治疗中是可行、有效的。     

支架型人工血管治疗主动脉夹层动脉瘤

目的　探讨支架型人工血管治疗胸主动脉和腹主动脉夹层动脉瘤的作用。方法　采用由不锈钢“Z”形支架和超薄绦纶组成的支架型人工血管治疗5 例胸主动脉夹层动脉瘤和1 例腹主动脉夹层动脉瘤。其中4 例已累及肾下主动脉, 且有明显肾功能损害。6 例均经CT 和动脉造影证实。在X 线监视下,经右股动脉切开, 将1 ～2 枚支架型人工血管置入。有1 例因进入困难,改用左侧股动脉进路。结果　术后造影和CT 均表明破口被成功封闭,假腔内血栓形成。本组未发生任何并发症。随访1 ～7 个月,有2 例高血压者,血压明显下降,2 例血尿治愈,2 例血尿减轻。结论　支架型人工血管治疗主动脉夹层动脉瘤明显简化了手术,减小了手术风险,其方法可行     

介入治疗内脏动脉瘤的远期疗效

目的观察介入治疗内脏动脉瘤(VAA)的远期疗效。方法回顾性分析30例接受介入治疗VAA患者(41个瘤灶),术后随访时间均12个月,观察治疗效果及并发症。结果对12个肾动脉瘤、8个脾动脉瘤行动脉瘤填塞术,其中5个脾动脉瘤、5个肾动脉瘤采用裸支架辅助填塞;对13个脾动脉瘤、1个肝动脉瘤行动脉瘤栓塞术;对4个肾动脉瘤行载瘤动脉支架植入术,其中3个采用多层裸支架植入术、1个采用覆膜支架植入术;对2个肾动脉瘤、1个腹腔干动脉瘤行保守治疗;均获得成功。1个脾动脉瘤栓塞术后出现部分脾梗死,1个左肾多发动脉瘤植入支架后瘤腔小部分显影。术后随访12～55个月,平均(23.44±12.48)个月,期间脾梗死者梗死面积未增大、未见脓肿形成,瘤腔部分显影病变显影面积未增大。30例患者中,1例因心力衰竭死亡,余均存活,无VAA复发及其他并发症。结论介入治疗VAA远期疗效较好,且安全性较高。     

腹主动脉瘤的血管腔内治疗

目的 探讨腹主动脉瘤(AAA)血管腔内治疗后的短期临床效果.方法 回顾性分析2009年4月～2010年7月我科收治的8例AAA患者的临床资料.结果 患者均接受血管腔内治疗,手术成功率7/8,死亡1人.5例植入分叉型支架,2例植入直型支架,1例支架释放不成功.1例术后第2天右髂动脉支架折叠成角,远端血栓形成,给予局部溶栓成功后第3天血栓再次形成,急诊行左股－右股动脉旁路转流术.1例术后第2天出现急性肾功能不全,2个月后出现结肠缺血表现,给予对症治疗后好转.1例术中主体支架释放不成功,急诊行开腹手术,取出支架,行AAA修补术,术后第2天因呼吸循环衰竭死亡.随访1～16个月,中位随访时间5个月,至最后一次随访(死亡)时止,无内漏发生,无支架明显移位及动脉瘤腔内血栓形成.结论 AAA血管腔内治疗后的短期临床疗效满意,远期疗效有待进一步随访.     

腹主动脉瘤的治疗

目的 探讨腹主动脉瘤(AAA)的治疗方法。方法 回顾性分析26例AAA的临床资料。结果 26例中夹层动脉瘤3例，真性动脉瘤21例，动脉瘤破裂后再形成的假性动脉瘤1例，动脉瘤穿破十二指肠空肠曲形成腹主动脉肠瘘1例。病变累及肾动脉平面以上者3例，肾动脉平面以下者23例：病变仅累及腹主动脉者4例，病变除累及腹主动脉外，尚合并有单侧或双侧髂总动脉瘤者／2例，合并双侧髂总动脉瘤及一例或双侧髂内动脉瘤者5例，合并一侧髂总、髂内、髂外动脉瘤1例，合并有双侧髂总、髂内、髂外动脉瘤1例。施行紧急手术治疗3例，择期手术治疗14例，施行支架型人工血管腔内微创治疗7例，未手术2例。术后发生并发症3例，无瘫痪、下肢动脉栓塞等发生。术中及术后30d死亡率为3．8％(1例)。支架型人工血管治疗的7例无漏血、移位等并发症发生，均痊愈出院。22例随访3个月至4年，均存活良好。结论 AAA的腔内血管外科治疗具有创伤小，术石恢复快，并发症少等优点，有条件行支架型人工血管作腔内治疗的应优先考虑腔内治疗，传统手术方法在技巧等方面的改进有利于提高手术的成功率，并能为不具备腔内治疗条件的患者解除疾患。     

高危复杂腹主动脉瘤腔内修复术临床分析

目的 评估应用多种腔内技术治疗高危复杂腹主动脉瘤的可行性.方法 2001年1月至2010年12月,共138例腹主动脉瘤患者接受腹主动脉腔内修复术(EVAR),其中9例患者为高危复杂性腹主动脉瘤.男性8例,女性1例,年龄26～87岁,平均67岁.其中2例近肾腹主动脉假性动脉瘤,5例近肾腹主动脉瘤,1例腹主动脉瘤合并双髂总动脉瘤及左侧髂内动脉瘤,1例EVAR术后右髂内动脉瘤.所采用的腔内技术包括:主动脉支架开窗技术和扇形技术2例,烟囱技术5例,球囊辅助下髂内动脉瘤腔内治疗1例和球囊辅助反转支架技术1例.结果 所有腔内技术均获得成功.术中支架释放后即刻发现内漏4例,其中1例患者为Ⅰ型和Ⅲ型内漏,经大动脉球囊扩张后内漏消失;2例Ⅰ型内漏,其中1例行弹簧栓栓塞成功,另1例行近端裸支架成功.1例Ⅱ型内漏,经随访瘤腔直径未增大,未处理.随访4～79个月,平均25.9个月.无动脉瘤破裂,动脉瘤瘤体直径均有不同程度的缩小.随访过程中7例患者的靶血管(肾动脉、肠系膜上动脉和髂内动脉)均保持通畅.1例髂内动脉重建支架术后18个月血栓形成,但无盆腔缺血等症状.结论 对于不能耐受手术的高危复杂腹主动脉瘤患者,选择合适的腔内技术可以增加EVAR术的成功率,近、中期效果满意.     

主动脉夹层动脉瘤合并腹主动脉瘤的一期腔内治疗(附1例报告)

目的 :探讨胸主动脉夹层动脉瘤合并腹主动脉瘤病人作一期腔内隔绝术治疗的可行性、手术操作技巧及并发症防治原则。临床资料 :1例StanfordB型胸主动脉夹层动脉瘤合并腹主动脉及双侧髂动脉瘤的病人于 2 0 0 1年 2月在本中心接受了腔内隔绝术。术前CTA显示 :主动脉自弓降部开始出现夹层 ,一直延伸到腹主动脉分叉上6cm ,假腔的最大直径达 6 .6cm ;肾下腹主动脉瘤的最大直径为 4 .5cm ,瘤颈受夹层累及 ;双侧髂总动脉各有一直径 2 .5cm的真性动脉瘤。手术在全麻下进行 ,降主动脉植入规格为 34mm× 34mm× 1 30mm的直管型Talent移植物封闭夹层裂口 ;腹主动脉植入规格为 2 6mm× 1 4mm× 1 4 5mm的分叉型Talent移植物。将腹主动脉瘤和双侧髂动脉瘤隔绝 ,手术耗时 30 0min ,失血 30 0ml,透视 62min ,造影 5次 ,使用造影剂 2 0 0ml。术后病人恢复顺利 ,术后第 2天出ICU ,术后 30d出院。随访 1年 ,病人生活质量良好 ,复查CT示胸主动脉、腹主动脉瘤及髂动脉瘤完全封闭。结论 :腔内隔绝术的微创特点使一期治疗StandordB型主动脉夹层动脉瘤合并腹主动脉瘤成为一种比较安全的手术。术后应先处理胸主夹层处理腹主动脉瘤 ,以减少后半程手术对先前植入物的影响     

支架型人工血管临床应用的初步经验

目的探讨支架型人工血管治疗各类动脉瘤的临床效果。方法本组包括夹层动脉瘤 4 8例 ;腹主动脉瘤 13例 ;降主动脉、左锁骨下动脉、肾下和肾上腹主动脉假性动脉瘤分别为 4例、1例、2例和 1例 ;左、右髂动脉瘤各 1例。对夹层动脉瘤和假性动脉瘤均行破口封堵术 ,真性腹主动脉瘤行隔绝术。结果本组均获技术成功。围手术期死亡 2例。 5例夹层动脉瘤术后近侧有少量残余漏 ,但 4例半年后近侧渗漏消失 ,9例残存远侧破口少量返流。腹主动脉瘤 6例术后即时有轻度内漏 ,3个月后 5例内漏消失。结论支架型人工血管治疗夹层动脉瘤、假性动脉瘤和真性动脉瘤手术微创、安全 ,但其远期疗效需进一步观察。     

血管腔内移植物治疗大动脉疾病的探讨

目的探讨以血管腔内移植物为主的血管腔内疗法治疗胸或胸腹主动脉疾病的疗效和存在问题。方法治疗包括夹层动脉瘤、真性和假性胸主动脉瘤、主动脉减速伤和缩窄患者共137例。主要病变的最低部位在腹腔动脉和肠系膜动脉之间。除血管腔内治疗法外,尚辅以腹主或髂动脉-肠系膜上动脉、或腋动脉-左颈总动脉等架桥术。结果发生急性内脏动脉缺血而急症开腹手术2例。早期漏7例。围手术期死亡6例(4．4％)。随访1～43(平均11)个月,发现后期内漏2例、血管腔内移植物部分断裂1例。DeBakeym型夹层治疗后发生Ⅰ型夹层病变1例。后期死亡5例(4例与腔内移植物无关,1例为多发性动脉瘤复发),失访11例,115例存活。结论以血管腔内移植物治疗高风险的大动脉病变相对安全有效,具有发展前景;但器材有待改进、远期疗效有待观察。     

Experience with endovascular grafts in the treatment of infrarenal aortic aneurysms associated with proximal aortic dissection

BACKGROUND: Chronic abdominal and thoracic aortic dissections often present with concomitant infrarenal aortic dilatation. We conducted a retrospective review of 6 patients treated with endovascular stent grafts for coexisting aortic dissection and infrarenal aneurysm. METHODS: Six patients with suprarenal aortic dissections and infrarenal aortic aneurysms (AAA) had their AAAs treated with endovascular grafts. Grafts were constructed of balloon expandable Palmaz stents and expanded polytetrafluoroethylene graft. The device was inserted transfemorally and deployed under fluoroscopy. RESULTS: Successfully primary AAA exclusion was achieved in 5 patients. One patient required a supplemental stent placed above the endograft and into the true lumen to seal the endoleak. No aneurysm has enlarged, and all remain thrombosed for 9 to 24 months (mean 20). One type III dissection enlarged 2 weeks after endograft insertion. One patient had uncomplicated cephalad fenestration of a dissection by the endograft. CONCLUSIONS: Endovascular grafts may be used to treat coexisting AAA and aortic dissection. Attention to the site or sites of reentry of a dissection is essential to insure full aortic aneurysm exclusion. The fate of a chronic aortic dissection cephalad to an endovascularly treated AAA is unclear and will require longer follow-up.     

巨大和长段胸主动脉瘤的血管腔内修复术治疗

目的探讨巨大和长段胸主动脉瘤行带膜支架主动脉腔内修复治疗的可行性。方法对3例10．6～28．0cm长真性胸主动脉瘤的男性患者,采用多个带膜支架相连接成一条长段支架型人工血管,行主动脉腔内修复治疗。对瘤体全长28．0cm、最大直径7．3cm的病例,采用4个长度为130mm的不同直径的带膜支架相连接覆盖胸主动脉;另2例分别用2枚、3枚带膜支架治疗。2例术中先行颈总动脉-颈总动脉和颈总动脉-锁骨下动脉旁路术。结果3例手术过程顺利,术后恢复良好。2例术后无内漏,分别随访1,2个月,瘤腔内血栓形成;1例在支架连接处有少量内漏,术后1年消失,瘤腔内血栓形成。1例术后出现短暂脑缺血表现,1个月后消失。结论采用多个带膜支架相连接对巨大和长段胸主动脉瘤行主动脉腔内修复治疗,安全、微创,疗效良好,远期效果有待观察。     

Transluminal placement of endovascular stent-grafts for the treatment of type A aortic dissection with an entry tear in the descending thoracic aorta

PURPOSE: The current therapy for type A aortic dissection is ascending aortic replacement. Operative mortality and morbidity rates have been markedly improved because of recent advances in surgical techniques and anesthesiology. However, type A aortic dissection with an entry tear in the descending thoracic aorta is still a surgical challenge because of the need for extensive aortic replacement. METHODS: Ten patients with type A aortic dissection were treated with endovascular stent-grafts. The false lumen of the ascending aorta was patent in five patients, and it was thrombosed in the other five patients. The entry tears were located in the descending thoracic aorta in all cases. Seven patients had acute dissection, and three patients had subacute dissection. Four patients had pericardial effusion. Stent-grafts were fabricated from expanded polytetrafluoroethylene and Z-stents. RESULTS: Entry closure was achieved in all patients. Complete thrombosis of the false lumen of the ascending aorta was observed after stent-grafting in all patients. A second stent-graft was required in two patients to obtain complete thrombosis of the false lumen of the descending thoracic aorta. No procedure-related complications were observed, with the exception of a minor stroke in one patient. During a mean follow-up period of 20 months, no aortic rupture or aneurysm formation was noted in either the ascending or descending thoracic aorta, and all patients were alive and doing well. The abdominal aortic aneurysm enlarged after stent-grafting in one patient, and this was treated by closing the fenestrations of the abdominal aorta with stent-grafts. CONCLUSION: Stent-graft repair of aortic dissection with an entry tear in the descending thoracic aorta is a safe and effective method and may be an alternative to surgical graft replacement in highly selected patients.     

胸主动脉夹层动脉瘤腔内隔绝术中椎动脉缺血的预防

目的:探讨腔内隔绝术治疗StanfordB型胸主动脉夹层动脉瘤时椎动脉缺血的预防方法。方法:对136例接受腔内隔绝术治疗的StanfordB型胸主动脉夹层动脉瘤病人,尤其是左锁骨下动脉血流受干扰者的病史资料进行回顾性分析。结果:136例病人中135例手术成功,66例左锁骨下动状脉开口受到干扰,其中5例因左锁骨下动脉距夹层破口太近,而有意将其封堵。8例有椎动脉缺血症,仅1例为急性脑缺血表现。2例术后被迫行颈动脉鄄椎动脉旁路术以缓解椎动脉缺血情况。而术前接受预防性颈动脉鄄椎动脉旁路术的4例病人,完全遮蔽左锁骨下动脉后无不适症状。结论:完全遮蔽左锁骨下动脉可能会引起左侧椎动脉的急性缺血而致严重并发症。根据夹层破口与左锁骨下动脉开口间的距离,术前选择性实施左颈动脉鄄左椎动脉旁路术可预防椎动脉缺血的发生。     

腔内人造血管移植术治疗腹主动脉瘤

目的 评价腔内人造血管移植术治疗腹主动脉瘤早期临床疗效。方法 总结对14例腹主动脉瘤患者采用经腹股沟切口腹主动脉瘤腔内人造管移植术的经验。结果 12例选用分叉型腔内人造血管,2例选用直型腔内人造人管,术后即刻DSA造影显示动脉瘤消失,近远端人造血管与宿主动脉结合处均未见渗漏,11例患者术后生命体征平稳,1例术后24h出现小面积急性心肌梗塞,经溶栓和抗凝治疗后缓解,术后死亡2例,技术成功率85.7%。12例患者术后1周随访螺旋CT,其中有4例术后3个月、1例术后12个月再次做螺旋CT,显示人造血管无移位,2例有渗漏,但动脉瘤腔无增大。结论 腔内人造血管移植术是一种创伤小、恢复快的治疗腹主动脉瘤新方法,但远期疗效有待随访。     

腹主动脉瘤大小对腔内隔绝术及其疗效的影响

目的 探讨腹主动脉瘤大小对腔内隔绝术及隔绝后治疗结果的影响.方法 回顾性分析1997年3月至2007年6月共429例腹主动脉瘤的临床资料,依腹主动脉瘤直径将患者分为＜55 mm组(A组,n=274)及≥55 mm组(B组,n=155).根据术前影像学资料研究两组动脉瘤大小、瘤颈长度、瘤颈直径、瘤颈扭曲程度及髂动脉是否受累等,并探讨动脉瘤大小对腔内隔绝术及治疗结果的影响.结果 A组平均年龄71.1岁,B组73.7岁(P＜0.05).B组有冠心病史者(36.1%)明显多于A组(18.6%)(P＜0.05),B组伴高血压病、糖尿病、慢性阻塞性肺疾病者多于A组,但两组间差异无统计学意义.A组腹主动脉瘤平均直径为(46.6±6.8)mm,B组为(66.8±11.2)mm(P＜0.05);B组腹主动脉瘤较A组近端瘤颈短、瘤颈直径大、瘤颈扭曲、易累及髂动脉(P＜0.05);B组患者应用腹膜外径路、髂内动脉重建或髂内动脉栓塞等附加手术、术中牵张导丝均多于A组,术中发生内漏数及使用移植物个数均高于A组(P＜0.05).围手术期并发症发生率B组高于A组,病死率无明显差异.术后B组内漏率及二次干预率均高于A组.结论 腔内隔绝术治疗腹主动脉瘤获得了较好的临床效果,而腹主动脉瘤的大小对腔内隔绝术存在一定影响,较小腹主动脉瘤无论在术中操作、围手术期并发症、术后随访等方面均优于较大腹主动脉瘤.     

Endovascular repair of thoracic aortic pathology with custom-made devices.

BACKGROUND: Open repair of thoracic aortic aneurysms (TAAs) is fraught with high morbidity and mortality rates. The availability of endoprostheses for treating thoracic aortic pathology has not kept pace with those for treating abdominal aneurysms. Technical feasibility, durability, and safety of custom-made stent-grafts for the treatment of TAAs and dissections are evaluated. METHODS: From July 2002 to October 2004 there were 15 patients with TAAs, intramural hematoma, or dissections treated with custom-made endografts. Grafts were deployed after brief adenosine-induced cardiac arrest. Computed tomography scans were obtained 1 month postoperatively and every 6 months thereafter. The mean follow-up period was 15 months (range, 3-31 mo). RESULTS: The mean age of patients was 67 +/- 11 years (range, 47-81 y; 67% men, 33% women). Indications for repair included TAA (10), chronic type B dissection (3), penetrating ulcer (1), and acute dissection (1). Planned concomitant procedures included subclavian-carotid transposition (2) and aortosplenic bypass (2) to achieve adequate proximal or distal landing seal zones, respectively. The mean length of hospital stay was 8 days (range, 1-49 d). Immediate complications included 2 access-related events, 1 cerebellar infarction treated expectantly, and 1 death from a large hemispheric stroke. There were no cases of postoperative paralysis and on follow-up imaging no cases of endoleak, endograft migration, or stent fractures were found. No late deaths occurred caused by stent-graft repair or aneurysm-related causes. CONCLUSIONS: Endoluminal exclusion of thoracic aortic aneurysms and dissections can be achieved successfully using custom-made stent-grafts. The use of specially designed devices appears to be technically feasible and durable, with acceptable morbidity and mortality rates.     

Aneurysmal degeneration of the aorta after stent-graft repair of acute aortic dissection

PURPOSE: Stent-graft repair of acute aortic dissection has only recently begun, and the true efficacy and safety of this technique have not yet been clarified. In this report, we describe a significant, previously unreported complication following stent-graft repair of acute aortic dissection.Materials and Methods: Fourteen patients with acute aortic dissection underwent stent-graft repair. All of the entry tears were located in the descending thoracic aorta. Five patients had type A aortic dissection, and nine patients had type B aortic dissection. The entry tears were closed with stent-grafts, which were fabricated from expanded polytetrafluoroethylene and Z-stents. RESULTS: Stent-graft placement was successfully performed without any complications in all patients. Entry closure was achieved in 13 (93%) of 14 patients. The mean follow-up period was 18 months (range, 9 days to 36 months). During this period, four patients had saccular aneurysms in the proximal descending thoracic aorta. A saccular aneurysm was noted during a mean follow-up period of 63 days (range, 38-99 days). Two of these patients were treated with stent-grafts. Conventional surgical repair is planned in one patient. The other patient is being treated with conservative management. CONCLUSIONS: Stent-graft repair is a technically feasible and effective method for the treatment of acute aortic dissection in selected patients. However, careful follow-up is mandatory to check for the development of saccular aneurysms.     

Self-expandable aortic stent-grafts for treatment of descending aortic dissections

BACKGROUND: Acute aortic dissection is a life-threatening medical condition that is associated with high morbidity and mortality. METHODS: Of 198 patients treated with a self-expanding polyester-covered stent-graft for various pathologic aortic conditions in our institution, we selected 70 consecutive patients with type B aortic dissection who were undergoing treatment. The stent-graft was introduced through the femoral artery in the angiography suite, under general anesthesia with systemic heparinization and induced hypotension. RESULTS: The procedure was performed in 70 patients; of these, 58 had descending aortic dissection and 12 had atypical dissections. The procedure was successful in 65 patients (92.9%), as documented by exclusion of the false lumen of the thoracic aorta. Eleven patients (18.9%) had persistent blood flow in the false lumen of the abdominal aorta due to distal reentries. Five patients (7.1%) underwent conversion to surgery. Insertion of additional stent-grafts was required in 34 patients (48.6%). At 29 months of follow-up, 91.4% of the patients were alive. CONCLUSIONS: Stent-grafts are an important means of treating aortic dissections, which may replace conventional medical treatment of this condition for the majority of patients.     

Simultaneous treatment of thoracic and infrarenal aortic aneurysm using a combination of conventional surgery and endoluminal stent grafting

INTRODUCTION: Patients with multiple aortic aneurysms represent a small subgroup with the need for extensive surgical treatment at considerable risk. Endovascular treatment in combination with conventional operation is possible. We demonstrate a case with simultaneous exclusion of aneurysms of the descending thoracic and the infrarenal aorta to outline the technical obligations. CONCLUSION: Simultaneous exclusion of a thoracic and an abdominal aneurysm can be performed successfully by conventional infrarenal aortic replacement with bifurcated dacron prosthesis and endovascular implantation of a thoracic stent-graft within one operation.