改良型杂交手术治疗De Bakey Ⅰ型主动脉夹层一例

<正>临床资料患者,男,39岁。主因"突发胸部疼痛伴头晕24 h"急诊入院,行主动脉CT血管造影(CTA)后发现为主动脉夹层形成,诊断为主动脉夹层动脉瘤(De BakeyⅠ型)。胸部增强CT(图1)显示破口位于升主动脉根部,累及主动脉瓣膜和右冠状动脉,顺行撕裂累及无名动脉、右锁骨下动脉、右颈总动脉及左颈总动脉,未累及左锁骨下动脉。在全身麻醉低温体外循环下行Bentall手术+改良型全主动脉弓置换术+主动脉弓覆膜支架植入术。手     

Ⅲ型夹层动脉瘤介入治疗误堵颈动脉的处理

目的 总结Ⅲ型夹层动脉瘤介入治疗误堵左颈总动脉的处理和经验教训.方法 4例Ⅲ型夹层动脉瘤患者行支架型人工血管封堵降主动脉内膜破口时不慎误堵塞左颈总动脉.4例患者均为男性,年龄37～45岁,平均年龄41岁.1例因存在内漏加Cuff时将第一个支架推向近侧导致左颈总动脉和左锁骨下动脉堵塞,经球囊拖向下方后解决;1例放置支架时支架前跳堵塞左颈总动脉和左锁骨下动脉.立即从股动脉进抓捕器抓住从左上肢肱动脉进入升主动脉的刻度猪尾导管将支架拖向远侧后恢复左颈总动脉和左锁骨下动脉血流;1例因定位误差导致支架堵塞2/3左颈总动脉和左锁骨下动脉,立即显露左颈总动脉分叉经颈外动脉置入左颈总动脉支架(chimney技术)后左颈总动脉血运完全恢复;1例是在心外科误将前端无裸支架的支架型人工血管当成有裸支架而将一半的无名动脉、左颈总动脉和左锁骨下动脉封堵,经正中开胸行升主动脉双颈动脉及左腋动脉人工血管搭桥后缓解.结果 4例患者均成功封堵Ⅲ型主动脉夹层的近侧内膜破口,无明显内漏,无脑梗死和左上肢缺血表现.结论 介入治疗Ⅲ型主动脉夹层误堵颈动脉后需立即通过手术或介入手段解决以避免发生脑缺血并发症.     

主动脉缩窄合并降主动脉瘤行升-腹主动脉搭桥术后动脉瘤自愈1例

病人　女,4 1岁。头晕、双下肢麻木15年,加重伴胸闷2月余。术前血压:右上肢16 0 5 0mmHg(1mmHg =0 133kPa) ,左上肢及双下肢均为90 70mmHg。磁共振血管造影示主动脉弓降部于左锁骨下动脉分支以近重度缩窄,狭窄以远左锁骨下动脉下方可见一动脉瘤形成,约2 0mm×30mm大小(图1)。因缩窄段累及主动脉弓远端,决定分期手术,先行升主动脉至腹主动脉搭桥术解除缩窄,二期手术切除动脉瘤。2 0 0 3年6月全麻下行升主动脉至腹主动脉搭桥术。胸腹正中联合切口,1 8cm×30cm人工血管经前纵隔及左结肠旁分别与腹主动脉及升主动脉行端侧吻合,开放后上下肢…     

真性动脉瘤合并假性动脉瘤动物模型的建立

我们通过建立符合疾病病理生理的犬颈总动脉真性合并假性动脉瘤(T F)动物模型,研究其形成过程、病理及影像学特点,为临床上诊断和治疗该疾病提供依据。 一、材料和方法 杂种犬15条,体重11.0～20.5kg。全麻后颈部正中作矢状切口,暴露左颈部皮下的颈外静脉(EJV),结扎EJV近、远端,取中间段长2 cm,分离出左侧颈总动脉(CCA),制作侧壁型动脉瘤(AN),待1～2周造影证实AN形成后,再行手术打开原切口,显露左侧颈总动脉。用双极电凝在左侧胸头肌中段内缘烧灼成一     

脾动脉起始部动脉瘤的切除及血管重建的手术探讨

目的探讨脾动脉起始部动脉瘤的切除及脾动脉重建的手术方法。方法回顾性分析1996年1月~2007年3月收治的8例脾动脉起始部动脉瘤患者的临床资料,经彩色超声、CT和血管造影检查证实脾动脉起始部真性动脉瘤;均在全身麻醉下首先阻断腹腔干起始部,远端脾动脉阻断后切除动脉瘤,1例行腹腔干-脾动脉自体静脉移植,4例行肾下主动脉-脾动脉人工血管转流,3例同时切除动脉瘤和脾脏。结果均于手术后10~14 d治愈出院。随访0.5~10年;其中1例人工血管转流术后2年死于急性心肌梗塞,余7例均健康生活,无动脉瘤复发。结论动脉瘤切除、脾动脉重建是一种较好的脾动脉起始部真性动脉瘤的治疗方案。     

肠系膜上动脉瘤缝闭、解剖外途径动脉重建术一例

患者，男，59岁，维吾尔族，高血压病史5年。突发性腹痛15d，向两侧腰背部放射，餐后加重。MRA示肠系膜上动脉瘤。查体：腹平、软，未触及包块，上腹部轻压痛，无反跳痛，肠鸣音正常。右侧经腹直肌切口入腹，见胰腺颈部后肠系膜上动脉呈瘤样扩张。近端瘤颈显露困难，决定行肠系膜上动脉瘤缝闭、解剖外途径腹主动脉一肠系膜上动脉人造血管搭桥术。Satinsky钳部分阻断腹主动脉后，用6mm带支撑环PTFE人造血管与腹主动脉行端侧吻合。横断肠系膜上动脉远端瘤颈，行人造血管与肠系膜上动     

累及弓部主动脉夹层手术方式选择及疗效

目的:探讨累及主动脉弓部主动脉夹层手术方式选择及疗效。方法:收集2010年2月—2015年5月因主动脉弓部夹层在广州军区武汉总医院心胸外科接受手术治疗病例资料,分析其手术方式选择及理由,不同术式并发症发生率等。结果:检索出符合条件的病例92例,其中仅行胸主动脉腔内修复术(TEVAR)36例,预开窗血管支架的TEVAR 2例,封闭左锁骨下动脉的TEVAR 31例,不开胸主动脉弓分支血管旁路术+TEVAR17例(左颈总动脉-左锁骨下动脉旁路术4例,右颈总动脉-左颈总动脉-左锁骨下动脉旁路术3例,右颈总动脉-左颈总动脉术、封闭左锁骨下动脉10例),开胸主动脉弓置换术6例。2例开胸主动脉弓置换术患者术后死亡,其余术后无严重并发症发生。结论:对于累及主动脉弓部夹层,开胸主动脉弓置换术是一种成熟的治疗方式;TEVAR是的一种快速、有效、经济、术后并发症少的手术方式,并可以通过开窗、分支血管旁路术等方式扩大其应用范围。     

激光原位开窗联合胸主动脉腔内修复术12例

目的探讨体内激光原位开窗联合胸主动脉腔内修复术治疗累及主动脉弓部甚至升主动脉的主动脉疾病的近期疗效。方法 2016年11月~2017年1月我科对12例累及主动脉弓部甚至升主动脉的主动脉疾病应用体内激光原位开窗技术进行覆膜支架腔内修复术,其中Stanford B型主动脉夹层7例,Stanford A型主动脉夹层2例,升主动脉合并主动脉弓部动脉瘤1例,升主动脉穿透性溃疡合并壁内血肿2例。左锁骨下动脉开窗7例,左颈总动脉+左锁骨下动脉开窗1例,头臂干+左颈总动脉+左锁骨下动脉开窗4例。急性期手术5例,慢性期手术7例。结果植入锥形大动脉覆膜支架12枚,Fluency plus直管型覆膜支架21枚。围手术期死亡2例(16.7%,2/12),其中术中升主动脉破裂死亡1例(8.3%,1/12),术后因消化道大出血合并多脏器功能衰竭死亡1例。术后早期并发症发生率16.7%(2/12),分别为短暂性神经功能障碍1例、呼吸功能不全合并肺部感染1例,经治疗后均痊愈出院。术后3个月随访显示夹层破口(或溃疡、动脉瘤)隔绝良好,无内漏,开窗血管通畅。结论激光原位开窗联合胸主动脉腔内修复术治疗累及主动脉弓部甚至升主动脉的主动脉疾病安全、有效,具有创伤小、恢复快、术中成功率高、内漏发生率低等优点,近期效果良好。     

巨大主动脉弓降部动脉瘤一例

患者男，46岁。因突发胸背部疼痛3d入院，入院检查：血压140／80mmHg，心肺未见异常。胸部x线片示主动脉弓降部动脉瘤，大小约90．6mm×61．1mm（图1），磁共振成像（MRI）提示：弓降部主动脉瘤约70mm×100mm（图2），起始端距颈总动脉开口约15mm，累及左锁骨下动脉。临床诊断：主动脉弓降部动脉瘤。     

DeBakey Ⅰ型主动脉夹层动脉瘤的血管腔内治疗

目的探讨血管腔内治疗DeBakeyⅠ型主动脉夹层动脉瘤的方法。方法对7例DeBakeyⅠ型主动脉夹层动脉瘤进行血管腔内治疗。7例均行磁共振血管造影、CT和动脉造影检查确诊。内膜撕裂口均位于升主动脉,距冠状动脉开口2．5-6．0cm,距右头臂干开口0．5-4．0cm。2例通过左颈总动脉置入带膜支架,术前行左锁骨下动脉-左颈总动脉间内转流术以保证左颈总动脉血供。5例通过右股总动脉置入带膜支架,其中2例先行左锁骨下动脉-左颈总动脉-右颈总动脉人工血管旁路术。结果全组均手术成功。3例第1枚支架释放后仍有较多内漏,即再放入第2枚支架,交错重叠于第1枚支架内面而成功封闭撕裂口,消灭内漏。除1例术后1个月因急性上消化道大出血死亡外,其余6例存活。6例的假腔均有血栓形成,无内漏,无新的夹层动脉瘤形成。结论DeBakeyⅠ型主动脉夹层动脉瘤的血管腔内治疗是可行、微创和有效的。病例选择应注意撕裂口距冠状动脉开口的距离。     

Proximal Left Subclavian Artery Aneurysm Presenting Hemoptysis,Hoarseness, and Diplopia: Repair through Partial Cardiopulmonary Bypass and Perfusion of the Left Common Carotid Artery

Isolated true aneurysm of the subclavian artery is rare and can rupture, thrombose, embolize, or cause symptoms by local compression. We describe a case of a 67-year-old man with proximal left subclavian artery aneurysm presenting with hemoptysis, hoarseness, and diplopia. These symptoms suggested that the aneurysm ruptured, that the left recurrent laryngeal nerve was compressed by it, and that its mural thrombus caused cerebral embolism. It was incidentally confirmed that the aneurysm grew at the rate of 1.31 cm/year, from 3.0 to 4.2 cm in diameter for 11 months, preciously measured in a computed tomography scan. The aneurysm was successfully repaired via partial cardiopulmonary bypass and separate perfusion of the left common carotid artery through cross-clamping the descending thoracic aorta and the aortic arch between the origins of the brachiocephalic artery and the left common carotid artery. Neither partial clamping of the aortic arch at the portion branching the left subclavian artery nor taping the aortic arch between the origins of the left common carotid artery and the left subclavian artery could be achieved.     

Selective Delayed Management of Blunt Traumatic Left Common Carotid Artery Injury Using Hypothermic Circulatory Arrest

Most traumatic carotid artery aneurysms occur at or close to its bifurcation, and traumatic aneurysm of the intrathoracic carotid arteries are rare. We describe a case of false aneurysm at the origin of the left common carotid artery (LCCA) after blunt trauma. A 53-year-old man suffered a blow from a broken steel plate, which flew from a working concrete crusher over his neck when he looked down the machine. Chest computed tomography revealed aneurysm of the LCCA, and aortic arch arteriography demonstrated a false aneurysm of about 3 × 5 cm at the origin of the LCCA, with loss of arterial continuity and abnormal tortuosity above the aneurysm. An ascending aorta to LCCA bypass graft was placed during the cooling period of cardiopulmonary bypass, and mattress sutures were placed in the normal aorta to close the origin of the LCCA under hypothermic circulatory arrest because of the extreme danger of dissection. The LCCA was transected partially at its origin from the aorta. We speculated that the direct lifting force which caused the carotid artery to move upward might produce a tear at the junction of the LCCA and the aortic arch.     

Cannulation of the Extrathoracic Left Common Carotid Artery for Thoracic Aorta Operations Through Left Posterolateral Thoracotomy

The femoral artery is the usual site of arterial cannulation in thoracic aorta operations through left posterolateral thoracotomy that require cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA). The advantage of this perfusion route is in limiting the duration of circulatory arrest. It is associated, however, with the risk of retrograde embolization or, in cases involving aortic dissection, malperfusion of vital organs. To prevent these risks, we have used the extrathoracic left common carotid artery as the perfusion route. From December 1999 to January 2003, we used cannulation of the left extrathoracic common carotid artery in 42 thoracic aorta operations through posterolateral thoracotomy with an open proximal anastomosis technique during DHCA. The indication for thoracic aortic repair was atherosclerotic ulcer in 7 cases, chronic aortic aneurysm in 18, acute type B dissection in 5, and chronic type B dissection in 12. Cannulation of the extrathoracic left common carotid artery was successful in all patients. Postoperative recovery was uneventful, with no cerebrovascular events in all cases. No cannulation-related complications were observed. One patient died from cardiac insufficiency on postoperative day 5. No peripheral neurological deficits (paraplegia or paraparesis) were observed. Postoperative complications included atrial fibrillation in five patients, reoperation to control hemorrhage in six, respiratory insufficiency in nine, and renal insufficiency in six. These results indicate that cannulation of the left extrathoracic common carotid artery is a useful, reliable method for proximal perfusion during CPB in patients undergoing repair of the descending thoracic aorta through left posterolateral thoracotomy. By providing effective perfusion of the brain, this technique can prolong safe DHCA time. Another advantage is the prevention of cerebral emboli, ensuring retrograde flow to the aortic arch.Presented at the Eighteenth Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, Toulouse, France, May 21-24, 2003.     

Contralateral pterional approach to a giant internal carotid-ophthalmic artery aneruysm: technical case report

OBJECTIVE AND IMPORTANCE: The contralateral approach to internal carotid-ophthalmic artery aneurysms has been used in selected cases but has rarely been described for a giant internal carotid artery aneurysm. We report a case of giant aneurysm that was successfully clipped via the contralateral pterional approach. CLINICAL PRESENTATION: A 69-year-old woman was found to have two aneurysms: a small aneurysm at the left internal carotid-posterior communicating artery and a giant aneurysm at the right internal carotid-ophthalmic artery. INTERVENTION: A direct clipping operation was performed via the left pterional approach. After the small left internal carotid artery aneurysm was clipped, the contralateral giant aneurysm was further exposed and successfully clipped by use of the same approach via the prechiasmatic space. CONCLUSION: The contralateral pterional approach can be applied even for a giant aneurysm of the carotid-ophthalmic artery aneurysm when the neck of the aneurysm is small and when there is a space between the anterior wall of the aneurysm and the tuberculum sellae. Furthermore, such a giant aneurysm can be clipped more easily and safely via the contralateral approach without compromising visual functions. To our knowledge, this is the first reported case of a giant internal carotid-ophthalmic artery aneurysm approached contralaterally. The feasibility of this approach can be assessed preoperatively by three-dimensional computed tomographic angiography as well as by conventional cerebral angiography.     

A Giant Thrombosed Aneurysm of the Petrous Carotid Artery Presenting with Cavernous Sinus Syndrome: Case Report

Aneurysms involving the petrous Carotid artery are rare and a review of the literature demonstrates that the mode of clinical presentation depends on the direction of expansion of the aneurysmal sac. The eighth nerve is the most commonly affected, followed by the fifth nerve, sixth nerve and seventh nerve, respectively. There has not been reported to date a lesion presenting with cavernous sinus syndrome. We present the case of a 46-year-old woman who complained of left facial pain and pan-ophthalmoplegia, and was shown to have a giant thrombosed aneurysm of the petrous carotid artery extending into the cavernous sinus. Because preoperative evaluation of the patient revealed good collateral flow, proximal balloon occlusion of the left internal carotid artery was performed. Neurological symptoms of the patient resolved 2 months after surgery except for the size of the left pupil. We conclude that an aneurysm of the petrous carotid artery should be included in the differential diagnosis of cases presenting with a cavernous sinus syndrome. Early diagnosis followed by definitive treatment is important for the alleviation of clinical symptoms associated with this lesion.     

杂交技术治疗主动脉弓降部病变的临床研究

目的:探讨杂交技术治疗主动脉弓降部病变的效果。方法:采用杂交技术(解剖外旁路联合血管腔内修复术)手术治疗10例患者,包括累及主动脉弓部分支的B型主动脉夹层4例和主动脉弓降部真性动脉瘤6例。其中左颈总动脉至左椎动脉旁路1例,右颈总动脉至左颈总动脉旁路5例,右颈总动脉至左颈总动脉及左颈总动脉至左锁骨下动脉旁路1例和升主动脉至无名动脉及左颈总动脉旁路3例。均经股动脉入路植入覆膜支架。结果:10例患者均获得技术成功,1例发生少量I型内漏,未处理。术后1例因脑梗塞伴肺炎、肾功能衰竭不治自动出院;其余9例均痊愈出院。9例随访时间3～33个月,均恢复正常生活,术后3个月CTA示:覆膜支架无移位,1例内漏已消失,无新的内漏发生,夹层假腔或动脉瘤腔内已有血栓形成,远端夹层假腔无明显扩大,旁路人工血管通畅。结论:杂交手术避免体外循环损害,减轻外科手术创伤,提高了治疗效果,是治疗累及分支的主动脉弓降部病变的重要方法。     

Treatment of a giant aneurysm of the cavernous internal carotid artery associated with a persistent primitive trigeminal artery: case report

A case of an unruptured giant aneurysm of the cavernous portion of the left internal carotid artery associated with a persistent primitive trigeminal artery (PTA) is presented. The usual surgical approach to giant aneurysms at this site, including ligation of the ipsilateral internal carotid artery (ICA) and an extracranial-intracranial (EC-IC) bypass, was inadequate because of continued blood supply to the aneurysm via the PTA from the vertebrobasilar system. The patient was successfully treated with a combination of EC-IC bypass surgery, ICA ligation, and simultaneous intravascular balloon obliteration of the ICA just distal to the junction of the PTA and immediately proximal to the aneurysmal neck. Follow-up radiological investigations showed thrombosis of the aneurysm.     

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。     

Acute Type A Dissection Treated with Combined Endovascular Repair of Arch and Surgical Bypass of Arch Vessels from Descending Aorta

We report a case of an endovascular repair of a recurrent dissecting aneurysm of the aortic arch and dissection of carotid vessels, 3 years after surgical repair of aortic valve and ascending aorta for a type A dissection. We performed a bypass from the descending aorta to right, left common carotid artery (CCA), to left subclavian artery with no cardiopulmonary bypass and thereafter, total ascending and aortic arch stent grafting. We suggest considering total aortic arch stent grafting with bypass of arch vessels in cases of complicated acute type A dissection. In cases where the ascending aorta cannot be used as donor site for bypass, we suggest the use of the descending aorta.     

颈内动脉眼动脉段动脉瘤的手术治疗

目的 对28例颈内动脉眼动脉段动脉瘤进行回顾分析,总结该部位动脉瘤手术方式和结果以进一步改善疗效.方法 2004年5月至2009年8月手术治疗28例(30个)颈内动脉眼动脉段动脉瘤,其中微小动脉瘤4个,小型动脉瘤2个,中型动脉瘤4个,大型、巨大动脉瘤20个.结果 共手术处理28例患者的28个眼动脉段动脉瘤.19例行动脉瘤夹闭或动脉瘤切除+颈内动脉重建,9例行高流量颅内外动脉搭桥+动脉瘤切除+颈内动脉重建或颈部颈内动脉结扎动脉瘤孤立.17例术后行数字减影血管造影、CT血管成像或磁共振血管成像复查,5例搭桥血管通畅,2例搭桥血管闭塞.1例动脉瘤少量残留,余动脉瘤不显影.GOS 4～5分占78%(22/28),死亡1例.结论 颈内动脉眼动脉段动脉瘤尤其是大型巨大型动脉瘤处理困难.辅助高流量颅内外搭桥手术、选择合适的动脉瘤夹,才能取得良好的手术效果.