杂交手术技术在复杂型Stanford B型主动脉夹层及其并发症治疗的临床研究
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摘要
目的探讨杂交手术治疗复杂型Stanford B型主动脉夹层的可行性。方法自2011年8月至2015年8月期间,笔者所在医院共有14例复杂型Stanford B型主动脉夹层患者完成腔内修复术(thoracic endovascular aortic repair,TEVAR)并行杂交手术治疗。其中男11例,女3例;年龄(44±7.2)岁(22~62岁)。12例患者夹层动脉瘤累及主动脉弓部及其三大分支血管,其中2例TEVAR手术患者分别于术后3年和5年支架近端新发夹层或假性动脉瘤形成行开胸杂交手术治疗;3例为累及左颈动脉行颈-颈杂交术;7例为累及左锁骨下动脉行颈-锁杂交术。另2例夹层动脉瘤累及髂动脉且合并血栓形成导致下肢缺血,行股-股杂交术。结果所有患者均成功完成覆膜支架的置入并行杂交手术。术中血管造影见支架释放位置准确,夹层隔绝成功,支架无明显内漏和移位,主动脉夹层真腔血流恢复正常,旁路及目标血管血流通畅。14例患者术后均获随访,随访时间为(24.0±8.2)个月(3~36)个月;术后2 d出现脑卒中1例,术后10 d出现切口下血肿1例,术后1个月出现胸腔积液1例,其余患者围手术期无死亡和严重并发症发生。随访的14例患者均恢复正常生活。结论对于复杂型Stanford B型主动脉夹层患者实施杂交手术可以增加TEVAR术的成功率及其使用范围,早、中期效果满意。
Objective To discusses the feasibilities of the hybrid surgical treatment of Stanford type B aortic dissection. Methods From August 2011 to August 2015 a total of 14 cases of complex Stanford type B aortic dissection patients had been completed hybrid surgery. Among them 11 cases of men and 3 cases of women, aged 22 to 62, an average of 44±7.2 years old. Twelve cases with dissecting aneurysm involving the aortic arch and its three vascular branch.There were 2 cases of patients after TEVER, occurred new dissection or pseudoaneurysms, and had hybrid surgery by traditional thoracotomy; 3 cases involving carotid artery were received neck-neck hybrid surgery, and 7 cases involving left subclavian artery were received neck-lock hybrid surgery. Two cases of dissecting aneurysm involving the iliac artery to thrombosis that result in lower limb ischemia, then femoral to femoral artery hybrid surgery were performed. Results All the patients were successfully completed the operation of covered stent implantation and hybrid surgery. Intraoperative angiography showed that the position of the stent was accurate, the interlayer isolation was successful, there was no obvious leakage and displacement of the stent, the true lumen blood flow of the aortic dissection was returned to normal,and bypass blood and target blood vessels were unobstructed. Fourteen patients were followed-up for a period of 3 to 36 months, with an average of(24.0±8.2) months. In 1 month after operation, pleural effusion occurred in 1 case, there was 1 case of cerebral stroke in two days after surgery, incision hematoma occurred in 1 case in 10 days after surgery, and the other patients had no postoperative death and severe complications. All 14 patients were followed-up and returned to normal life. Conclusion The hybrid operations can increase the success rate of TEVAR in complex Stanford type B aortic dissection patients, and early and mid-term results are satisfactory.
Objective To discusses the feasibilities of the hybrid surgical treatment of Stanford type B aortic dissection. Methods From August 2011 to August 2015 a total of 14 cases of complex Stanford type B aortic dissection patients had been completed hybrid surgery. Among them 11 cases of men and 3 cases of women, aged 22 to 62, an average of 44±7.2 years old. Twelve cases with dissecting aneurysm involving the aortic arch and its three vascular branch.There were 2 cases of patients after TEVER, occurred new dissection or pseudoaneurysms, and had hybrid surgery by traditional thoracotomy; 3 cases involving carotid artery were received neck-neck hybrid surgery, and 7 cases involving left subclavian artery were received neck-lock hybrid surgery. Two cases of dissecting aneurysm involving the iliac artery to thrombosis that result in lower limb ischemia, then femoral to femoral artery hybrid surgery were performed. Results All the patients were successfully completed the operation of covered stent implantation and hybrid surgery. Intraoperative angiography showed that the position of the stent was accurate, the interlayer isolation was successful, there was no obvious leakage and displacement of the stent, the true lumen blood flow of the aortic dissection was returned to normal,and bypass blood and target blood vessels were unobstructed. Fourteen patients were followed-up for a period of 3 to 36 months, with an average of(24.0±8.2) months. In 1 month after operation, pleural effusion occurred in 1 case, there was 1 case of cerebral stroke in two days after surgery, incision hematoma occurred in 1 case in 10 days after surgery, and the other patients had no postoperative death and severe complications. All 14 patients were followed-up and returned to normal life. Conclusion The hybrid operations can increase the success rate of TEVAR in complex Stanford type B aortic dissection patients, and early and mid-term results are satisfactory.
引文
1韩啸,宋来春,符竣,等.杂交手术治疗Stanford B型复杂型主动脉夹层的近中期效果.中国心血管病研究,2015,13(8):744-746.
2 Kuratani T.Best surgical option for arch extension of type B dissection:the endovascular approach.Ann Cardiothorac Surg,2014,3(3):292-299.
3 Hogendoorn W,Schlosser FJ,Moll FL,et al.Thoracic endovascular aortic repair with the chimney graft technique.J Vase Surg,2013,58(2):502-511.
4 Schoder M,Lammer J,Czerny M.Endovascular aortic arch repair:hopes and certainties.Eur J Vase Endovasc Surg,2009,38(3):255-261.
5韩向军,徐克.B型主动脉夹层腔内修复治疗的荟萃分析.介入放射学杂志,2011,20(7):530-533.
6 Gandet T,Canaud L,Ozdemir BA,et al.Factors favoring retrograde aortic dissection after endovascular aortic arch repair.J Thorac Cardiovasc Surg,2015,150(1):136-142.
7 Matalanis G,Hata M,Buxton BF.A retrospective comparative study of deep hypothermic circulatory arrest,retrograde,and antegrade cerebral perfusion in aortic arch surgery.Ann Thorac Cardiovasc Surg,2003,9(3):174-179.
8鲍春荣,梅举,丁芳宝,等.27例主动脉弓部病变患者一期杂交技术治疗的早中期结果.中华胸心外科杂志,2015,31(5):293-296.
9魏以桢,常谦,于存涛,等.一期杂交手术治疗累及主动脉弓远端的降主动脉病变.中国胸心血管外科临床杂志,2011,18(2):99-103.
10丁盛,张近宝,张立平,等.杂交手术治疗累及弓部的主动脉夹层的临床研究.生物医学工程与临床,2012,16(5):434-437.
11 Mitchell RS,Ishimaru S,Ehrlich MP,et al.First International Summit on Thoracic Aortic Endografting:roundtable on thoracic aortic dissection as an indication for endografting.J Endovasc Ther,2002,9(Suppl 2):Ⅱ98-105.
12张勇,王胜,梁家立.杂交手术在治疗B型主动脉夹层中的应用.中国结合临床,2013,29(1):87-89.
13 Fujikawa T,Yamamoto S,Sekine Y,et al.Operative results and clinical features of chronic Stanford type B aortic dissection:examination of 234 patients over 6 years.Eur J Vase Endovasc Surg,2015,50(6):738-743.
14 Bell D,Bassin L,Neale M,et al.A review of the endovascular management of thoracic aortic pathology.Heart Lung Circ,2015,24(12):1211-1215.
15 Lu Q,Feng J,Zhou J,et al.Endovascular repair by customized branched stent-graft:a promising treatment for chronic aortic dissection involving the arch branches.J Thorac Cardiovasc Surg,2015,150(6):1631-1638.e5.
16张宏鹏,郭伟,刘小平,等.杂交技术治疗主动脉弓部病变的近远期结果.中国普外基础与临床杂志,2011,18(10):1039-1042.
17 Zhang T,Jiang W,Lu H,et al.Thoracic endovascular aortic repair combined with assistant techniques and devices for the treatment of acute complicated Stanford type B aortic dissections involving aortic arch.Ann Vasc Surg,2016,32:88-97.
18 Ramdass M.TEVAR for symptomatic Stanford B dissection:a systematic review of 30-day mortality and morbidity.Thorac Cardiovasc Surg,2015,63(2):97-112.
19 Wang S,Chang G,Li X,et al.Endovascular treatment of arch and proximal thoracic aortic lesions.J Vasc Surg,2008,48(1):64-68.
20 Melissano G,Civilini E,Bertoglio L,et al.Results of endografting of the aortic arch in different landing zones.Eur J Vasc Endovasc Surg,2007,33(5):561-566.
2 Kuratani T.Best surgical option for arch extension of type B dissection:the endovascular approach.Ann Cardiothorac Surg,2014,3(3):292-299.
3 Hogendoorn W,Schlosser FJ,Moll FL,et al.Thoracic endovascular aortic repair with the chimney graft technique.J Vase Surg,2013,58(2):502-511.
4 Schoder M,Lammer J,Czerny M.Endovascular aortic arch repair:hopes and certainties.Eur J Vase Endovasc Surg,2009,38(3):255-261.
5韩向军,徐克.B型主动脉夹层腔内修复治疗的荟萃分析.介入放射学杂志,2011,20(7):530-533.
6 Gandet T,Canaud L,Ozdemir BA,et al.Factors favoring retrograde aortic dissection after endovascular aortic arch repair.J Thorac Cardiovasc Surg,2015,150(1):136-142.
7 Matalanis G,Hata M,Buxton BF.A retrospective comparative study of deep hypothermic circulatory arrest,retrograde,and antegrade cerebral perfusion in aortic arch surgery.Ann Thorac Cardiovasc Surg,2003,9(3):174-179.
8鲍春荣,梅举,丁芳宝,等.27例主动脉弓部病变患者一期杂交技术治疗的早中期结果.中华胸心外科杂志,2015,31(5):293-296.
9魏以桢,常谦,于存涛,等.一期杂交手术治疗累及主动脉弓远端的降主动脉病变.中国胸心血管外科临床杂志,2011,18(2):99-103.
10丁盛,张近宝,张立平,等.杂交手术治疗累及弓部的主动脉夹层的临床研究.生物医学工程与临床,2012,16(5):434-437.
11 Mitchell RS,Ishimaru S,Ehrlich MP,et al.First International Summit on Thoracic Aortic Endografting:roundtable on thoracic aortic dissection as an indication for endografting.J Endovasc Ther,2002,9(Suppl 2):Ⅱ98-105.
12张勇,王胜,梁家立.杂交手术在治疗B型主动脉夹层中的应用.中国结合临床,2013,29(1):87-89.
13 Fujikawa T,Yamamoto S,Sekine Y,et al.Operative results and clinical features of chronic Stanford type B aortic dissection:examination of 234 patients over 6 years.Eur J Vase Endovasc Surg,2015,50(6):738-743.
14 Bell D,Bassin L,Neale M,et al.A review of the endovascular management of thoracic aortic pathology.Heart Lung Circ,2015,24(12):1211-1215.
15 Lu Q,Feng J,Zhou J,et al.Endovascular repair by customized branched stent-graft:a promising treatment for chronic aortic dissection involving the arch branches.J Thorac Cardiovasc Surg,2015,150(6):1631-1638.e5.
16张宏鹏,郭伟,刘小平,等.杂交技术治疗主动脉弓部病变的近远期结果.中国普外基础与临床杂志,2011,18(10):1039-1042.
17 Zhang T,Jiang W,Lu H,et al.Thoracic endovascular aortic repair combined with assistant techniques and devices for the treatment of acute complicated Stanford type B aortic dissections involving aortic arch.Ann Vasc Surg,2016,32:88-97.
18 Ramdass M.TEVAR for symptomatic Stanford B dissection:a systematic review of 30-day mortality and morbidity.Thorac Cardiovasc Surg,2015,63(2):97-112.
19 Wang S,Chang G,Li X,et al.Endovascular treatment of arch and proximal thoracic aortic lesions.J Vasc Surg,2008,48(1):64-68.
20 Melissano G,Civilini E,Bertoglio L,et al.Results of endografting of the aortic arch in different landing zones.Eur J Vasc Endovasc Surg,2007,33(5):561-566.