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Endovascular Treatment of Renal Artery Stenosis

自1934年Goldblatt 发现肾动脉狭窄与高血压的关系以及1978年Gruntzig首次报道1例经皮腔内肾血管成形术（percutaneous transluminal renal angioplasty, PTRA）以来，肾动脉狭窄可导致肾血管性高血压和缺血性肾病已形成共识。目前，肾动脉狭窄的治疗方式包括药物治疗、手术治疗及腔内治疗，合理治疗仍存在争议。但不可否认，腔内治疗是目前多数医疗机构普遍采用的治疗方法。......

Endovascular Therapy for Aortic Diseases

Endovascular Treatment of Aortic Diseases: Progress and Future

1990年阿根廷医生Parodi的首次成功的经股动脉植入腔内移植物治愈一例腹主动脉瘤，在此后10余年中，腔内技术的发展使主动脉疾病的治疗模式发生了巨大的改变，例如腹主动脉瘤的治疗，在发达国家的多数血管外科中心利用腔内移植物进行的腔内隔绝术已经替代了一半以上的开腹手术，在主动脉夹层和胸主动脉瘤的治疗中，腔内技术的使用也日益普及。

不同杂交方式治疗累及弓部的主动脉夹层

目的　探讨不宜单独行腔内隔绝治疗、累及弓部的主动脉夹层杂交手术治疗方法及其疗效。　方法　回顾性分析2008年11月至2011年8月成都军区总医院15例累及弓部的主动脉夹层患者行杂交手术治疗的临床资料，其中男10例，女5例；年龄51～72 （58.2±7.2）岁。Stanford A型主动脉夹层4例，B型主动脉夹层11例，病变均累及主动脉弓。采用胸骨正中切口或加颈部切口行升主动脉至头臂动脉旁路移植、单纯颈部切口行头臂动脉间旁路移植，然后行股动脉切口逆行主动脉腔内覆膜支架植入。术后即刻行数字减影血管造影（DSA），术后3个月、术后1年和2年分别随访CT造影资料，观察支架和人工血管通畅情况。　结果　所有患者均成功完成手术，并植入覆膜支架。术中血管造影证实支架植入定位准确，支架无明显内漏和移位。主动脉夹层真腔血流恢复正常，旁路血管血流通畅，围术期无死亡和严重并发症发生。随访15例，随访时间3～20 （12.0±4.1）个月，所有患者均生存，恢复正常生活。术后3个月及术后1年、2年复查主动脉增强CT示：支架无移位和内漏，支架内及人工血管旁路血流通畅，未见脑部和肢体缺血征象。　结论　累及弓部的主动脉夹层可根据受累部位和程度采用不同的杂交手术方法，安全、有效，能明显减轻患者的创伤和痛苦，该方法扩大了介入覆膜支架腔内治疗的适应证，但远期疗效有待进一步观察。

OneStage Hybrid Operation for Treating Descending Aortic Diseases Involving Distal Aortic Arch

Abstract: Objective To summarize the clinical experiences of onestage hybrid operation for treating typeB aortic dissection and aortic aneurysm involving distal aortic arch, explore the indication for this special technique and analyze shortterm followup results. Methods From October 2008 to May 2010, 16 consecutive patients received onestage hybrid operation in Fu Wai Hospital for aortic dissection or aortic aneurysm involving distal aortic arch. There were 12 males and 4 females. Their age ranged from 38.0 to 67.0 years (54.0±9.2 years). There were 14 patients of typeB aortic dissection, 1 patient of thoracic aortic aneurysm involving the aortic arch, and 1 patient of penetrating aortic ulcer. Among them, 10 were acute ones and 6 were chronic ones. Brachiocephalic artery bypass using neck incision with retrograde endovascular stent graft implantation was used. Four patients received bypass from the left common carotid artery to the left subclavian artery; 11 patients underwent bypass from the right common carotid artery to the left common carotid artery; and 1 patient had both of the bypasses. Intensive care unit(ICU) stay, hospital stay， and incidence of complications were closely monitored after operation. Computed tomography(CT) and general condition of the bypass grafts and its blood flow were followed up at three months and one year after operation.  Results No death or severe complications occurred perioperatively. All onestage surgeries were technically successful with stent grafts implanted. Angiography during the operation showed 100% patency of all the bypass grafts and no obvious translocation or endoleakage of the stent grafts. One patient had mild paraplegia and recovered soon after treatment. Ventilation time of these patients was 2.010.0 hours (5.3±2.7 hours). The ICU stay was 0.0-2.0 days (1.1±0.4 days) and hospital stay was 4.0-7.0 days (5.3±0.8 days). The expenditure of blood products was 0.0-1 016.5 RMB (134.5±281.8 RMB). All patients were followed up with a followup period of 3.0 to 26.0 months (130±5.1 months). All patients recovered to normal social life. Enhanced CT scanning at three months and one year after operation showed no endoleakage or translocation of the stent grafts and 100% patency of the bypass grafts. There was no obvious change of the distal part of the dissection except some thrombosis formation in nine patients. Conclusion Onestage hybrid operation is safe and effective in shortening the duration of the operation and hospital stay, reducing the surgical trauma and sufferings of the patients, and lowering the risk of staged operations with satisfactory shortterm results. This special technique may expand the indications of simple endovascular repair. The mid and longterm results still need to be followed up.

ENDOVASCULAR REPAIR OF STANFORD TYPE B AORTIC DISSECTIONS WITH SEVERE COMPLICATIONS

Objective To investigate the security and efficiency of endovascular repair for Stanford type B aortic dissection (AD) with severe complications. Methods Between January 2003 and December 2009, 60 patients having Stanford type B AD with severe compl ications were treated, including 39 males and 21 females with an average age of 43.7 years (range, 34-71 years). Severe compl ications included 27 cases of huge hemothorax, 1 case of paraplegia, 7 cases of acute renal failure,10 cases of cel iac trunk ischemia, 10 cases of superior mesenteric artery ischemia, and 5 cases of severe limb schemia. Emergency stent-graft deployment were appl ied in all patients, and 64 stent-grafts were successfully implanted. Results All patients survived and were followed up 3-86 months. Hemothorax disappeared after 28 days to 3 months of operation in all hemothorax patients; renal function returned normal after 1 to 9 days; l imb and visceral ischemia disappeared gradually after 1 to 14 days; and muscular strength of lower limb in the paraplegia patient began to recover after 4 hours of operation. The postoperative CT angiography showed enlarged true lumen and thrombosis in the false lumen. Conclusion Emergency endovascular repair is a safe and effective method to treat Stanford type B AD with severe complications.

Curative Effect of Endovascular Angioplasty in Treatment for Iliofemoral Venous Post-Thrombotic Syndrome

Objective　To evaluate the clinical effect of staging endovascular angioplasty in treatment for iliofemoral venous post-thrombotic syndrome （PTS）. Methods　The clinical data of 45 patients with iliofemoral venous PTS from May 2008 to October 2011 in this hospital were analyzed retrospectively. After the identification of the stenosis or occlusion by angiography via femoral vein by percutaneous puncture or incision puncture， recanalization of the occlusion was done by guide wire. Then the percutaneous transluminal angioplasty （PTA） was performed. Results　A total of 45 cases （45 legs） had been undergone PTA. The procedures were technically successful in all the patients. No serious complications such as lumen rupture happened. Follow-up time was 6-30 months with （18.06±3.12） months， the symptoms of the affected limb were obviously relieved in 31 cases， partly relieved in 10 cases， not relieved in 4 cases. Reexamination of venous angiography， 9 cases were cured， 18 cases were excellent， 14 cases were improved， 4 cases were ineffective. The total effective rate was 91.11% （41/45）. Conclusion　PTA is a safe and effective method in treatment for iliofemoral venous PTS.

Hybrid Procedures in Treatment for Aortic Arch Lesions: Short- and Long-Term Results

ObjectiveTo evaluate the short-and long-term results of hybrid procedures in the treatment for aortic arch lesions. MethodsFrom October 2002 to March 2011, 28 patients with thoracic aortic aneurysms or dissections involving the aortic arch were treated with hybrid endovascular treatment in our center. Twenty-two males and 6 females were in the series. The mean age of the patients was 68 years old. Of 28 patients, 15 were atherosclerotic thoracic aortic aneurysms and 13 were thoracic aortic dissection. Follow-up protocol consisted of computed tomography (CT) angiograms or ultrasound was performed in 3, 6, and 12 months, and annually thereafter. The main goal was to evaluate the operative mortality, morbidity, and the longterm survival of these patients. ResultsHybrid procedures included 12 totalarch transpositions, 3 left common carotid artery (LCCA)left subclavian artery (LSA) bypass, 11 right common carotid artery (RCCA)LCCA-LSA bypass, 2 RCCA-LCCA bypass. The technical success rate was 92.9% (26/28). The complications occurred in 10 patients (35.7%). Operative mortality was 7.1% (2/28). The apoplexia rate was 7.1% (2/28). The time of followup was (36±3) months. The patency rates of 1-year, 3-year, and 5-year were 100%, 92.9% (26/28), and 85.7% (24/28), respectively. The survival rates of 1-year, 3-year, and 5-year were 89.3% (25/28), 71.4% (20/28), and 60.7% (17/28), respectively. ConclusionsThe short-and long-term results with hybrid procedures in the treatment for aortic arch diseases are satisfactory. Further reducing the complications is the key to increase the survival rate.

Application of Hybrid Procedures for Thoracoabdominal Aortic Aneurysm

Progress in Endovascular Treatment for Peripheral Arterial Disease