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胸腹主动脉瘤Ⅳ型行外科及腔内微创术围手术期护理

【摘要】　目的　总结对胸腹主动脉瘤IV型行血管外科和腔内微创术治疗患者的护理要点及经验。　方法　2007年11月-2008年1月对收治的1例胸腹主动脉瘤IV型行血管外科和腔内微创术患者，术前做好心理护理，控制血压，完善术前相关检查等；术后做好生命体征的监测、预防术后吻合口出血、支架移位、内漏、肠坏死、肾功能衰竭等并发症发生的各项护理工作。　结果　患者无并发症发生，痊愈出院，治疗和护理效果满意。　结论　围手术期实施正确恰当的护理是保证手术和治疗效果的关键。

The Treatment of Traumatic Carotid Cavernous Fistula with Covered Stent

目的：探讨覆膜支架治疗外伤性颈内动脉海绵窦瘘（TCCF）的临床治疗经验。方法：11例TCCF经血管内介入治疗，1例外伤性颈内动脉海绵窦瘘患者复发，压迫颈总动脉无效，行球囊闭塞颈内动脉及瘘口。结果：术后杂音立即消失，数天后结膜水肿消退，造影见瘘口完全闭塞，10例TCCF患者颈内动脉保持通畅。1例患者颈内动脉闭塞。无操作所产生的并发症出现。结论：覆膜支架是处理TCCF的有效手段；瘘口再通可能与支架移位、贴壁不良有关。压迫颈总动脉对再通瘘口的治疗无效。

覆膜支架腔内隔绝术治疗Stanford B型主动脉夹层

目的　总结采用覆膜支架腔内隔绝术治疗Stanford B型主动脉夹层的临床经验。 方法　2008年8月至2012年10月安庆市立医院对26例Stanford B型主动脉夹层患者行覆膜支架腔内隔绝术治疗，男21例，女5例；年龄（52.4±10.3）岁。术后定期复查CT血管成像。 结果　所有患者支架释放全部成功，无死亡、中转开胸和截瘫。术后发现支架覆盖腹腔干及肠系膜上动脉1例，急诊行旁路移植术；多发性脑梗塞1例，轻度Ⅰ型内漏2例，未予特殊处理；股动脉狭窄3例，其中1例严重狭窄者行大隐静脉移植术，2例中度狭窄者给予保守治疗。随访22例，随访时间（23.5±15.9）个月。随访期间CT血管成像显示所有患者支架无移位，主动脉真腔较术前明显扩大，假腔血栓形成。 结论　覆膜支架腔内隔绝术创伤小、效果佳、并发症少，是治疗Stanford B型主动脉夹层的有效方法。

主动脉覆膜支架腔内隔绝术治疗成人巨大动脉导管未闭

目的总结主动脉覆膜支架腔内隔绝术治疗成人巨大动脉导管未闭（ PDA）的经验，并对其疗效进行评价。方法回顾性分析 2010年 9月至 2011年 8月青海省心脑血管病专科医院 8例 PDA患者行主动脉覆膜支架腔内隔绝术治疗的临床资料，其中男 5例，女 3例；年龄（30.4±9.3）岁。主动脉造影显示 PDA最窄内径为（21.0±3.0）mm；肺动脉收缩压（ 76.6±9.4）mm Hg。结果 8例患者中 7例一次性隔绝成功。术后即刻血管造影显示 6例动脉导管完全封闭， 2例残余少量左向右分流。术后 2周超声心动图及大血管 CT血管造影显示：残余分流消失，肺动脉收缩压（ 43.5±7.2）mm Hg，显著降低。术后左心室舒张期末内径较术前明显减小［（52.0±5.2） mm vs.（69.0±11.1）mm］。随访 8例，随访时间 1～ 11（7.2±1.1）个月，随访期间胸部 X线示：肺血明显减少，心胸比率明显减小。结论应用主动脉覆膜支架腔内隔绝术治疗成人巨大 PDA是一种安全、有效的方法。

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。

Observation and Care of Endovascular Covered Stent Graft in Treating Abdominal Aortic Aneurysm

【摘要】　目的　总结血管腔内覆膜支架植入术治疗腹主动脉瘤患者围手术期并发症的预防、观察和临床护理要点。　方法　对2008年1-8月行血管腔内覆膜支架植入术治疗的27例腹主动脉瘤患者的临床资料进行回顾性分析。　结果　27例手术均获成功，术后未发生严重并发症，治疗及护理效果良好。　结论　有效的护理措施是保证治疗成功的重要因素。【Abstract】　Objective　To summarize and analyze the prevention, observation and clinical care of perioperative complications in patients with abdominal aortic aneurysm (AAA).　Methods　We retrospectively analyzed the clinical data of 27 patients with AAA who underwent endovascular covered stent grafting surgery in our hospital from January to August 2008.　Results　With appropriate treatment and good care, all grafting surgeries were successful without any severe postoperative complications.　Conclusion　Effective care measures are an important factor to ensure successful treatment.

EFFECTIVENESS OF COVERED Cheatham-platinum STENT FOR TREATMENT OF COARCTATION OF AORTA

ObjectiveTo evaluate the effectiveness of covered Cheatham-platinum (CP) stent for treatment of coarctation of aorta (CoA). MethodsBetween January 2007 and September 2013, 15 patients (16 lesions) with CoA underwent covered CP stent implantation, and the clinical data were analyzed retrospectively. Of 15 cases, 8 were male and 7 were female, aged 13-56 years (mean, 27.7 years). Fifteen lesions located beyond the origin of the left subdavian artery, and 1 lesion located between the origin of the left common carotid artery and the origin of the left subdavian artery. Proper covered CP stent and balloon-in-balloon (BIB) catheter were selected according to the data of computed tomography angiography or digital subtraction angiography examination. Under fluoroscopic guidance, the covered CP stent was placed at lesion accurately by expanding the inner balloon and the outer balloon sequentially. The variation of the systolic pressure gradient across the lesion and the stenosis extent of the aorta before and after the procedure were recorded. ResultsFifteen patients were all treated by covered CP stent implantation successfully. The systolic pressure gradient across the lesion decreased from (58.1±19.5) mm Hg (1 mm Hg=0.133 kPa) at preoperation to (6.2±5.6) mm Hg at immediate after CP stent implantation, and the stenosis extent of the aorta decreased from 73.8%±12.8% at preoperation to 16.7%±5.6% at immediate after CP stent implantation, all showing significant difference (t=12.483, P=0.000; t=15.631, P=0.000). All puncture points healed well with no aortic dissection, pseudoaneurysm, or obvious subcutaneous hematoma. All the patients could walk moderately within 48 hours after procedure. The average hospitalization time was 11.1 days (range, 6-18 days). During a mean follow-up of 29.7 months (range, 1-81 months), the symptom of dizziness and exercise tolerance were improved obviously, and the systolic pressures gradient between upper and lower extremity was below 20 mm Hg. The systolic and diastolic pressures at last follow-up were significantly improved when compared with preoperative values (t=7.725, P=0.000; t=3.651, P=0.000). According to radiography, the location and shape of the stent were good, and no aortic dissection, aneurysm, or recoarctation occurred. ConclusionAccording to the initial and midterm results, the covered CP stent is an effective treatment for CoA in adolescents and adults with a low rate of complication. However, long-term results still require further follow-up.

EFFECTIVENESS EVALUATION OF THORACIC ENDOVASCULAR AORTIC REPAIR FOR BLUNT THORACIC AORTIC INJURY WITH HOSTILE STENT-GRAFT PROXIMAL LANDING ZONE

ObjectiveTo explore the effectiveness of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) with hostile stent-graft proximal landing zone. MethodsA retrospective analysis was made on the clinical data of 13 patients with BTAI with hostile stent-graft proximal landing zone treated by TEVAR between December 2007 and December 2014. There were 10 males and 3 females with the mean age of 44 years (range, 24-64 years). The imaging examination indicated Stanford type B aortic dissection in 7 cases, pseudoaneurysm in 3 cases, aneurysm in 1 case, and penetrating ulcer in 2 cases. According to the partition method of thoracic aortic lesion by Mitchell, 8 cases underwent stent-graft with left subclavian artery (LSA) coverage, 3 underwent chimney stents for LSA, and 2 for left common carotid artery (LCCA). In 2 cases receiving chimney TEVAR involving LCCA, one underwent steel coils at the proximal segment of LSA to avoid type II endoleak and the other underwent in situ fenestration for endovascular reconstruction of LSA. ResultsAll TEVAR procedures were successfully performed. The mean operation time was 1.8 hours (range, 1-3 hours); the mean intraoperative blood loss was 120 mL (range, 30-200 mL); and the mean hospitalization time was 15 days (range, 7-37 days). No perioperative death and paraplegia occurred. The patients were followed up 3-30 months (mean, 18 months). Type I endoleak occurred in 1 case during operation and spontaneously healed within 6 months. Hematoma at brachial puncture site with median nerve compression symptoms occurred in 1 case at 3 weeks after operation; ultrasound examination showed brachial artery pseudoaneurysm and thrombosis, and satisfactory recovery was obtained after pseudoaneurysmectomy. No obvious chest pain, shortness of breath, left upper limbs weakness, numbness, and dizziness symptoms were observed. Imaging examination revealed that stentgraft and branched stent remained in stable condition. Meanwhile the blood flow was unobstructed. No lesions expanded and ruptured. No new death, bacterial infection, or other serious complications occurred. ConclusionAccording to Mitchell method, individualized plan may be the key to a promising result. More patients and further follow-up need to be included, studied, and observed.

创伤性主动脉夹层并发肾功能衰竭一例

Thoracic Endovascular Aortic Repair for Stanford Type B Aortic Dissection

ObjectiveTo evaluate clinical outcomes of thoracic endovascular aortic repair (TEVAR)for the treatment of Stanford type B aortic dissection (AD)and descending aortic aneurysm. MethodsClinical data of 20 patients with Stanford type B AD or descending aortic aneurysm who underwent TEVAR in West China Hospital from March to June 2013 were retrospectively analyzed. There were 19 male and 1 female patients with their age of 41-76 (58.3±10.2)years. Clinical outcomes were analyzed. ResultsAmong the 20 patients, 18 patients were successfully discharged, 1 patient refused further postoperative treatment and was discharged, and 1 patient died postoperatively. Sixteen patients (88.9%)were followed up for over 3 months. In all the patients during follow-up, true lumen diameter recovered within the scope of intravascular stents, and there was thrombosis in false lumen or aneurysm lumen. ConclusionTEVAR provides a new choice with significant advantages for the treatment of Stanford type B AD, especially for the elderly and patients with concomitant serious diseases, so it is worthy of clinical application.