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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。

创伤性主动脉夹层并发肾功能衰竭一例

Short-term outcome of ascending aorta replacement combined with total aortic arch fenestration technique for acute type A aortic dissection

ObjectiveTo report our clinical experience and outcomes of thoracic endovascular aortic repair (TEVAR) for acute Stanford type A dissection using ascending aorta replacement combined with implantation of a fenestrated stent-graft of the entire aortic arch through a minimally invasive technique. MethodsFrom 2016 to 2020 in our hospital, 24 patients (17 males and 7 females, aged 45-72 years) with complicated Stanford type A aortic dissection, underwent replacement of the proximal ascending aorta with TEVAR. None of the patients with dissection involved the three branches of the superior arch, and all patients were replaced with artificial blood vessels of the ascending aorta under non-hypothermic cardiopulmonary bypass, preserving the arch and the three branches above the arch, and individualized stent graft fenestration. ResultsSurgical technical success rate was 100.0%. There was no intraoperative complication or evidence of endo-leak in 1 month postoperatively. Hospital stay was 10±5 d. During postoperative follow-up, the stent was unobstructed without displacement, the preserved branch of the aortic arch was unobstructed, and the true lumen of the descending aorta was enlarged. Conclusion This hybrid technique by using TEVAR with fenestrated treatment is a minimally invasive and effective method to treat high-risk patients with acute Stanford type A aortic dissection.

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。

三分支覆膜支架行主动脉弓重建治疗 Stanford A 型主动脉夹层效果的临床随访

目的通过长期随访采用三分支覆膜支架重建主动脉弓治疗 Stanford A 型主动脉夹层患者的临床治疗效果，评价三分支覆膜支架行主动脉弓重建的安全性和可行性。方法纳入 2009 年 3 月至 2014 年 6 月我院心脏大血管外科应用三分支覆膜支架治疗的 Stanford A 型主动脉夹层患者 17 例，其中男 11 例、女 6 例，年龄 35～72 岁。观察其临床疗效及并发症发生率以及术后 CT 随访结果。结果三分支主动脉弓覆膜支架治疗组患者随访期间死亡 1 例。术后不同随访时间 64 排 CT 血管造影结果显示支架血管位置满意，支架打开完全，无扭曲及内漏发生。主动脉各分支血管血流通畅，无狭窄及闭塞。3 个月后随访观察到有 8 例假腔血栓形成闭塞，6 个月后随访观察到所有患者假腔全部血栓闭塞。3 年后随访观察到支架稳定，未发生支架扭曲、变形或者断裂情况，假腔消失。结论三分支覆膜支架重建主动脉弓治疗 A 型主动脉夹层临床效果可靠，值得推广应用。

The feasibility study of transjugular extrahepatic portacaval shunt

Objective To evaluate the feasibility of X-ray guided access to the extrahepatic segment of the main portal vein (PV) to create a transjugular extrahepatic portacaval shunt (TEPS). Methods 5F pigtail catheter was inserted into the main PV as target catheter by percutaneous transhepatic path under ultrasound guidance. The RUPS-100 puncture system was inserted into the inferior vena cava (IVC) by transjugular path under ultrasound guidance. Fluency covered stent was deployed to create the extrahepatic portacaval shunt after puncturing the target catheter from the IVC under the X-ray guidance, then shunt venography was performed. Enhanced CT of the abdomen helped identify and quantify the patency of the shunt and the presence of hemoperitoneum. Results The extrahepatic portacaval shunts were created successfully by only 1 puncture in 6 pigs. No extravasation was observed in shunt venography. One pig died of anesthesia on the day of operation. The extrahepatic portacaval shunts were failed in 2 pigs 3 days after the operation (one was occluded and the other one was narrowed by 80%). The extrahepatic portacaval shunts were occluded 2 weeks after the operation in the remaining 3 pigs. The shunts were out of the liver and no hemoperitoneum was identified at necropsy in the 6 pigs. Conclusion TEPS is technically safe and feasible under the X-ray guidance.

Finite element simulation of stent implantation and its applications in the interventional planning for hemorrhagic cardio-cerebrovascular diseases

Numerical simulation of stent deployment is very important to the surgical planning and risk assess of the interventional treatment for the cardio-cerebrovascular diseases. Our group developed a framework to deploy the braided stent and the stent graft virtually by finite element simulation. By using the framework, the whole process of the deployment of the flow diverter to treat a cerebral aneurysm was simulated, and the deformation of the parent artery and the distributions of the stress in the parent artery wall were investigated. The results provided some information to improve the intervention of cerebral aneurysm and optimize the design of the flow diverter. Furthermore, the whole process of the deployment of the stent graft to treat an aortic dissection was simulated, and the distributions of the stress in the aortic wall were investigated when the different oversize ratio of the stent graft was selected. The simulation results proved that the maximum stress located at the position where the bare metal ring touched the artery wall. The results also can be applied to improve the intervention of the aortic dissection and the design of the stent graft.

Therapy experience of multiple interventional technologies for visceral artery aneurysms in 32 cases

ObjectiveTo investigate treatment methods and effect of endovascular interventional therapy for visceral artery aneurysms.MethodsThe clinical data of 32 patients with visceral artery aneurysms, who were treated in the No. 960 Hospital of PLA from February 2011 to April 2018, were retrospectively analyzed. It was proveded by the CT or digital subtraction angiography before the interventional therapy. The implantation of covered stent, coil embolization together with stent implantation, double stents placement or pure coil embolization were performed. The postoperative antithrombotic therapy was adopted in the patients accepted the stent implantation. The CT angiography was performed on the month of 1, 6, 12, 24 or the patient was uncomfortable after the treatment to evaluate the obstruction condition of the aneurysms, stent blood flow, and branches arteries, etc..ResultsThe success rate of the endovascular interventional therapy was 100%. In the 11 patients underwent the implantation of covered stent, the postoperative angiography showed that the stent lumen was patent and the aneurysm was not visualized. In the 9 patients underwent the coil embolization together with stent implantation and 3 patients underwent the double stents placement, the postoperative angiography results of the aneurysm showed that it was faintly visualized and the branch arteries were not involved. In the 9 patients underwent the pure coil embolization, the postoperative angiography showed that the aneurysm was not visualized. No perioperative mortality or procedure related complications occurred. No case was lost during the follow-up of a median period of 25.5 (6–48) months. During the follow-up, one patient developed the mild abdominal pain in one month, which disappeared after the symptomatic medication management. Except for 1 patient developed the mild stent stenosis (<30%) on the 12th month after the procedure, the stent and the branch arteries of the other patients were completely patent, and no aneurysms recurred.ConclusionFor treatment of visceral artery aneurysms, endovascular interventional therapy is safe and effective and shows an excellent short-term and mid-term effects.

Advances in the study of morphological evaluation of the landing zone and clinical outcomes in endovascular aortic aneurysm repair

ObjectiveTo summarize the research progress of relationship between distal landing zone geometric and outcomes of endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm. MethodsThe domestic and foreign literature on the accumulation of the impact of proximal and distal landing zone geometric morphology on clinical outcomes, the evaluation methods for related complications of proximal and distal landing zones, preventive measures for adverse outcomes related to the geometric morphology of the distal landing zone, and the pathophysiological mechanisms of complications related to the distal landing zone were retrieved to make an review. ResultsThe irregular geometric morphology of the proximal landing zone was closely associated with adverse events following EVAR. The morphology of the distal landing zone was actually more complex than that of the proximal zone, and the measurement methods for its parameters were also more complicated. Common methods used in the literature for studying landing zones included the centerline distance method, the minimum distance method, and the landing area method. Primary preventive measures for adverse outcomes related to the geometry of the distal landing zone included increasing radial support force and contact area, using endostaples, and extending the landing zone. In addition to anatomical factors, the distal landing zone was also influenced by various pathophysiological factors. ConclusionsThe morphology and related pathological changes of the distal landing zone significantly impact the clinical outcomes following EVAR for abdominal aortic aneurysm. However, current research on the distal landing zone is limited. Future studies should focus on developing new technologies and methods to improve the evaluation and management of the distal landing zone, thereby reducing the complications after EVAR, enhancing the success rate of the surgery, and improving patient survival quality.

覆膜支架治疗难治性股动脉假性动脉瘤的探讨

目的探讨覆膜支架置入治疗难治性股动脉假性动脉瘤的有效性及其安全性。方法2012 年 8 月至 2017 年 8 月期间，河西学院附属张掖人民医院血管外科共收治了 26 例难治性股动脉假性动脉瘤患者，其中属外伤性股动脉假性动脉瘤 20 例，医源性股动脉假性动脉瘤 6 例；26 例中有 8 例合并股动-静脉瘘。26 例患者术前全部经彩超检查得以确诊，并在彩超引导下进行常规压迫或瘤腔内注射血凝酶治疗，但均未获成功，26 例患者最终改行股动脉覆膜支架置入术治疗，其中 4 例同期行血肿清除术，2 例行假性动脉瘤腔内穿刺引流术。结果全部患者一期置入覆膜支架均获成功，股动脉假性动脉瘤及动-静脉瘘均治愈，6 例患者股深动脉封闭，无手术死亡及严重并发症发生。术后 6 个月及 12 个月进行随访，26 例患者均无瘤体复发及支架移位、断裂、栓塞和内瘘发生。结论覆膜支架置入治疗难治性股动脉假性动脉瘤是安全、有效、微创的方法，其短期效果满意，远期疗效有待进一步观察。