蒋俊豪 符伟国 王玉琦 复旦大学附属中山医院血管外科 主动脉夹层的腔内治疗 : 中期随访报告

Vascular Surgery Zhongshan Hospital 发病率不断增高 中山医院每年收入的 Stanford B 型夹层患者

Vascular Surgery Zhongshan Hospital 治疗方法的演变 腔内治疗 ( 始于 2000 年 ): 550 多例

Vascular Surgery Zhongshan Hospital 腔内治疗的指征 急性期主动脉直径大于 40mm 或慢性期大于 55mm 持续或反复的疼痛 破裂征兆 分支血管缺血

Vascular Surgery Zhongshan Hospital CT 血管外科 心脏外科 开放手术 急性期 58% 慢性期 42% 腔内治疗 Stanford B Stanford A 等待 3 周 血压控制

Vascular Surgery Zhongshan Hospital 支架尺寸的选择 放大 10%~15%

Vascular Surgery Zhongshan Hospital 选用的支架 Talent/Valiant (Medtronic) TX2 (COOK) Aegis/Hercules (Microport) Endofit (Endomed) Ankura Relay

Vascular Surgery Zhongshan Hospital 手术方式

Vascular Surgery Zhongshan Hospital 标准治疗

Vascular Surgery Zhongshan Hospital 覆盖左锁骨下动脉 锚定区 <15mm 主动脉弓成角过大

Vascular Surgery Zhongshan Hospital 210 例 完全覆盖 20% 部分覆盖 18% 覆盖左锁骨下动脉

Vascular Surgery Zhongshan Hospital 锚定区不足 左颈总动脉距破口 <15mm

Vascular Surgery Zhongshan Hospital 右颈 - 左颈动脉 - 左锁 骨下动脉转流 锚定区不足

Vascular Surgery Zhongshan Hospital 3 例 25 例 锚定区不足

Vascular Surgery Zhongshan Hospital 远端动脉瘤的处理

Vascular Surgery Zhongshan Hospital 左肾动脉 脾动脉 肠系膜 上动脉 远端动脉瘤的处理

Vascular Surgery Zhongshan Hospital 动态闭塞 (3.4%, 19/554) 分支血管缺血的处理

Vascular Surgery Zhongshan Hospital 左肾动脉 静态闭塞 (1.2%, 7/554) 肠系膜上动脉血栓 分支血管缺血的处理

Vascular Surgery Zhongshan Hospital 左髂动脉 – 肠系膜上动脉旁路 旁路血管 分支血管缺血的处理

Vascular Surgery Zhongshan Hospital 早期并发症

Vascular Surgery Zhongshan Hospital 早期死亡率 死亡率 : 1.9% (11/554) 心梗 1 中风 1 逆行夹层 4 破裂 5

Vascular Surgery Zhongshan Hospital 主要并发症 心梗 1 (0.2%) 中风 6 (1.1%) 逆行夹层 12 (2.1%) 破裂 5 (0.9%) 截瘫 1 (0.2%) 肾动脉闭塞 1 (0.2%)

Vascular Surgery Zhongshan Hospital 中风

Vascular Surgery Zhongshan Hospital 12 例 术中 ~36 月 再次开放手术 : 8 例 死亡率 50% ( 4/8) 保守治疗 : 4 例 逆行夹层

Vascular Surgery Zhongshan Hospital 主动脉壁的病理性改变 亚急性期 (10/12) 4 例马凡综合征 逆行夹层

Vascular Surgery Zhongshan Hospital 支架相关因素 夹层 逆行夹层

Vascular Surgery Zhongshan Hospital Talent Valiant 逆行夹层

Vascular Surgery Zhongshan Hospital COOK TX2 Hercules 逆行夹层

Vascular Surgery Zhongshan Hospital 其它注意事项 支架尺寸不宜过大 谨慎操作 逆行夹层

Vascular Surgery Zhongshan Hospital 肾动脉闭塞 肠系 膜上 动脉 假腔

Vascular Surgery Zhongshan Hospital 收缩压下降 15~64mmHg ( 平均 40mmHg) 眩晕 16.6% (7/42) 左上肢乏力 9.5% (4/42) 覆盖左锁骨下动脉

Vascular Surgery Zhongshan Hospital 腋 - 腋动脉转流 Willis 环不健全 覆盖左锁骨下动脉

Vascular Surgery Zhongshan Hospital 随访

Vascular Surgery Zhongshan Hospital 2003 年 1 月 ~ 2007 年 12 月 191 本地患者 ( 男性 164, 女性 27) 平均年龄 57 岁 随访 9 月 to 65 月, 平均 30.6 月 随访

Vascular Surgery Zhongshan Hospital 随访方案 CT 第一年 : 3/6 月, 12 月 第二年起每年一次

Vascular Surgery Zhongshan Hospital 内漏 即时内漏 : 20.4% (39/191) CT 随访 : 3.6% (7/191) 6 例 I 型内漏 4 例近端内漏 2 例远端内漏 1 例 II 型内漏

Vascular Surgery Zhongshan Hospital 近端 I 型内漏 左颈动脉转流 + 短支架

Vascular Surgery Zhongshan Hospital 短支架 近端 I 型内漏

Vascular Surgery Zhongshan Hospital 远端 I 型内漏

Vascular Surgery Zhongshan Hospital LSA II 型内漏

Vascular Surgery Zhongshan Hospital 远端动脉瘤 术前 术后

Vascular Surgery Zhongshan Hospital 内张力 术前 术后

Vascular Surgery Zhongshan Hospital 假腔的转归 重塑 10.4% (20/191)

Vascular Surgery Zhongshan Hospital 血栓形成 20.4% (39/191) 假腔的转归

Vascular Surgery Zhongshan Hospital 远端假腔未封闭 66.4% (127/191) 假腔的转归

Vascular Surgery Zhongshan Hospital 中山医院 谢谢

Vascular Surgery Zhongshan Hospital

Vascular Surgery Zhongshan Hospital Jiang Junhao Fu Weiguo Wang Yuqi Division of Vascular Surgery, Zhongshan Hospital, Fudan University Shanghai, China Endovascular Treartment of Thoracic Dissection: Mid-term Report

Vascular Surgery Zhongshan Hospital An Increasing Incidence Annual inpatients of Stanford B dissection in Zhongshan Hospital

Vascular Surgery Zhongshan Hospital Choice of Management Endovascular treatment (since 2000): cases

Vascular Surgery Zhongshan Hospital Indications for Endovascular Treatment Aortic diameter >40mm in acute phase or >55mm in chronic phase Persistent or recurrent pain Aortic rupture Branch vessels compromise

Vascular Surgery Zhongshan Hospital Preoperative Management CT Vascular Cardiovascular Surgery Acute 58% Chronic 42% Stent-grafting Stanford B Stanford A 3w interval BP control

Vascular Surgery Zhongshan Hospital Stent-graft planning 10%~15% over-sizing

Vascular Surgery Zhongshan Hospital Stent-graft Devices Talent/Valiant (Medtronic) TX2 (COOK) Aegis/Hercules (Microport) Endofit (Endomed) Ankura Relay

Vascular Surgery Zhongshan Hospital Procedures

Vascular Surgery Zhongshan Hospital Standard Procedure

Vascular Surgery Zhongshan Hospital Covering the LSA <15mm landing zone sharp angle

Vascular Surgery Zhongshan Hospital 210 cases Complete coverage 20% Partial coverage 18% Covering the LSA

Vascular Surgery Zhongshan Hospital Inadequate Landing Zone <15mm between entry tear and LCCA

Vascular Surgery Zhongshan Hospital Inadequate Landing Zone Right-left carotid & left carotid-subclavian bypass

Vascular Surgery Zhongshan Hospital Inadequate Landing Zone 3 cases 25 cases

Vascular Surgery Zhongshan Hospital Management of Distal Aneurysm

Vascular Surgery Zhongshan Hospital Management of Distal Aneurysm Left renal A Splenic A SMA

Vascular Surgery Zhongshan Hospital Management of Branch Vessel Compromise Dynamic obstruction (3.4%, 19/554)

Vascular Surgery Zhongshan Hospital Management of Branch Vessel Compromise left renal Static obstruction (1.2%, 7/554) thrombosed SMA

Vascular Surgery Zhongshan Hospital Management of Branch Vessel Compromise Iliac – SMA bypass bypass

Vascular Surgery Zhongshan Hospital Early Complications

Vascular Surgery Zhongshan Hospital In-hospital Mortality Mortality: 1.9% (11/554) Myocardial infarction 1 Stroke 1 Retrograde dissection 4 Rupture 5

Vascular Surgery Zhongshan Hospital Major Complications Myocardial Infarction 1 (0.2%) Stroke 6 (1.1%) Retrograde dissection 12 (2.1%) Rupture 5 (0.9%) Paraplegia 1 (0.2%) Renal thrombosis 1 (0.2%)

Vascular Surgery Zhongshan Hospital Stroke

Vascular Surgery Zhongshan Hospital 12 cases Intra-operative to 36m Surgical rescue: 8 mortality 50% ( 4/8) Medical treatment: 4 Retrograde Dissection

Vascular Surgery Zhongshan Hospital Pathological nature of the aortic wall Sub-acute phase (10/12) 4 Marfan’s syndrome Retrograde Dissection

Vascular Surgery Zhongshan Hospital Stent-graft related factors Retrograde Dissection Dissection

Vascular Surgery Zhongshan Hospital Retrograde Dissection Talent Valiant

Vascular Surgery Zhongshan Hospital Retrograde dissection COOK TX2 Hercules

Vascular Surgery Zhongshan Hospital Retrograde Dissection Other considerations less over-sizing careful manipulation

Vascular Surgery Zhongshan Hospital Renal Thrombosis SMA false lumen

Vascular Surgery Zhongshan Hospital Systolic BP drop 15~64mmHg (mean 40mmHg) Dizziness 16.6% (7/42) Weakness in the arm 9.5% (4/42) LSA Coverage

Vascular Surgery Zhongshan Hospital Axillary-axillary bypass LSA Coverage Inadequate Willis Circle

Vascular Surgery Zhongshan Hospital Follow-up

Vascular Surgery Zhongshan Hospital January 2003 ~ December local patients (male 164, female 27) Mean age 57y 9m to 65m, mean 30.6m Follow-up

Vascular Surgery Zhongshan Hospital Follow-up Protocol CT 3/6, 12m in the 1st year 12m since the 2nd year

Vascular Surgery Zhongshan Hospital Endoleak 20.4% (39/191) on completion angiogram 3.6% (7/191) on follow-up CT 6 Type I endoleak 4 proximal 2 distal 1 Type II endoleak

Vascular Surgery Zhongshan Hospital Proximal Type I Endoleak Left carotid transposition + Cuff

Vascular Surgery Zhongshan Hospital Proximal Type I Endoleak Cuff

Vascular Surgery Zhongshan Hospital Distal Type I Endoleak

Vascular Surgery Zhongshan Hospital Type II Endoleak LSA

Vascular Surgery Zhongshan Hospital Distal Aneurysm Pre-operative Post-operative

Vascular Surgery Zhongshan Hospital Endotension Pre-operative Post-operative

Vascular Surgery Zhongshan Hospital Outcome of the False Lumen Resolution 10.4% (20/191)

Vascular Surgery Zhongshan Hospital Outcome of the False Lumen Thrombosis 20.4% (39/191)

Vascular Surgery Zhongshan Hospital Outcome of the False Lumen Patent distal false lumen 66.4% (127/191)

Vascular Surgery Zhongshan Hospital Thank you