主动脉夹层腔内修复的现状与问题课件

Institute of Vascular Surgery,Fudan University,Vascular Surgery,Zhongshan Hospital,*,单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,主动脉夹层腔内修复的现状与问题,复旦大学附属中山医院 血管外科,复旦大学血管外科研究所,符伟国胡国华王玉琦,2019,年,Dake,和,Nienaber,分别,报道,TEVAR,技术治疗急性,B,型主动脉夹层。,TEVAR,治疗,15,年来，在治疗理念、操作技术及支架器具方面都取得了较大进展，如在升主动脉夹层及弓部夹层领域也逐渐应用。,长期的随访结果证实了,TEVAR,已成为,B,型夹层的首先治疗方式。,内漏及逆撕等仍是需要继续攻克的难题。,既往：急性期：发病,14d,内,慢性期：发病,14d,后,目前提出亚急性期，但定义不一：,INSTEAD,：,2w-6w,VIRTUE,：,14d-28d,IRAD,：,8d-30d,目前基于安全性倾向于在亚急性期行,TEVAR,术,临床分期,Steuer,J.,Bjorck,M.,Mayer,D.,et al.,Distinction between acute and chronic type B aortic,dissection:is there a sub-acute phase?,Eur J Vasc Endovasc Surg,2019.45(6):627-31.,复杂性与非复杂性,急性期复杂性：,胸痛,组织器官低灌注,难治性高血压,进行性主动脉周或胸膜腔血肿,2,周内主动脉直径增加,1cm,慢性期复杂性：,夹层动脉瘤直径大于,5.5cm,复杂性,AD,如不处理有较高的死亡率，被认为是,TEVAR,的绝对手术指征,!,Fattori,R.,Tsai,T.T.,Myrmel,T.,et al.,Complicated acute type B dissection:is surgery still the best option?:a report from the International Registry of Acute Aortic Dissection.,JACC Cardiovasc Interv,2019.1(4):395-402.,非复杂,TBAD,中也有因假腔通畅而预后差的亚群，所谓非复杂性可能是误称，还需要仔细分出真正稳定的,AD,！,Augoustides,J.G.,Szeto,W.Y.,Woo,E.Y.,et al.,The complications of uncomplicated acute,type-B dissection:the introduction of the Penn classification,.J Cardiothorac Vasc Anesth,2019.26(6):1139-44.,临床分型,40多年前De Bakey分型和Stanford分型,2019年景在平 “3N3V”分型,2009年Augoustides提出 Penn分型,2019年Dake教授提出DISSECT分类,N:裸区,V：内脏区,Penn classification of ischemic presentations in acute type A aortic dissection,No ischemia,(Penn class Aa),Localized ischemia,(Penn class Ab),Generalized ischemia,(Penn class Ac),Combined ischemia,(Penn class Ab&c),localized and generalized ischemia together,University of Pennsylvania Classification of Acute Stanford Type-B Aortic Dissection,Clinical Presentation,Definition of Clinical Presentation Class,Class A(Uncomplicated),Absence of branch-vessel ischemia or circulatory compromise,Type I high risk for future aortic complications,Type II low risk for future aortic complications,Class B(Complicated),Branch-vessel malperfusion,Class C(Complicated),Circulatory compromise,Type-I aortic rupture with hemorrhage outside the aortic wall with/without cardiac arrest,shock,and hemothorax,Type-II threatened aortic rupture typically heralded by refractory pain and/or hypertension,Class BC(Complicated),Branch-vessel malperfusion combined with circulatory compromise,DISSECT:,D,uration of dissection,I,ntimal tear(primary)location within the aorta,S,ize of aorta,Se,gmentalextent of aortic,involvement from proximal to distal boundary,C,linical complications related to dissection,T,hrombosis of aortic false lumen,Dake,M.D.,Thompson,M.,Van Sambeek,M.,et al.,DISSECT:A New Mnemonic-based Approach to the Categorization of Aortic Dissection.,European Journal of Vascular and Endovascular Surgery,2019.,46,(2):175-190.,主动脉弓,TEVAR,主动脉弓,TEVAR,近左锁骨下破口：,覆盖,LSA,取得足够的锚定，但仍有截瘫风险,重建,LSA,LCCA-LSA,转流,LSA,烟囱支架,开窗开槽,单分支支架,Brian J.Manning,Krassi Ivancev,Peter L.Harris,，,In situ fenestration in the aortic arch,，,Journal of Vascular Surgery Volume 52,Issue 2 2019 491-494,LSA烟囱支架,开窗、开槽支架,整体式,分体式,单分支支架,微创 Castor,近左颈总破口：,杂交技术,RCCA-LCCA/RCCA-LCCA-LSA,烟囱技术,LCCA,烟囱,LSA,和,LCCA,双烟囱,分支支架,+LCCA-LSA,旁路,主动脉弓,TEVAR,近无名破口：,杂交技术,升主动脉,-IA-LCCA-LSA,旁路,烟囱技术,IA,和,LCCA,双烟囱,三分支支架,主动脉弓,TEVAR,烟囱支架,三分支支架,Inoue K et al.Circulation 2019;100:II-316-Ii-321,Moon,等通过,CTA,行对,162,例患者的升主动脉重建和精确测量，从解剖方面认为,32%,适合,TEVAR,，开口没有累及主动脉瓣和冠状动脉，具有合适的直径和长度以及足够的锚定区。,升主动脉,TEVAR,Moon,M.C.,Greenberg,R.K.,Morales,J.P.,et al.,Computed tomography-based anatomic characterization of proximal aortic dissection with consideration for endovascular candidacy.,J Vasc Surg,2019.,53,(4):942-9.,保留冠脉灌注、主动脉瓣功能和弓上分支的血供是升主动脉夹层,TEVAR,手术成功的关键。,以前认为破口距离冠状动脉开口至少,2cm,和距,IA,开口,5mm,才适合,TEVAR,，现在则距冠状动脉开口,2cm,和距,IA,开口,5mm,为关键点。,升主动脉,TEVAR,Ronchey,S.,Serrao,E.,Alberti,V.,et al.,Endovascular stenting of the ascending aorta for type A aortic dissections in patients at high risk for open surgery.,Eur J Vasc Endovasc Surg,2019.,45,(5):475-80.,杂交手术,升主动脉置换,+,弓上三分支支架,单纯,TEVAR,覆盖破口,经右颈动脉,经股动脉,穿房间隔，经股动静脉,升主动脉,TEVAR,G.Matthew Longo,Iraklis I.,Pipinos,Endovascular techniques for arch vessel reconstruction,，,Journal of Vascular Surgery Volume 52,Issue 4,Supplement 2019 77S-81S,Lu,Q.,Feng,J.,Zhou,J.,et al.,Endovascular repair of ascending aortic dissection:a novel treatment option for patients judged unfit for direct surgical repair.,J Am Coll Cardiol,2019.,61,(18):1917-24.,选择的内支架要相对短（,10cm,）和较大直径（,46cm,），不推荐近端带有裸架的移植物，因为会损伤主动脉瓣并不能达到合适的锚定。,也有报道在紧急情况给下将头端有裸架,Talent,移植物,(Medtronic Inc,Minneapolis,MN),倒装后释放成功,升主动脉,TEVAR,Mccallum,J.C.,Limmer,K.K.,Perricone,A.,et al.,Case report and review of the literature total endovascular repair of acute ascending aortic rupture:a case report and review of the literature.,Vasc Endovascular Surg,2019.,47,(5):374-8.,46 100mm Talent or Valor graft,Medtronic,40 100mm CTAG graft,Gore,46 85 mm,Jotec,Cook,off-the-shelf device for ascending,S.Ronchey,E.et al,Endovascular Stenting of the Ascending Aorta for Type A Aortic Dissections in Patients at High Risk for Open Surgery,Europe