主动脉夹层详解ppt课件

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,*,*,Fundamentals of Aortic Surgery,华中科技大学同济医学院附属协和医院心外科,孙图成,Fundamentals of Aortic Surgery,Modern Era,1955:Debakey/Cooley,perform replacement of,aorta using homograft.,1965:Wheat proposes modern,pharmacological anti-impulse,therapy(dp/dt),1970:Stanford Classification,1975:HCA for aortic arch repair by Griep and colleagues,2019 first FDA-approved TEVAR,2024/11/11,2,Modern Era1955:Debakey/Cooley,Overview,Pathologies of thoracic aorta,Medical management,Open repair,Endovascular repair,2024/11/11,3,OverviewPathologies of thoraci,Pathologies of Thoracic Aorta,Thoracic aorta aneurysm(TAA),Acute and chronic dissections,Aortic transections,Penetrating ulcer,Intramural hematoma,Aortoesophageal and aortobronchial fistula,Shaggy Aorta,Coarctation of the aorta and its aneurysm,2024/11/11,4,Pathologies of Thoracic AortaT,Guidelines,Hiratzka LF et al.,Circulation 2019,2024/11/11,5,GuidelinesHiratzka LF et al.,Thoracic Aorta Aneurysm,Aneurysmal dilatation=50%increase over the normal diameter,majority w/o symptoms,Svensson LG,Crawford ES.,Cardiovascular and vascular,disease of the aorta.Philadelphia:WB Saunders,2019,2024/11/11,6,Thoracic Aorta AneurysmAneurys,TAA-Lifetime Rates of rupture,dissection or death,34%for ascending thoracic aorta at 6 cm,43%for descending thoracic aorta at 7 cm,2024/11/11,7,TAA-Lifetime Rates of ruptur,Medical Management,Control BP and HR(dp/dt)*,multiple intravenous medication:B-blocker,calcium-antagonists,etc.,Pray!,No weight lifting,skiing,horseback riding,contact,sports,etc.,*7th JNC guidelines:Chobanian et al.,Hypertension 2019;42(6):1206-52.,2024/11/11,8,Medical ManagementControl BP a,Indications for operation,5.5 cm in ascending aorta(or smaller!),5.5 cm in arch and DTA(or larger),faster growth rate,rupture,intractable pain,viscero-renal symptoms,concomitant operations,2024/11/11,9,Indications for operation5.5 c,Aortic dissection,发病率,10-29/10,万，,男、女比例,3:1,急性：,14,天以内,亚急性：,14,天,-2,月,慢性：,2,月以上,发病凶险，若未及时治疗，,48,小时死亡率可高达,80%,2024/11/11,10,Aortic dissection发病率10-29/10万，,病因,主动脉中层变性（,Marfans syndrome),主动脉粥样硬化,高血压,胸部外伤,医源性（主动脉插管、,AVR,、,CABG,）,2024/11/11,11,病因主动脉中层变性（Marfans syndrome)20,病理,内膜破口：,95%,的病人主动脉夹层起自两个部位之一：升主动脉、胸降主动脉起始部（导管韧带附着处）。其中,66%,为升主动脉破口。,假腔形成：主动脉内膜和中层分离。假腔内可有血液流动或血栓形成。可向下撕裂至腹主动脉、髂总动脉。远端可有,1,个或多个破口，为假腔出口。,假腔因高压可使外膜膨出形成动脉瘤，严重者外膜可破裂出血。高压的假腔可压迫真腔或主动脉的各分支血管（如冠状动脉、弓部分支、肾动脉等）,2024/11/11,12,病理内膜破口：95%的病人主动脉夹层起自两个部位之一：升主动,并发症和主要死亡原因,主动脉破裂,心包填塞,血胸,急性主动脉瓣关闭不全,充血性心衰,灌注不良综合征 ,急性心梗,卒中,（偏瘫等）,截瘫,肝、肾、肠,肢体缺血,2024/11/11,13,并发症和主要死亡原因主动脉破裂,分型,2024/11/11,14,分型2023/10/614,症状,突发的撕裂样疼痛,（前胸、颈部、两肩胛骨之间、腰背部甚至腹股沟。一旦假腔形成并稳定，锐痛可转为持续的钝痛。疼痛突然加重提示破裂征象）,休克症状,（出汗、四肢皮肤湿冷、晕厥）,神经系统症状,（偏瘫、失语）,少尿或无尿,下肢缺血,2024/11/11,15,症状突发的撕裂样疼痛（前胸、颈部、两肩胛骨之间、腰背部甚至腹,体征,四肢脉搏强弱不等，血压相差较大,心前区听诊往往无特殊发现，部分病人因主动脉瓣受累关闭不全，可闻及舒张期杂音,如并发休克、神经系统并发症或累及肠系膜动脉、股动脉等可出现相应体征,2024/11/11,16,体征四肢脉搏强弱不等，血压相差较大2023/10/616,辅助检查,超声（,TTE,、,TEE,）：可发现主动脉内漂浮物或夹层，动脉直径增粗，并可探及主动脉瓣返流情况。,CT,：通过增强可发现夹层的部位和长度,MRI,：可扫描到夹层的部位和长度，需时较长,血管造影：因属于创伤性检查对夹层病人有较大的威胁，常常不被使用。,2024/11/11,17,辅助检查超声（TTE、TEE）：可发现主动脉内漂浮物或夹层，,诊断,A,型,or B,型？,心包积液？,主动脉瓣关闭不全？,主动脉瓣病变？,LVEF,？,内膜破口,/,剥离范围？,血胸？,尿量？,脉搏？,神经系统病理体征？,鉴别诊断：急性心梗,vs,夹层,急性肺栓塞,vs,夹层,2024/11/11,18,诊断A型 or B型？2023/10/618,治疗,药物治疗,：早期处理十分重要。主要包括镇痛、控制血压以防夹层进展、对症支持治疗。,早期静脉降压药：,受体阻滞剂（艾司洛尔）、钙拮抗剂、硝普钠,对于,A,型：经上述药物适当控制后，积极准备手术,对于,B,型：经上述药物控制血压，度过急性期后，逐渐改,为口服，包括长效,受体阻滞剂（美托洛尔）、,钙拮抗剂、,ACEI,以及利尿剂多种药物联用,血压控制目标,：既要尽量减少主动脉破裂可能，又要使病变血管床获得足够灌注,2024/11/11,19,治疗药物治疗：早期处理十分重要。主要包括镇痛、控制血压以防夹,手术适应症,Typ A,Typ B,Only by complication,-Rupture,-Malperfusion,Always OP.,2024/11/11,20,手术适应症Typ A Typ B Only by com,Standford A,型,根据病变程度分为,A1,、,A2,、,A3,亚型,2024/11/11,21,Standford A型根据病变程度分为A1、A2、A3亚型,根据弓部病变情况分为,C,、,S,型,C,型,Complex Type,（符合下列任意一项者）,1,、内膜破口在弓部或其远端 夹层逆行剥离,2,、弓部或其远端有动脉瘤形成,3,、头臂动脉有夹层剥离,4,、病因为马凡综合征,S,型,Simple Type,内膜破口在升主动脉，不合并以上情况,2024/11/11,22,根据弓部病变情况分为C、S型2023/10/622,Standford A,型手术方式,体外循环技术：,1,动脉插管：根据病变部位可选择腋动脉、,无名动脉、股动脉,2,静脉插管：心房二阶管,3,温度：涉及弓部的采用深低温停循环，,其余采用中低温体外循环,4,停循环的脑保护：顺行选择性脑灌注或,经上腔静脉逆行脑灌注,2024/11/11,23,Standford A型手术方式体外循环技术：2023/10,Standford A,型手术方式,A1,型,：单纯升主动脉替换,2024/11/11,24,Standford A型手术方式A1型：单纯升主动脉替换20,Standford A,型手术方式,A2,型,：主动脉瓣交界悬吊,+,升主动脉替换，,或保留瓣膜的根部置换（,David,手术），,或主动脉瓣,+,升主动脉替换（,Wheat,手术）,主动脉瓣交界悬吊,2024/11/11,25,Standford A型手术方式A2型：主动脉瓣交界悬吊+升,David,手术,2024/11/11,26,David手术2023/10/626,Wheat,手术,2024/11/11,27,Wheat手术2023/10/627,Standford A,型手术方式,A3,型,：主动脉根部置换（,Bentall,或,Cabrol,）手术,以,Bentall,术为例：,1,植入带瓣管道,2024/11/11,28,Standford A型手术方式A3型：主动脉根部置换（Be,2,移栽冠脉,3,远端吻合,2024/11/11,29,2移栽冠脉 3远端,手术照片,2024/11/11,30,手术照片2023/10/630,Standford A,型手术方式,C,型,：全弓置换,+,象鼻手术,Combining both steps in one:,Open total arch replacement,with endovascular DTA repair,2024/11/11,31,Standford A型手术方式C型：全弓置换+象鼻手术20,Standford B,型,根据降主动脉扩张部位及是否累及弓部分为：,2024/11/11,32,Standford B型根据降主动脉扩张部位及是否累及弓部分,O,pen operation,目的：,防止破裂,重建内脏灌注,关键：,脏器保护（体外循环）,2024/11/11,33,Open operation目的：2023/10/633,E,ndovascular repair,2024/11/11,34,Endovascular repair2023/10/634,2024/11/11,35,2023/10/635,关于“额外解剖分流”,（,extra-anatomic bypass,）,2024/11/11,36,关于“额外解剖分流”2023/10/636,