夹层动脉瘤杂交手术弓上分支转流方式探讨_1课件

夹层动脉瘤杂交手术夹层动脉瘤杂交手术 弓上分支转流方式探讨弓上分支转流方式探讨 Aortic Arch BypassAortic Arch Bypass in Hybrid Operation for in Hybrid Operation for Aortic Dissection AneurysmAortic Dissection Aneurysm 哈尔滨医科大学附属第二医院哈尔滨医科大学附属第二医院 血管外科血管外科 姜维良姜维良 WEILIANG JIANGWEILIANG JIANG Dept. of Vascular Surgery, Dept. of Vascular Surgery, 2 2 ndnd Teaching Hosp. Teaching Hosp. Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang, China 150086Harbin, Heilongjiang, China 150086 夹层动脉瘤杂交手术弓上分支转流夹层动脉瘤杂交手术弓上分支转流 Aortic Dissection Hybrid Operation with Arch Bypass Aortic Dissection Hybrid Operation with Arch Bypass 涉及主动脉弓分支的夹层动脉瘤，通过 外科手术改变供血位置，可以创造出腔 内修复的条件，使得腔内修复手术可以 进行。 Aortic Dissection involving arch braches can be repaired with the assistance of the surgical operations alternating the vessel anatomy and creating optimal settings for endovascular repair. 病例资料病例资料 Cases Cases 我科共完成主动脉夹层我科共完成主动脉夹层EVAR 112EVAR 112例例 弓上分支转流弓上分支转流 6 6例例5.3%5.3%（6/1126/112） Totally 112 cases of TEVAR for aortic Totally 112 cases of TEVAR for aortic dissection were performed in our unit, 6 dissection were performed in our unit, 6 (5.3%)of which with auxiliary arch bypass (5.3%)of which with auxiliary arch bypass 病例资料病例资料CasesCases 转流原因转流原因 Cause of bypassCause of bypass 同侧转流同侧转流 Ipsilateral bypass Ipsilateral bypass 对侧转流对侧转流 Contralateral bypassContralateral bypass 弓上分支转位弓上分支转位 Arch branch translocationArch branch translocation 2 2 左侧优势椎动脉左侧优势椎动脉 Left side predominant Left side predominant vertebral arteryvertebral artery 2 2 瘘口位于主动脉弓瘘口位于主动脉弓 Arch entryArch entry 1 1 左颈动脉动脉瘤左颈动脉动脉瘤 Aneurysm on left carotid Aneurysm on left carotid arteryartery 1 1 Total 6Total 6 4 4 2 2 弓上分支转流方式分类弓上分支转流方式分类 Type of aortic arch bypass Type of aortic arch bypass n1.同侧转位 颈动脉-锁骨下动脉 目的：重建左侧优势椎动脉血流 n2.对侧转位 颈-颈-锁骨下动脉 目的：重建左颈动脉左锁骨下动脉 n3.升主动脉转流 目的：重建弓上血运 n n 1. 1. IpsilateralIpsilateral：Carotid A.-SCA.Carotid A.-SCA. aimaim：to reconstruct the dominant vertebral A.to reconstruct the dominant vertebral A. n n 2. 2. ContralateralContralateral： Carotid - Carotid Carotid - Carotid SCA. SCA. aimaim：to reconstruct LCA. L. SCA.to reconstruct LCA. L. SCA. n n 3. Bypass of arch:3. Bypass of arch: aimaim：to reconstruct the arch branchesto reconstruct the arch branches 1.1.同侧转位同侧转位 颈动脉颈动脉- -锁骨下动脉锁骨下动脉 Ipsilateral bypass: Ipsilateral bypass: Carotid A.-Carotid A.- SCA.SCA. n n 1.1.锁骨下动脉锁骨下动脉- -颈动脉颈动脉 端侧吻合端侧吻合 （SCA-CA: end-to-sideSCA-CA: end-to-side） n n 2.2.颈动脉颈动脉- -锁骨下动脉锁骨下动脉 人造血管转流（人造血管转流（CA-SCA: artificial CA-SCA: artificial graft bypassgraft bypass） 2.2.对侧转位对侧转位 颈颈- -颈颈- -锁骨下动脉锁骨下动脉 Contralateral Bypass: Contralateral Bypass: CA-CA-SCACA-CA-SCA 合理的重建方法合理的重建方法尽量缩短颈动脉阻断时间尽量缩短颈动脉阻断时间 Ideal methods should shorten the carotid blocking timeIdeal methods should shorten the carotid blocking time 2.2.对侧转位对侧转位 颈颈- -颈颈- -锁骨下动脉锁骨下动脉 Contralateral BypassContralateral Bypass：CA-CA-SCACA-CA-SCA n n 可能延长颈动脉阻断时间的重建方式可能延长颈动脉阻断时间的重建方式 n n Styles that may prolong blocking time of carotid Styles that may prolong blocking time of carotid arteryartery . . 3.3.升主动脉转流升主动脉转流 3. Bypass involving 3. Bypass involving ascending aortaascending aorta 弓上分支转位病例弓上分支转位病例同侧转流同侧转流 Case 1: arch branch translocation Case 1: arch branch translocation (Ipsilateral bypass)(Ipsilateral bypass) BYPASSBYPASSCase 1Case 1 BYPASSBYPASSCase 1Case 1 BYPASSBYPASSCase 1Case 1 BYPASSBYPASSCase 1Case 1 BYPASSBYPASSCase 1Case 1 锁骨下动脉锁骨下动脉- -颈动颈动 脉转流前后对比脉转流前后对比 Effect of BypassEffect of Bypass 转流前转流前 Before BypassBefore Bypass 转流后转流后 After BypassAfter Bypass TEVARTEVAR手术后手术后 After TEVARAfter TEVAR Case 1Case 1 锁骨下动脉锁骨下动脉- -颈动脉颈动脉 对端吻合对端吻合(SCA-CA: end-to-end)(SCA-CA: end-to-end) 右位主动脉弓夹层动脉瘤右位主动脉弓夹层动脉瘤 Case 2: aortic dissection with right sided aortic archCase 2: aortic dissection with right sided aortic arch 瘘口位于弓顶，食道受压，进食困难。瘘口位于弓顶，食道受压，进食困难。 Entry at the top of the arch, esophagus compressed and Entry at the top of the arch, esophagus compressed and dysphasia developeddysphasia developed Case 2Case 2 双侧锁骨下动脉发自降主动脉 双侧颈动脉起自升主动脉 Bilateral SCA arise from descending aorta, bilateral Bilateral SCA arise from descending aorta, bilateral carotid A. from ascending aorta.carotid A. from ascending aorta. Case 2Case 2 锁骨下动脉锁骨下动脉- -颈动脉同侧转流颈动脉同侧转流 Ipsilateral Bypass from SCA to CAIpsilateral Bypass from SCA to CA Case 2Case 2 Angiography of After EVARAngiography of After EVAR Case 2Case 2 术后术后1 1个月复查个月复查CTACTA 术后术后CTACTA CTA Follow-up CTA Follow-up 1m after TEVAR1m after TEVAR Case 2Case 2 对侧转位对侧转位 颈颈- -颈颈- -锁骨下动脉转流锁骨下动脉转流 Contralateral bypassContralateral bypass：Carotid - Carotid SCA.Carotid - Carotid SCA. n n 颈颈- -颈颈- -锁骨下动脉人造血管转流锁骨下动脉人造血管转流 n n Carotid - Carotid SCACarotid - Carotid SCA：Artificial graft Artificial graft bypassbypass 瘘口位于主动脉弓病例瘘口位于主动脉弓病例 Case 3Case 3： entry on the arch entry on the arch 降主动脉多发瘘口降主动脉多发瘘口 左侧血胸左侧血胸 Multiple entry on descending aorta Multiple entry on descending aorta with left side hemothoraxwith left side hemothorax Case 3Case 3 弓上瘘口位置弓上瘘口位置 Entry on the archEntry on the arch Case 3Case 3 瘘口位于颈动脉开口附近瘘口位于颈动脉开口附近 Entry near Left Carotid ArteryEntry near Left Carotid Artery Case 3Case 3 Case 3Case 3BYPASSBYPASS 颈颈- -颈动脉转流颈动脉转流+左颈锁骨下动脉侧侧吻合左颈锁骨下动脉侧侧吻合 CA-CA bypass+L. CA-SCA side-side anastomosisCA-CA bypass+L. CA-SCA side-side anastomosis Case 3Case 3TEVARTEVAR Case 3Case 3Closed hemothorax drainageClosed hemothorax drainage 主动脉夹层伴左侧颈动脉受累病例主动脉夹层伴左侧颈动脉受累病例 Case 4: aortic dissection with left carotid artery Case 4: aortic dissection with left carotid artery involvementinvolvement 瘘口位置瘘口位置 entry positionentry position Case 4Case 4 Case 4Case 4BYPASSBYPASS 颈颈转流颈颈转流+颈锁骨下对端吻合颈锁骨下对端吻合 CA-CA bypass + CA-SCA end-end CA-CA bypass + CA-SCA end-end anastomosisanastomosis Case 4Case 4 总结总结summarysummary n n 1.1.颈部杂交手术可以对瘘口位于主动脉弓的夹层进行颈部杂交手术可以对瘘口位于主动脉弓的夹层进行TEVARTEVAR手手 术术 n n 2.2.手术并发症发生率相对较低手术并发症发生率相对较低 n n 3.3.转流方式可以根据患者情况个体化选择转流方式可以根据患者情况个体化选择 n n 4.4.防止并发症发生的要点是尽量缩短颈动脉阻断时间防止并发症发生的要点是尽量缩短颈动脉阻断时间 Carotid hybrid operations make TEVAR procedure safe and Carotid hybrid operations make TEVAR procedure safe and possible for the aortic dissections with arch entries. possible for the aortic dissections with arch entries. With relatively low complication rate, With relatively low complication rate, the procedure can be the procedure can be customized for individual patient.customized for individual patient. Key point for complication prevention is to reduce the carotid Key point for complication prevention is to reduce the carotid artery blocking time as much as possible.artery blocking time as much as possible. Thanks for your attentionThanks for your attention ！ 谢谢谢！谢！ Dept. of Vascular Surgery, Dept. of Vascular Surgery, 2 2 ndnd Teaching Hosp. Teaching Hosp. Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang, ChinaHarbin, Heilongjiang, China 哈尔滨医科大学附属第二医院哈尔滨医科大学附属第二医院 血管外科血管外科 FyeSu2fu0r*7!J6F+PwFE)Tcm$q-vO(LMizRH+0%jVKRsm2)%boeRK$0%Xq2R#pOVfnYOqBjR7PDJc$Op6NjX*EbztxbBDK)p691ee$-C)mHl(EW0k+Vap%FR*EPtSN6f#4Ubm!Hs04%HzGWSo3ZVsD&pVzQaGs&K!zghHyl*Ew4HIzpN+%xvJ9Pw9UHc9)TYt5KyBkXEAoKu)d3iqfSc9wDyP9!KhTfkauk87v$%iSfOVAy5*+H5U+Qmdwmj0%OkFZsv*sZ#xk)ezf0F2M51O+QOU)(6Gp6WAm$jqAGkKJgE8upSzDVsHr69PKb5IrtJO+7gnrnHtF4vo4GH0f-hw-p%vTim3MJ+#6+*P7o9Jq)CVZ- #2S9Erg%lQc2SnH2&E7Prlicm0fxpySReB&54F8e6RtrFiLe7PRc#ltaVsCudc+HrYlyPJ0jmi4!1B3-*Axqy-mqSzh+!HOI6n6liPd(wk4w)C6uMbvLVu-gS)$(kLojR*dv*xk2qJ7WA5AB58+ktAldigAmH)hDsr8WEiQ00$4Gj*#38V)-rNlOhV+App$%lK!%EPS!gU5M7bRC)k8D+5HXr3iIz&ramoeI*-*Ew%ZS)mp7G7U&V(-3g9Zg)gQYIWeOLoQlTa9vl-w(8ea+doJnx73wud+tc$Xo7)JRryi73tl(MQmI2j- 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