精品课件教案ppt 主动脉夹层腔内修复的现状与问题

Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 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 Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 1999年Dake和Nienaber分别报道TEVAR技术治疗 急性B型主动脉夹层。 Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 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。 Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 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, 2013. 45(6): 627-31. Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 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, 2008. 1(4): 395-402. Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 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, 2012. 26(6): 1139-44. Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 临床分型 40多年前De Bakey分型和Stanford分型 2005年景在平 “3N3V”分型 2009年Augoustides提出 Penn分型 2013年Dake教授提出DISSECT分类 Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital N: 裸区 V：内脏区 Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 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 Ab100:II-316-Ii-321 Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 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, 2011. 53(4): 942-9. Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 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, 2013. 45(5): 475-80. Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 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 Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital G. Matthew Longo , Iraklis I. Pipinos Endovascular techniques for arch vessel reconstruction，Journal of Vascular Surgery Volume 52, Issue 4, Supplement 2010 77S - 81S Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 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, 2013. 61(18): 1917-24. Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 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, 2013. 47(5): 374-8. Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 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, European Journal of Vascular and Endovascular Surgery Volume 45, Issue 5 2013 475 - 480 Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 最新随访结果 Fattori等报告IRAD试验从1995年到2012年收集 的1 129例急性TBAD，其中药物组和TEVAR组的1 年死亡率基本相同(9.8% vs. 8.1%，p=0.604)，而 TEVAR组的5年死亡率较低(15.5% vs. 29.0%， p=0.018)。 Fattori, R., Montgomery, D., Lovato, L., et al., Survival After Endovascular Therapy in Patients With Type B Aortic Dissection: A Report From the International Registry of Acute Aortic Dissection (IRAD). JACC: Cardiovascular Interventions, 2013. 6(8): 876- 882. Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 最新随访结果 对于慢性TBAD，INSTEAD-XL实验结果表明 TEVAR组比单独药物组具有较低的死亡率，能提 高5年生存率和延缓病情进展，并且提到TEVAR可 成为复杂性或非复杂性TBAD的一线治疗！ Nienaber, C.A., Kische, S., Rousseau, H., et al., Endovascular Repair of Type B Aortic Dissection: Long-term Results of the Randomized Investigation of Stent Grafts in Aortic Dissection Trial. Circ Cardiovasc Interv, 2013. 6(4): 407-16. Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 并发症及问题 Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital Dong Z H et al. Circulation 2009;119:735-741 逆向撕裂成A型 Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 由于弓部的角度及支架的刚性使得两端对动脉壁 造成损伤，所以TEVAR过程要考虑弓部形态学及 支架的柔顺性，尽量选用近端无刚性裸架结构。 支架节段的拐角与弓降部转角契合，防止“杠杆效 应”及 “鸟嘴”，减少内漏及支架移位。 选择合适的放大率，目前我们认为是0-10%。 Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital 内 漏 分5型：型内漏最常见，是型的五倍，与近端 锚定区较短以及支架与弓的形态契合差、钙化较 重密切相关。 处理方法有球囊贴覆、增加Cuff或 杂交手术。 目前我们认识到假腔血栓化的重要性，一期或二 期封堵远端高流量破口，从而保证TEVAR对主动 脉重塑和远期治疗效果。 Nienaber, C.A., Kische, S., Rousseau, H., et al., Endovascular Repair of Type B Aortic Dissection: Long- term Results of the Randomized Investigation of Stent Grafts in Aortic Dissection Trial. Circ Cardiovasc Interv, 2013. 6(4): 407-16. Institute of Vascular Surgery Fudan University Vascular Surgery Zhongshan Hospital Ludovic Canaud ,et al Lessons learned from midter