动脉瘤杂交手术转流方式探讨课件

动脉瘤杂交手术 转流方式探讨 Bypass in Hybrid Operation for Aortic Aneurysm,哈尔滨医科大学附属第二医院 血管外科 姜维良,WEILIANG JIANG Dept. of Vascular Surgery, 2nd Teaching Hosp. Harbin Medical University, Harbin, Heilongjiang, China 150086,动脉瘤杂交手术转流方法 Aortic Dissection Hybrid Operation with Arch Bypass,通过外科手术改变主动脉分支供血位置，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 Cases,我科共完成主动脉夹层EVAR 112例 弓上分支转流 6例5.3%（6/112） 腹部分支动脉转流2例4%（2/52） Totally 112 cases of TEVAR for aortic dissection were performed in our unit, 6 (5.3%)of which with auxiliary arch bypass,病例资料 Cases,弓上分支转流方式分类 Type of aortic arch bypass,1.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 2.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 3.升主动脉转流 目的：重建弓上血运 1. Ipsilateral：Carotid A.-SCA. aim：to reconstruct the dominant vertebral A. 2. Contralateral： Carotid - Carotid SCA. aim：to reconstruct LCA. L. SCA. 3. Bypass of arch: aim：to reconstruct the arch branches,1.同侧转位 颈动脉-锁骨下动脉 Ipsilateral bypass: Carotid A.-SCA.,1.锁骨下动脉-颈动脉 端侧吻合 （SCA-CA: end-to-side） 2.颈动脉-锁骨下动脉 人造血管转流（CA-SCA: artificial graft bypass）,2.对侧转位 颈-颈-锁骨下动脉 Contralateral Bypass: CA-CA-SCA,合理的重建方法尽量缩短颈动脉阻断时间 Ideal methods should shorten the carotid blocking time,2.对侧转位 颈-颈-锁骨下动脉 Contralateral Bypass：CA-CA-SCA,可能延长颈动脉阻断时间的重建方式 Styles that may prolong blocking time of carotid artery.,3.升主动脉转流,3. Bypass involving ascending aorta,弓上分支转位病例同侧转流 Case 1: arch branch translocation (Ipsilateral bypass),BYPASS,Case 1,BYPASS,Case 1,BYPASS,Case 1,BYPASS,Case 1,BYPASS,Case 1,锁骨下动脉-颈动脉转流前后对比 Effect of Bypass,转流前 Before Bypass,转流后 After Bypass,TEVAR手术后 After TEVAR,Case 1,锁骨下动脉-颈动脉 对端吻合(SCA-CA: end-to-end) 右位主动脉弓夹层动脉瘤 Case 2: aortic dissection with right sided aortic arch,瘘口位于弓顶，食道受压，进食困难。,Entry at the top of the arch, esophagus compressed and dysphasia developed,Case 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 carotid A. from ascending aorta.,Case 2,Angiography of After EVAR,Case 2,术后1年CTA复查,术后CTA,CTA Follow-up 1m after TEVAR,Case 2,对侧转位 颈-颈-锁骨下动脉转流 Contralateral bypass：Carotid - Carotid SCA.,颈-颈-锁骨下动脉人造血管转流 Carotid - Carotid SCA：Artificial graft bypass,瘘口位于主动脉弓病例 Case 3： entry on the arch,降主动脉多发瘘口 左侧血胸 Multiple entry on descending aorta with left side hemothorax,Case 3,弓上瘘口位置 Entry on the arch,Case 3,瘘口位于颈动脉开口附近 Entry near Left Carotid Artery,Case 3,Case 3,BYPASS,颈-颈动脉转流+左颈锁骨下动脉侧侧吻合 CA-CA bypass+L. CA-SCA side-side anastomosis,Case 3,TEVAR,Case 3,Closed hemothorax drainage,主动脉夹层伴左侧颈动脉受累病例 Case 4: aortic dissection with left carotid artery involvement,瘘口位置 entry position,Case 4,Case 4,BYPASS,颈颈转流+颈锁骨下对端吻合 CA-CA bypass + CA-SCA end-end anastomosis,Case 4,跨肾动脉型腹主动脉瘤的杂交手术 Bypass for Juxtarenal AAA,髂肾动脉（和/或腹腔干动脉）；髂肠系膜动脉旁路EVAR IliacRenal and/or Celiac A. bypass; Iliac-SMA bypass + EVAR,总结 summary,1.颈部杂交手术可以拓展锚定区 2.手术并发症发生率相对较低 3.转流方式可以根据患者情况个体化选择 4.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 possible for the aortic dissections with arch entries. With relatively low complication rate, the procedure can be customized for individual patient. Key point for complication prevention is to reduce the carotid artery blocking time as much as possible.,术前CT扫描 pre-op CT scan,肾上型假性AAA False aneurysm involving aorta above renal A.,Case 5,右髂动脉-人造血管吻合 R. Iliac Artificial Graft Bypass,Case 5,大隐静脉人工血管吻合 GSV then Anastomosed with Artificial Graft,Case 5,人造血管-肠系膜上动脉吻合 Artificial Graft-SMA Bypass,Case 5,大隐静脉-右肾动脉吻合 GSV Graft- Right Renal A. Bypass,Case 5,大隐静脉肝总动脉吻合 GSV Graft-Common Hepatic Artery Bypass,Case 5,Case 5,介入手术术中 during EVAR,Case 5,术后CTA,post-op CTA,Case 5,术后造影 Angiography after EVAR,Case 5,胸腹主动脉瘤杂交手术 Hybrid EVAR case 2,TAAA RUPTURE Age79 Male shock,Case 6,胸腹动脉口径 Diameter of Thoracic and Abdominal Aorta,Case 5,人造血管吻合方式 Manner of Artificial Bypass,Case 5,右肾动脉-肠系膜上动脉吻合 Right Renal A.-SMA Anastomosis,Case 5,左肾动脉吻合 Left Renal A. Anastomosis,Case 5,腹腔动脉干吻合 Bypassing the Celiac A.,Case 5,总结