人造主动脉弓覆膜支架的实验性研究
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摘要
背景与目的：
急性A型主动脉夹层一种严重危及病人生命的灾难性疾病。其特点是起病突然，病情进展迅速，死亡率高，如不及时诊治，急性A型主动脉夹层发病后最初的48小时内，每小时病死率达1％～4％，48小时内自然死亡率可达50%。及时的外科手术治疗能够有效防止夹层破裂、心包填塞、心力衰竭等致命性并发症的发生。目前的治疗方法主要有传统手术治疗以及在此基础上发展的传统手术结合冰冻象鼻干技术和血管腔内隔绝手术治疗。然而传统手术操作复杂，吻合困难；需要长时间的体外循环（CPB）和深低温停循环（DHCA），手术创伤大，且极易发生术后出血，术后需要大量输血。即使近几年来经过手术技术和围手术期处理技术的提高，手术死亡率和术后并发症发生率仍然居高不下。腔内隔绝治疗由于主动脉解剖因素以及支架本身制作因素的影响限制了其目前在临床的广泛应用。为此，近年有学者尝试应用杂交手术技术治疗急性A型主动脉夹层，并取得了一定的发展，其结果令人鼓舞。然而由于主动脉弓部解剖结构的特殊性和血流动力学的复杂性，目前世界上还没有专门针对杂交手术中治疗主动脉弓部疾病的血管支架。
本课题的目的在于研制一种全新结构的人造主动脉弓血管覆膜支架,覆膜支架经过体外测试合格后应用于动物实验，通过动物实验验证其临床应用的可行性和安全性。我们期望这种人造主动脉弓覆膜支架在应用过程中能在保证手术质量的同时大大简化手术过程，缩短手术时间，降低手术并发症，改善生存率，提高治疗效果，从而应用于临床时能更加有效的解除主动脉弓部疾病患者的痛苦，造福于该类患者。
方法：
1.人造主动脉弓覆膜支架的设计及体外性能测试
1）人造主动脉弓覆膜支架的基本构架。主动脉术中覆膜支架系统由术中覆膜支架（简称术中支架）和输送系统组成，术中支架由裸支架、ePTFE覆膜和涤纶布组成。裸支架在ePTFE覆膜内外层的中间，涤纶布固定在术中支架的近端，并被ePTFE覆膜包覆在内层。支架为自膨胀式支架。血管支架整体结构设计成与主动脉弓部形态相符合的结构，由1个主体和多个（1-3）分支构成，主体对应主动脉弓部位的大动脉，分支分别对应主动脉弓上头臂干、左颈总动和、左锁骨下动脉分支血管。输送系统由手柄、固定杆和鞘芯、主体包膜和拉线、Tip和鞘芯、分支包膜和分支拉线、导丝等部件组成。固定杆和手柄固定在一起，鞘芯从手柄中间穿过；拉线和固定块连接在一起，通过固定块可以将拉线抽掉；导丝从Tip和鞘芯中间穿过。术中支架的主体会固定在固定杆上并被主体包膜包覆，支架的分支部分会装入分支包膜中。
2）人造主动脉弓覆膜支架的体外性能测试。
A.人造主动脉弓覆膜支架外观和主要尺寸测试：通过目测和电子显微镜下放大2.5倍检查支架和输送系统：检查支架是否有断裂、有灰尘、污垢、松动等；覆膜材料的表面是否光滑整洁，有无破洞、裂缝、伤痕。检查输送系统的外表面是否清洁光滑，有无折痕、硬弯、污渍、裂纹、毛刺等加工缺陷。用游标卡尺和直尺检测主动脉术中覆膜支架系统的尺寸。
B.人造主动脉弓覆膜支架物理性能测试：a、通过拉力机及相应的夹具分别进行覆膜支架系统的支架连接强度、支架和覆膜间连接强度、支架的径向支撑力以及覆膜破裂力的物理力学方面的检测； b、通过压力泵向覆膜支架内腔注入常温蒸馏水，进行覆膜渗透量的测试； c、将对应的小于支架直径10-20%的血管模型放在水浴锅中用输送系统将支架释放到的血管模型中，目测支架金属部分与血管模型的柔顺性和贴壁性；d、用输送系统将支架释放到30-37℃水浴锅中用正常视力或矫正视力在放大5倍的条件下检查支架外表面，进行回弹性的测试；e、将装好支架的硅胶管安装到疲劳机中，启动试验机开关，按照调好的频率、振幅、零位点进行疲劳强度的测试；f、将主动脉术中覆膜支架直接放置在X射线成像设备上，进行成像观察及射线可探测性测试。
C.人造主动脉弓覆膜支架化学性能测试：将包装灭菌好的主动脉术中覆膜支架与输送系统分开分别取样制作检验液，进行还原物质、酸碱度、发残渣、重金属总含量、紫外吸光度、环氧乙烷残留量的测定。
D.人造主动脉弓覆膜支架输送系统物理性能测试：a、将固定杆和手柄分别固定在拉力机上的上下夹具上，以一定的移动速度进行拉伸，进行固定杆和手柄连接力的测试；b、同样的方法进行鞘芯与固定杆连接力、鞘芯与Tip头连接力以及拉线和固定块连接力的测试；c、将支架试样预先脱脂清洗干净后全部浸入（全浸法）温度为20℃±5℃的0.5mol/L氯化钠溶液中，保持168h。用10倍显微镜放大观察试件表面的腐蚀痕迹。进行输送系统金属部分耐腐蚀性能测试。
E.人造主动脉弓覆膜支架输送系统显微结构测试:将试样经仔细抛光后,不进行腐蚀，观察夹杂物的形态和数量，用专业金相分析软件Image Plus Pro6.0定量分析夹杂物的面积百分比；将抛光后的试样经腐蚀剂（4%硝酸）腐蚀后，放在镜相显微镜下观察其微观组织，并定量统计晶粒度。
3．人造主动脉弓覆膜支架的动物实验研究
1）以犬为实验对象，挑选了20条杂种德国牧羊犬深低温停循环条件下切开升主动脉远端，植入导丝并将人造主动脉弓覆膜支架沿导丝分别引导进入远端降主动脉、左锁骨下动脉、右侧头臂动脉，待支架位于恰当位置后释放支架，缝合支架与主动脉远端，并与主动脉近端做端端吻合。术后均予围手术期的临床观察。观测手术时间、主动脉阻断时间、手术出血量、术后输血量、术后死亡率、并发症发生率等指标。
2）观察术后中期（6个月内）实验动物的恢复情况，有无严重并发症的发生；并在6个月后行主动脉CT血管造影术及数字减影血管造影（DSA）检查，进一步明确支架情况。
3）影像学检查后处死动物并取出标本。标本固定后分别行苏木精－伊红（HE）染色、维多利亚蓝（VB）染色观察覆膜支架在体内的组织结构。
结果：
1．通过体外实验得到主动脉术中覆膜支架系统外观和主要尺寸满足产品设计要求。实验组所有支架支架连接强度测试均远大于5N；支架径向支撑力>4N；ePTFE膜与支架间连接强度、包裹针织涤纶布区域覆膜与支架间连接强度均远大于15N；覆膜渗透量均≤100ml/cm2/min；覆膜破裂力≥10N；所有支架柔顺性良好，无绞结现象、无折弯、贴壁性、回弹性较好，均能恢复原来形状；经疲劳实验后所有支架覆膜与支架连接完好，覆膜无破洞，裂缝，缝线无脱落，金属丝无断裂，金属丝连接点无松脱；X射线影像观察显示支架可探测性良好。所有检测均证实主动脉术中覆膜支架物理性能满足产品设计要求。覆膜支架与输送系统制样检验液还原物质<2ml、酸碱度<1.5、发残渣<2mg、重金属总含量<1μ g/ml、紫外吸光度<0.1、未测及环氧乙烷残留。所有检测均证实主动脉术中覆膜支架化学性能满足产品设计要求。固定杆和手柄连接力、鞘芯与固定杆连接力和鞘芯与Tip头连接力的测试、拉线和固定块连接力均远大于15N；所有样品金属部分表面无锈蚀，为a级。所有检测均证实主动脉术中覆膜支架输送系统物理连接力性能满足产品设计要求。所有样品的NiTi丝及钢套中晶粒度不粗于4级；所有样品的NiTi丝及钢套中疏松和非金属夹杂物的颗粒不超过39μ m，面积百分比不超过2.8%，符合要求。
2．动物实验20例，手术死亡2例（死亡率10%），手术平均体外循环时间和停循环时间分别为80.2±7.54和10.7±1.94min，存活的动物均恢复良好，术后无明显并发症。
术后6个月CT增强造影及血管造影检查示：支架主体和两个分支形态正常，未见血栓堵塞和狭窄。未见支架的移位、内漏。覆膜支架腔内面光滑，完整覆盖白色的膜状物，未见血栓形成。
覆膜支架标本HE染色：对比未植入支架覆膜支架主动脉壁，植入覆膜支架后组织标本切片提示主动脉壁中膜和内膜无明显改变，腔内有均有内膜组织增生，组织结构一致，伴大量新生血管形成。VB染色：对比未植入支架覆膜支架主动脉壁，植入覆膜支架后组织标本切片提示实验组中膜弹力纤维完整，内膜弹力纤维排列轻度紊乱。
结论：
1.我们设计的新型人造主动脉弓覆膜支架具备合格的外观和尺寸。并且覆膜支架以及其输送系统物理性能、化学性能、以及显微镜检测均合符要求。
2.动物实验证明新型人造主动脉弓覆膜支架符合人造血管代用品的基本要求，安全性可靠，具有一定的临床价值。
3.实验研究表明应用新型人造主动脉弓覆膜支架的杂交手术技术与传统开放手术和腔内隔绝技术相比，在简化手术操作、减少手术时间和手术创伤、减少手术死亡率和术后并发症发生率等方面具有较明显的优势。
4.本动物实验仅是小样本的动物实验，本产品的临床效果还需要大样本远期随访以及临床试验进一步证实。
Background:
Acute type A aortic dissection(ATAAD) remains a life threatening disease. It ischaracterized by sudden onset, rapid progression and high mortality. Without timelydiagnosis and treatment, the fatality rate was from1%to4%per hour within the first48hours after the onset of Stanford type A aortic dissection, and the natural mortality up to50%within48hours.
Timely surgical treatment can prevent fatal complications such as cardiac tamponade,heart failure, and aortic rupture. The current treatment methods include the traditionalsurgical treatment, the treatment combining traditional surgery frozen elephant trunktechnology and endovascular repair. However, the traditional surgery accompaniescomplex surgical techniques, slow anastomosis, a long period of cardiopulmonary bypass(CPB) and deep hypothermic circulatory arrest (DHCA), and postoperative anastomoticbleeding. The overall in-hospital mortality and complications following conventionalsurgical treatment of acute Stanford type A dissection remains high, despite theimprovements in surgical techniques and perioperative care. Endovascular therapy islimited by many anatomic factors when it was applied in patients with Stanford Adissection. Recently, several studies have been performed and reported the initialencouraging results of hybrid aortic arch repair in small series. But because of theparticularity of the anatomical structure of the aortic arch and the complexity ofhemodynamic, we couldn’t find a kind of specifically stent targeted hybrid surgicaltreatment of aortic arch disease at home and abroad.
The purpose of this topic is to develop an artificial aortic arch stent-graft with newstructures. After passing the in vitro testing, the stent grafts were used in experimentalresearchs to test the feasibility and safety of clinical application in animal experiments. Wehope that the artificial aortic arch grafts could greatly simplify the surgical process, shortenthe operation time, reduce complications and improve patient survival, and moreeffectively relieve the pain of the patients with aortic arch diseases, while the quality of thesurgery must be guaranteed.
Methods:
1. Design and ex vivo test of the artificial aortic arch prosthesis
1) Basic structure of the artificial aortic arch prosthesis.
The main part of the device consists of a stent-graft and a delivery system, thestent-graft consists of bare Nitinol stent, ePTFE membrane and the polyester suture portion.The ePTFE membrane covers on the two sides of the metal skeleton and the polyestersuture portion located in the proximal end of the stent-grafts. The stent-grafts enabledself-expansion. The overall structure of the stent is designed to be consistent with aorticarch morphology structure, including a main body, and1to3branches. The main bodycorresponds to the aortic arch, the branches correspond to the left subclavian artery, leftcommon carotid artery and brachiocephalic trunk, respectively. The delivery systemconsists of the handle member, the fixed rod and the sheath core member, the mainenvelope and the wire member, Tip and the sheath core member, branch envelope and thebranch pull member and guidewire. Fixed rod and handle are fixed together, the core of thesheath passes through from the handle middle. The pull member and fixed blocks areconnected together, and the pull member could be deprived through a fixed block. Theguide wire passes through the middle of Tip and sheath core. The main body of stent-graftis fixed with the fixed rod and covered with the main envelope, and the branches areloaded into the branch envelopes.
2) Ex vivo test of the artificial aortic arch prosthesis
A. The appearance and size testing of the artificial aortic arch stent-graft: thestent-grafts and delivery system are check through visual and electronic microscope (2.5times zoom): check if the bracket is broken, dust, dirt, loose; if the graft surface is smoothand clean, if there are holes, cracks and scratches. Check if the outer surface of the deliverysystem is clean and smooth, no creases, no hard bends, no stains, no cracks, no glitches, noprocessing defects. The size of the artificial aortic arch prosthesis is detect by verniercaliper and ruler.
B. Physical performance testing of artificial aortic arch graft: a) The detection ofphysical mechanics including the strength of the stent-graft connection, the connectionstrength between the tectorial membrane and the metal stent, the stent radial force and thelamination rupturing force was tested by the tensile machine and the mold; b) Injecting intothe stent lumen with room temperature distilled water via pressure pump, to test thepermeation amount of the stent graft; c) The vessel model whose diameter is10-20%smaller than the stent is on the water bath, releasing the stent into the vessel model with the delivery system, checking the flexibility and adherent of the stent-graft underdirect vision; d) Release the stent-graft into water bath under the conditions of30-37℃bythe delivery system to check the outer surface of the stent, for testing the reboundresilience; e) The silicone tube fixed with the stent-graft is installed into fatigue machine,opening test switch, to test fatigue strength in accordance with a good tune frequency,amplitude, and zero points; f) The stent-graft is placed directly on the X-ray imagingapparatus, for rays detect testing.
C. Chemical properties testing of the artificial aortic arch graft: the sterilizedstent-graft and stent system were sampled to product testing liquids separately, check thereducing substances, pH, fat residue, the total content of heavy metals, ultravioletabsorbance, ethylene oxide residues.
D. Physical performance testing of delivery system: a) The fixed rod and the handleare respectively fixed to the upper and lower jig in the tensile machine, setting the tensilemachine to be stretched under a certain speed, testing connecting force between the fixedrod and the handle. b) The connecting force between the sheath core and the fixed rod, thecore of the sheath and the Tip head as well as the cable and fixed block were tested in thesame way; c) Cable and fixed block are fixed to the upper and lower jig in the tensilemachine respectively, testing connecting force between; d) The sample was pre-degreasingcleaned, and then was immersed into20℃±5℃0.5mol/L sodium chloride solution,keeping168h. Signs of corrosion of the specimen surface were enlarged and observed witha microscope (10times), to test the corrosion resistance of the metal transported system.
E. Microstructure testing of the delivery system: a sample after carefully polished, nocorroded was performed to observe the morphology and quantity of inclusions, quantitativeanalysis of the percentage of the area of the inclusions was performing using professionalmetallographic analysis software Image Plus Pro6.0; a sample after polished andcorroded(4%nitric acid), on the mirror phase under the microscope to observe themicrostructure, and quantitative statistics crystallite size.2.Animal Experiments of the artificial aortic arch prosthesis
1)20adult German sheepdogs were used as surgical objects in our experiments.Incising distal ascending aorta under deep hypothermic circulatory arrest, introducing theguide wires of the stent system, advancing the main body and the branches carefully intothe proximal descending aorta, left subclavian artery, and brachiocephalic artery along individual guide wires, deploying the stent-graft when the main body and branches of thisstent graft system were satisfactorily positioned, suturing the suturing portion to thetransected distal stump of the ascending aorta, and proximal ascending aorta in end-to-endanastomosis fashion. Clinical observation of peroperative period and the short and mediumterm (6months) was performed. We observed operation time, circulatory arrest time,operative bleeding, postoperative drainage, postoperative mortality, complications rate andso on.
2) CTA and DSA were performed on the animals6months after the surgery.
3)Animals were sacrificed after imaging test and the specimen were removed.Hematoxylin-eosin (HE) staining and Victoria Blue (VB) were performed to observe theorganizational structure of the body.
Results:
1. Appearance and size of the stent graft system is qualified. The connection strength of allthe stents were much larger than5N; stent radial force was greater than4N; the connectionstrength between the ePTFE tectorial membrane and the metal stent is much greater than15N; permeation amount of the tectorial membrane coating penetration volume is far lessthan100ml/cm2/min; membrane rupture force is much greater than10N. All stent-graftswere described with good flexibility, without kinking phenomenon, no bending, with goodadherence, good rebound resilience, being able to restore the original shape; the connectionbetween all stents and tectorial membrane was intact after fatigue test, tectorial membranewith no holes or cracks, the suture without shedding, wire without fracture, wireconnection point with no loose; observation of X-ray images confirmed good stentdetectability. All tests were confirmed stent physical properties to meet product designrequirements. Sample test solution of the stent-graft and the delivery system showedreducing substances <2ml, pH <1.5, fat residue <2mg, total content of heavy metals<1μg/ml, ultraviolet absorbance <0.1, and unmeasured ethylene oxide residues. All testswere confirmed chemical properties of the stent to meet product design requirements. Theconnection force between the fixed rod and the handle, the core of the sheath and the fixedrod, the core of the sheath and the Tip head was much larger than15N; there was nocorrosion on the surface of all the metal part, as a class. All tests were confirmed physicalconnection force properties of the delivery system to meet product design requirements.The crystallite size of the NiTi wire and the steel sleeve is not thicker than4; inclusions particles in NiTi wire and steel sets in all samples does not exceed39μm; area percentagedoes not exceed2.8%, to meet the requirements.
2. Two cases died in experiemental group (mortality of10%), the mean cardiopulmonarybypass time, circulatory arrest time were80.2±7.54and10.7±1.94min, respectively.The surviving animals recovered well with no significant complications.
Aortic imaging including CTA and DSA6months after surgery indicated that the mainbody and branches of the stent grafts were of normal morphology, no thrombus and narrow,no stent displacement, no internal leakage was observed. The luminal surface of theendoprosthesis had a thin but full coverage layer of uniform white neointima, without anyloosely attached mural thrombus. Histologic sections with H&E stain displayed a normalarrangement of the media and adventitia and exuberant circumferential intimalproliferation with or without neo-microvessels, compared with the control sections.Histologic sections with VB stain showed a normal distribution pattern and density of theelastic fibers and collagen bundles in the medial and adventitial layer, and the integrity ofinternal elastic lamina in the experiment group was moderately destoried by the extrusionof proliferated intima.
Conclusions:
1. The new type of artificial aortic arch stent-grafts we designed have qualified appearanceand size. And physical properties, chemical properties, and microscopic examination of thegrafts as well as their delivery system complied with requirements.
2. The animal experiments show that the new artificial aortic arch grafts meet the basicrequirements of artificial vascular substitutes. It is safe and reliable and has real clinicalvalue.
3. Compared with traditional open surgery and endovascular exclusion technology, thestudy shows that our new artificial aortic arch stent-grafts combining hybrid surgicaltechnique simplifies the surgical procedure, reduces the surgical time and surgical trauma,and brings down surgical mortality and incidence of postoperative complications.
4. This experiment is only a small sample of the animal experiment, the clinical effects ofthe products requires a large sample, long-term follow-up and clinical trials to confirm.
急性A型主动脉夹层一种严重危及病人生命的灾难性疾病。其特点是起病突然，病情进展迅速，死亡率高，如不及时诊治，急性A型主动脉夹层发病后最初的48小时内，每小时病死率达1％～4％，48小时内自然死亡率可达50%。及时的外科手术治疗能够有效防止夹层破裂、心包填塞、心力衰竭等致命性并发症的发生。目前的治疗方法主要有传统手术治疗以及在此基础上发展的传统手术结合冰冻象鼻干技术和血管腔内隔绝手术治疗。然而传统手术操作复杂，吻合困难；需要长时间的体外循环（CPB）和深低温停循环（DHCA），手术创伤大，且极易发生术后出血，术后需要大量输血。即使近几年来经过手术技术和围手术期处理技术的提高，手术死亡率和术后并发症发生率仍然居高不下。腔内隔绝治疗由于主动脉解剖因素以及支架本身制作因素的影响限制了其目前在临床的广泛应用。为此，近年有学者尝试应用杂交手术技术治疗急性A型主动脉夹层，并取得了一定的发展，其结果令人鼓舞。然而由于主动脉弓部解剖结构的特殊性和血流动力学的复杂性，目前世界上还没有专门针对杂交手术中治疗主动脉弓部疾病的血管支架。
本课题的目的在于研制一种全新结构的人造主动脉弓血管覆膜支架,覆膜支架经过体外测试合格后应用于动物实验，通过动物实验验证其临床应用的可行性和安全性。我们期望这种人造主动脉弓覆膜支架在应用过程中能在保证手术质量的同时大大简化手术过程，缩短手术时间，降低手术并发症，改善生存率，提高治疗效果，从而应用于临床时能更加有效的解除主动脉弓部疾病患者的痛苦，造福于该类患者。
方法：
1.人造主动脉弓覆膜支架的设计及体外性能测试
1）人造主动脉弓覆膜支架的基本构架。主动脉术中覆膜支架系统由术中覆膜支架（简称术中支架）和输送系统组成，术中支架由裸支架、ePTFE覆膜和涤纶布组成。裸支架在ePTFE覆膜内外层的中间，涤纶布固定在术中支架的近端，并被ePTFE覆膜包覆在内层。支架为自膨胀式支架。血管支架整体结构设计成与主动脉弓部形态相符合的结构，由1个主体和多个（1-3）分支构成，主体对应主动脉弓部位的大动脉，分支分别对应主动脉弓上头臂干、左颈总动和、左锁骨下动脉分支血管。输送系统由手柄、固定杆和鞘芯、主体包膜和拉线、Tip和鞘芯、分支包膜和分支拉线、导丝等部件组成。固定杆和手柄固定在一起，鞘芯从手柄中间穿过；拉线和固定块连接在一起，通过固定块可以将拉线抽掉；导丝从Tip和鞘芯中间穿过。术中支架的主体会固定在固定杆上并被主体包膜包覆，支架的分支部分会装入分支包膜中。
2）人造主动脉弓覆膜支架的体外性能测试。
A.人造主动脉弓覆膜支架外观和主要尺寸测试：通过目测和电子显微镜下放大2.5倍检查支架和输送系统：检查支架是否有断裂、有灰尘、污垢、松动等；覆膜材料的表面是否光滑整洁，有无破洞、裂缝、伤痕。检查输送系统的外表面是否清洁光滑，有无折痕、硬弯、污渍、裂纹、毛刺等加工缺陷。用游标卡尺和直尺检测主动脉术中覆膜支架系统的尺寸。
B.人造主动脉弓覆膜支架物理性能测试：a、通过拉力机及相应的夹具分别进行覆膜支架系统的支架连接强度、支架和覆膜间连接强度、支架的径向支撑力以及覆膜破裂力的物理力学方面的检测； b、通过压力泵向覆膜支架内腔注入常温蒸馏水，进行覆膜渗透量的测试； c、将对应的小于支架直径10-20%的血管模型放在水浴锅中用输送系统将支架释放到的血管模型中，目测支架金属部分与血管模型的柔顺性和贴壁性；d、用输送系统将支架释放到30-37℃水浴锅中用正常视力或矫正视力在放大5倍的条件下检查支架外表面，进行回弹性的测试；e、将装好支架的硅胶管安装到疲劳机中，启动试验机开关，按照调好的频率、振幅、零位点进行疲劳强度的测试；f、将主动脉术中覆膜支架直接放置在X射线成像设备上，进行成像观察及射线可探测性测试。
C.人造主动脉弓覆膜支架化学性能测试：将包装灭菌好的主动脉术中覆膜支架与输送系统分开分别取样制作检验液，进行还原物质、酸碱度、发残渣、重金属总含量、紫外吸光度、环氧乙烷残留量的测定。
D.人造主动脉弓覆膜支架输送系统物理性能测试：a、将固定杆和手柄分别固定在拉力机上的上下夹具上，以一定的移动速度进行拉伸，进行固定杆和手柄连接力的测试；b、同样的方法进行鞘芯与固定杆连接力、鞘芯与Tip头连接力以及拉线和固定块连接力的测试；c、将支架试样预先脱脂清洗干净后全部浸入（全浸法）温度为20℃±5℃的0.5mol/L氯化钠溶液中，保持168h。用10倍显微镜放大观察试件表面的腐蚀痕迹。进行输送系统金属部分耐腐蚀性能测试。
E.人造主动脉弓覆膜支架输送系统显微结构测试:将试样经仔细抛光后,不进行腐蚀，观察夹杂物的形态和数量，用专业金相分析软件Image Plus Pro6.0定量分析夹杂物的面积百分比；将抛光后的试样经腐蚀剂（4%硝酸）腐蚀后，放在镜相显微镜下观察其微观组织，并定量统计晶粒度。
3．人造主动脉弓覆膜支架的动物实验研究
1）以犬为实验对象，挑选了20条杂种德国牧羊犬深低温停循环条件下切开升主动脉远端，植入导丝并将人造主动脉弓覆膜支架沿导丝分别引导进入远端降主动脉、左锁骨下动脉、右侧头臂动脉，待支架位于恰当位置后释放支架，缝合支架与主动脉远端，并与主动脉近端做端端吻合。术后均予围手术期的临床观察。观测手术时间、主动脉阻断时间、手术出血量、术后输血量、术后死亡率、并发症发生率等指标。
2）观察术后中期（6个月内）实验动物的恢复情况，有无严重并发症的发生；并在6个月后行主动脉CT血管造影术及数字减影血管造影（DSA）检查，进一步明确支架情况。
3）影像学检查后处死动物并取出标本。标本固定后分别行苏木精－伊红（HE）染色、维多利亚蓝（VB）染色观察覆膜支架在体内的组织结构。
结果：
1．通过体外实验得到主动脉术中覆膜支架系统外观和主要尺寸满足产品设计要求。实验组所有支架支架连接强度测试均远大于5N；支架径向支撑力>4N；ePTFE膜与支架间连接强度、包裹针织涤纶布区域覆膜与支架间连接强度均远大于15N；覆膜渗透量均≤100ml/cm2/min；覆膜破裂力≥10N；所有支架柔顺性良好，无绞结现象、无折弯、贴壁性、回弹性较好，均能恢复原来形状；经疲劳实验后所有支架覆膜与支架连接完好，覆膜无破洞，裂缝，缝线无脱落，金属丝无断裂，金属丝连接点无松脱；X射线影像观察显示支架可探测性良好。所有检测均证实主动脉术中覆膜支架物理性能满足产品设计要求。覆膜支架与输送系统制样检验液还原物质<2ml、酸碱度<1.5、发残渣<2mg、重金属总含量<1μ g/ml、紫外吸光度<0.1、未测及环氧乙烷残留。所有检测均证实主动脉术中覆膜支架化学性能满足产品设计要求。固定杆和手柄连接力、鞘芯与固定杆连接力和鞘芯与Tip头连接力的测试、拉线和固定块连接力均远大于15N；所有样品金属部分表面无锈蚀，为a级。所有检测均证实主动脉术中覆膜支架输送系统物理连接力性能满足产品设计要求。所有样品的NiTi丝及钢套中晶粒度不粗于4级；所有样品的NiTi丝及钢套中疏松和非金属夹杂物的颗粒不超过39μ m，面积百分比不超过2.8%，符合要求。
2．动物实验20例，手术死亡2例（死亡率10%），手术平均体外循环时间和停循环时间分别为80.2±7.54和10.7±1.94min，存活的动物均恢复良好，术后无明显并发症。
术后6个月CT增强造影及血管造影检查示：支架主体和两个分支形态正常，未见血栓堵塞和狭窄。未见支架的移位、内漏。覆膜支架腔内面光滑，完整覆盖白色的膜状物，未见血栓形成。
覆膜支架标本HE染色：对比未植入支架覆膜支架主动脉壁，植入覆膜支架后组织标本切片提示主动脉壁中膜和内膜无明显改变，腔内有均有内膜组织增生，组织结构一致，伴大量新生血管形成。VB染色：对比未植入支架覆膜支架主动脉壁，植入覆膜支架后组织标本切片提示实验组中膜弹力纤维完整，内膜弹力纤维排列轻度紊乱。
结论：
1.我们设计的新型人造主动脉弓覆膜支架具备合格的外观和尺寸。并且覆膜支架以及其输送系统物理性能、化学性能、以及显微镜检测均合符要求。
2.动物实验证明新型人造主动脉弓覆膜支架符合人造血管代用品的基本要求，安全性可靠，具有一定的临床价值。
3.实验研究表明应用新型人造主动脉弓覆膜支架的杂交手术技术与传统开放手术和腔内隔绝技术相比，在简化手术操作、减少手术时间和手术创伤、减少手术死亡率和术后并发症发生率等方面具有较明显的优势。
4.本动物实验仅是小样本的动物实验，本产品的临床效果还需要大样本远期随访以及临床试验进一步证实。
Background:
Acute type A aortic dissection(ATAAD) remains a life threatening disease. It ischaracterized by sudden onset, rapid progression and high mortality. Without timelydiagnosis and treatment, the fatality rate was from1%to4%per hour within the first48hours after the onset of Stanford type A aortic dissection, and the natural mortality up to50%within48hours.
Timely surgical treatment can prevent fatal complications such as cardiac tamponade,heart failure, and aortic rupture. The current treatment methods include the traditionalsurgical treatment, the treatment combining traditional surgery frozen elephant trunktechnology and endovascular repair. However, the traditional surgery accompaniescomplex surgical techniques, slow anastomosis, a long period of cardiopulmonary bypass(CPB) and deep hypothermic circulatory arrest (DHCA), and postoperative anastomoticbleeding. The overall in-hospital mortality and complications following conventionalsurgical treatment of acute Stanford type A dissection remains high, despite theimprovements in surgical techniques and perioperative care. Endovascular therapy islimited by many anatomic factors when it was applied in patients with Stanford Adissection. Recently, several studies have been performed and reported the initialencouraging results of hybrid aortic arch repair in small series. But because of theparticularity of the anatomical structure of the aortic arch and the complexity ofhemodynamic, we couldn’t find a kind of specifically stent targeted hybrid surgicaltreatment of aortic arch disease at home and abroad.
The purpose of this topic is to develop an artificial aortic arch stent-graft with newstructures. After passing the in vitro testing, the stent grafts were used in experimentalresearchs to test the feasibility and safety of clinical application in animal experiments. Wehope that the artificial aortic arch grafts could greatly simplify the surgical process, shortenthe operation time, reduce complications and improve patient survival, and moreeffectively relieve the pain of the patients with aortic arch diseases, while the quality of thesurgery must be guaranteed.
Methods:
1. Design and ex vivo test of the artificial aortic arch prosthesis
1) Basic structure of the artificial aortic arch prosthesis.
The main part of the device consists of a stent-graft and a delivery system, thestent-graft consists of bare Nitinol stent, ePTFE membrane and the polyester suture portion.The ePTFE membrane covers on the two sides of the metal skeleton and the polyestersuture portion located in the proximal end of the stent-grafts. The stent-grafts enabledself-expansion. The overall structure of the stent is designed to be consistent with aorticarch morphology structure, including a main body, and1to3branches. The main bodycorresponds to the aortic arch, the branches correspond to the left subclavian artery, leftcommon carotid artery and brachiocephalic trunk, respectively. The delivery systemconsists of the handle member, the fixed rod and the sheath core member, the mainenvelope and the wire member, Tip and the sheath core member, branch envelope and thebranch pull member and guidewire. Fixed rod and handle are fixed together, the core of thesheath passes through from the handle middle. The pull member and fixed blocks areconnected together, and the pull member could be deprived through a fixed block. Theguide wire passes through the middle of Tip and sheath core. The main body of stent-graftis fixed with the fixed rod and covered with the main envelope, and the branches areloaded into the branch envelopes.
2) Ex vivo test of the artificial aortic arch prosthesis
A. The appearance and size testing of the artificial aortic arch stent-graft: thestent-grafts and delivery system are check through visual and electronic microscope (2.5times zoom): check if the bracket is broken, dust, dirt, loose; if the graft surface is smoothand clean, if there are holes, cracks and scratches. Check if the outer surface of the deliverysystem is clean and smooth, no creases, no hard bends, no stains, no cracks, no glitches, noprocessing defects. The size of the artificial aortic arch prosthesis is detect by verniercaliper and ruler.
B. Physical performance testing of artificial aortic arch graft: a) The detection ofphysical mechanics including the strength of the stent-graft connection, the connectionstrength between the tectorial membrane and the metal stent, the stent radial force and thelamination rupturing force was tested by the tensile machine and the mold; b) Injecting intothe stent lumen with room temperature distilled water via pressure pump, to test thepermeation amount of the stent graft; c) The vessel model whose diameter is10-20%smaller than the stent is on the water bath, releasing the stent into the vessel model with the delivery system, checking the flexibility and adherent of the stent-graft underdirect vision; d) Release the stent-graft into water bath under the conditions of30-37℃bythe delivery system to check the outer surface of the stent, for testing the reboundresilience; e) The silicone tube fixed with the stent-graft is installed into fatigue machine,opening test switch, to test fatigue strength in accordance with a good tune frequency,amplitude, and zero points; f) The stent-graft is placed directly on the X-ray imagingapparatus, for rays detect testing.
C. Chemical properties testing of the artificial aortic arch graft: the sterilizedstent-graft and stent system were sampled to product testing liquids separately, check thereducing substances, pH, fat residue, the total content of heavy metals, ultravioletabsorbance, ethylene oxide residues.
D. Physical performance testing of delivery system: a) The fixed rod and the handleare respectively fixed to the upper and lower jig in the tensile machine, setting the tensilemachine to be stretched under a certain speed, testing connecting force between the fixedrod and the handle. b) The connecting force between the sheath core and the fixed rod, thecore of the sheath and the Tip head as well as the cable and fixed block were tested in thesame way; c) Cable and fixed block are fixed to the upper and lower jig in the tensilemachine respectively, testing connecting force between; d) The sample was pre-degreasingcleaned, and then was immersed into20℃±5℃0.5mol/L sodium chloride solution,keeping168h. Signs of corrosion of the specimen surface were enlarged and observed witha microscope (10times), to test the corrosion resistance of the metal transported system.
E. Microstructure testing of the delivery system: a sample after carefully polished, nocorroded was performed to observe the morphology and quantity of inclusions, quantitativeanalysis of the percentage of the area of the inclusions was performing using professionalmetallographic analysis software Image Plus Pro6.0; a sample after polished andcorroded(4%nitric acid), on the mirror phase under the microscope to observe themicrostructure, and quantitative statistics crystallite size.2.Animal Experiments of the artificial aortic arch prosthesis
1)20adult German sheepdogs were used as surgical objects in our experiments.Incising distal ascending aorta under deep hypothermic circulatory arrest, introducing theguide wires of the stent system, advancing the main body and the branches carefully intothe proximal descending aorta, left subclavian artery, and brachiocephalic artery along individual guide wires, deploying the stent-graft when the main body and branches of thisstent graft system were satisfactorily positioned, suturing the suturing portion to thetransected distal stump of the ascending aorta, and proximal ascending aorta in end-to-endanastomosis fashion. Clinical observation of peroperative period and the short and mediumterm (6months) was performed. We observed operation time, circulatory arrest time,operative bleeding, postoperative drainage, postoperative mortality, complications rate andso on.
2) CTA and DSA were performed on the animals6months after the surgery.
3)Animals were sacrificed after imaging test and the specimen were removed.Hematoxylin-eosin (HE) staining and Victoria Blue (VB) were performed to observe theorganizational structure of the body.
Results:
1. Appearance and size of the stent graft system is qualified. The connection strength of allthe stents were much larger than5N; stent radial force was greater than4N; the connectionstrength between the ePTFE tectorial membrane and the metal stent is much greater than15N; permeation amount of the tectorial membrane coating penetration volume is far lessthan100ml/cm2/min; membrane rupture force is much greater than10N. All stent-graftswere described with good flexibility, without kinking phenomenon, no bending, with goodadherence, good rebound resilience, being able to restore the original shape; the connectionbetween all stents and tectorial membrane was intact after fatigue test, tectorial membranewith no holes or cracks, the suture without shedding, wire without fracture, wireconnection point with no loose; observation of X-ray images confirmed good stentdetectability. All tests were confirmed stent physical properties to meet product designrequirements. Sample test solution of the stent-graft and the delivery system showedreducing substances <2ml, pH <1.5, fat residue <2mg, total content of heavy metals<1μg/ml, ultraviolet absorbance <0.1, and unmeasured ethylene oxide residues. All testswere confirmed chemical properties of the stent to meet product design requirements. Theconnection force between the fixed rod and the handle, the core of the sheath and the fixedrod, the core of the sheath and the Tip head was much larger than15N; there was nocorrosion on the surface of all the metal part, as a class. All tests were confirmed physicalconnection force properties of the delivery system to meet product design requirements.The crystallite size of the NiTi wire and the steel sleeve is not thicker than4; inclusions particles in NiTi wire and steel sets in all samples does not exceed39μm; area percentagedoes not exceed2.8%, to meet the requirements.
2. Two cases died in experiemental group (mortality of10%), the mean cardiopulmonarybypass time, circulatory arrest time were80.2±7.54and10.7±1.94min, respectively.The surviving animals recovered well with no significant complications.
Aortic imaging including CTA and DSA6months after surgery indicated that the mainbody and branches of the stent grafts were of normal morphology, no thrombus and narrow,no stent displacement, no internal leakage was observed. The luminal surface of theendoprosthesis had a thin but full coverage layer of uniform white neointima, without anyloosely attached mural thrombus. Histologic sections with H&E stain displayed a normalarrangement of the media and adventitia and exuberant circumferential intimalproliferation with or without neo-microvessels, compared with the control sections.Histologic sections with VB stain showed a normal distribution pattern and density of theelastic fibers and collagen bundles in the medial and adventitial layer, and the integrity ofinternal elastic lamina in the experiment group was moderately destoried by the extrusionof proliferated intima.
Conclusions:
1. The new type of artificial aortic arch stent-grafts we designed have qualified appearanceand size. And physical properties, chemical properties, and microscopic examination of thegrafts as well as their delivery system complied with requirements.
2. The animal experiments show that the new artificial aortic arch grafts meet the basicrequirements of artificial vascular substitutes. It is safe and reliable and has real clinicalvalue.
3. Compared with traditional open surgery and endovascular exclusion technology, thestudy shows that our new artificial aortic arch stent-grafts combining hybrid surgicaltechnique simplifies the surgical procedure, reduces the surgical time and surgical trauma,and brings down surgical mortality and incidence of postoperative complications.
4. This experiment is only a small sample of the animal experiment, the clinical effects ofthe products requires a large sample, long-term follow-up and clinical trials to confirm.
引文
1. Pitt MP, Bonser RS. The natural history of thoracic aortic aneurysm disease: an overview. J CardSurg1997;12(suppl):270–278.
2. Anagnostopoulos CE, Prabhar MJS, Kittle CF. Aortic dissection and dissecting aneurysms. Am JCardiol1972;30:263-273.
3. Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, Rakowski H, Struyven J, RadegranK, Sechtem U, Taylor J, Zollikofer C, Klein WW, Mulder B, Providencia LA. Diagnosis andmanagement of aortic dissection. Eur Heart J.2001;22:1642-1681
4. Tsai, T.T., C.A. Nienaber, and K.A. Eagle, Acute aortic syndromes [J]. Circulation,2005.112(24):p.3802-13.
5. Borst HG, Heinemann MK, Stone CD. Surgical treatment of aortic dissection. New York: ChurchillLivingstone;1996:357.
6. Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB. Kirklin/Barratt-Boyes CardiacSurgery,3rd ed. Salt Lake City: Churchill Livingstone;2003:1938.
7. Fleck T, Hutschala D, Czerny M, et al. Combined surgical and endovascular treatment of acuteaortic dissection type A:preliminary results. Ann Thorac Surg2002;74:761–6.
8. Cohn LH, Edmunds LH Jr, et al. Cardiac Surgery in the Adult. New York: McGraw-Hill,2003:1095-1122.
9. Fann JI, Smith JA, Miller DC, Mitchell RS, Moore KA, Grunkemeier G, Stinson EB, Oyer PE,Reitz BA, Shumway NE. Surgical management of aortic dissection during a30-year period.Circulation.1995;92:II113-121
10. Ehrlich M, Fang WC, Grabenwoger M, Cartes-Zumelzu F, Wolner E, Havel M. Perioperative riskfactors for mortality in patients with acute type a aortic dissection. Circulation.1998;98:II294-298
11. Bachet J, Goudot B, Dreyfus GD, Brodaty D, Dubois C, Delentdecker P, Guilmet D. Surgery foracute type a aortic dissection: The hopital foch experience (1977-1998). Ann Thorac Surg.1999;67:2006-2009; discussion2014-2009
12. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, Evangelista A,Fattori R, Suzuki T, Oh JK, Moore AG, Malouf JF, Pape LA, Gaca C, Sechtem U, Lenferink S,Deutsch HJ, Diedrichs H, Marcos y Robles J, Llovet A, Gilon D, Das SK, Armstrong WF, DeebGM, Eagle KA. The international registry of acute aortic dissection (irad): New insights into an olddisease. JAMA: the journal of the American Medical Association.2000;283:897-903
13. Chiappini B, Schepens M, Tan E, Dell' Amore A, Morshuis W, Dossche K, Bergonzini M, CamurriN, Reggiani LB, Marinelli G, Di Bartolomeo R. Early and late outcomes of acute type a aorticdissection: Analysis of risk factors in487consecutive patients. Eur Heart J.2005;26:180-186
14. Trimarchi S, Nienaber CA, Rampoldi V, Myrmel T, Suzuki T, Mehta RH, Bossone E, Cooper JV,Smith DE, Menicanti L, Frigiola A, Oh JK, Deeb MG, Isselbacher EM, Eagle KA. Contemporaryresults of surgery in acute type a aortic dissection: The international registry of acute aorticdissection experience. J Thorac Cardiovasc Surg.2005;129:112-122
15. Kawahito K, Adachi H, Yamaguchi A, et al. Long-Term surgical outcomes following intraluminalsutureless graft insertion for type A aortic dissection. Surg Today.2001;31(10):866-71.
16. Sun LZ, Qi RD, Chang Q, Zhu JM, Liu YM, Yu CT, Lv B, Zheng J, Tian LX, Lu JG. Surgery foracute type a dissection using total arch replacement combined with stented elephant trunkimplantation: Experience with107patients. J Thorac Cardiovasc Surg.2009;138:1358-1362
17.薛松，急性主动脉夹层的治疗策略.中国综合临床，2011，12(27):1233-35
18.孙立忠，刘志刚，常谦，等．主动脉弓替换加支架“象鼻”手术治疗Stanford A型主动脉夹层．中华外科杂志，2004，42:812-816．
19. Nienaber CA，Eagle KA．Aortic dissection：new frontiers in diagnosis and management：Part II：therapeutic management and foHow—up．Circulation，2003，108:772—778．
20. Moil Y，Hirose H，Takagi H，et a1．Aortic arch repair for Stanford type A aortic dissection withdistal anastomosis so the proximal level of the distal aortic arch．J Thorac Cardiovasc Surg，2003，126:415—419
21. Uchida N，Shibamura H，Katayama A，et a1．Operative strategy for acute type a aortic dissection：ascending aortic or hemiarch versus total arch replacement with frozen elephant trunk．Ann ThoracSurg，2009，87:773—777．
22.汪忠镐.微创外科在胸主动脉瘤治疗中的作用.中国微创外科杂志,2002;2(suppl):13-16.
23. Ehrlich MP, Dumfarth J, Schoder M, Gottardi R, Holfeld J, Juraszek A, Dziodzio T, Funovics M,Loewe C, Grimm M, Sodeck G, Czerny M. Midterm results after endovascular treatment of acute,complicated type b aortic dissection. Ann Thorac Surg.2010;90:1444-1448
24. White RA, Miller DC, Criado FJ, Dake MD, Diethrich EB, Greenberg RK, Piccolo RS, Siami FS.Report on the results of thoracic endovascular aortic repair for acute, complicated, type b aorticdissection at30days and1year from a multidisciplinary subcommittee of the society for vascularsurgery outcomes committee. J Vasc Surg.2011;53:1082-1090
25. Kim U, Hong SJ, Kim J, Kim JS, Ko YG, Choi D, Lee do Y, Chang BC, Shim WH. Intermediate tolong-term outcomes of endoluminal stent-graft repair in patients with chronic type b aorticdissection. J Endovasc Ther.2009;16:42-47
26. Steuer J, Eriksson MO, Nyman R, Bjorck M, Wanhainen A. Early and long-term outcome afterthoracic endovascular aortic repair (tevar) for acute complicated type b aortic dissection. Eur J VascEndovasc Surg.2011;41:318-323
27. Dake MD, Kato N, Mitchell RS, Semba CP, Razavi MK, Shimono T, Hirano T, Takeda K, Yada I,Miller DC. Endovascular stent-graft placement for the treatment of acute aortic dissection. TheNew England journal of medicine.1999;340:1546-1552
28. Szeto WY, Bavaria JE, Bowen FW, Woo EY, Fairman RM, Pochettino A. The hybrid total archrepair: Brachiocephalic bypass and concomitant endovascular aortic arch stent graft placement. JCard Surg.2007;22:97-102; discussion103-104
29. Mestres CA, Fernandez C, Josa M, Mulet J. Hybrid antegrade repair of the arch and descendingthoracic aorta with a new integrated stent-dacron graft in acute type a aortic dissection: A look intothe future with new devices. Interact Cardiovasc Thorac Surg.2007;6:257-259
30. Chavan A, Karck M, Hagl C, Winterhalter M, Baus S, Galanski M, Haverich A. Hybrid endograftfor one-step treatment of multisegment disease of the thoracic aorta. J Vasc Interv Radiol.2005;16:823-829
31. Schumacher H, Bockler D, Bardenheuer H, Hansmann J, Allenberg JR. Endovascular aortic archreconstruction with supra-aortic transposition for symptomatic contained rupture and dissection:Early experience in8high-risk patients. J Endovasc Ther.2003;10:1066-1074
32. Green RM. Patient selection for endovascular abdominal aortic aneurysm repair. J Am Coll Surg.2002;194:S67-73
1. Auer J，Berent R，Eher B．Aortic dissection：incidence，natural history and impact of surgery [J]．JClinic Basic Cardiol,2000,3(3):151-154
2. Pitt MP, Bonser RS. The natural history of thoracic aortic aneurysm disease: an overview. J CardSurg1997;12(suppl):270–278.
3. Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, Rakowski H, Struyven J, RadegranK, Sechtem U, Taylor J, Zollikofer C, Klein WW, Mulder B, Providencia LA. Diagnosis andmanagement of aortic dissection. Eur Heart J.2001;22:1642-1681
4. Tsai TT, CA Nienaber, and KA Eagle, Acute aortic syndromes [J]. Circulation,2005.112(24): p.3802-3813
5. Sun L, Qi R, Zhu J, et a1. Total arch replacement combined with stented elephant trunkimplantation: a new "standard" therapy for type a dissection involving repair of the aortic arch[J]?Circulation,2011;123:971-978
6. Sun LZ, Qi RD, Chang Q, Zhu JM, Liu YM, Yu CT, Lv B, Zheng J, Tian LX, Lu JG. Surgery foracute type a dissection using total arch replacement combined with stented elephant trunkimplantation: Experience with107patients. J Thorac Cardiovasc Surg.2009;138:1358-1362
7. Chang GQ，Li ZL．Endovascular stent—graft placement in Stanford type B aortic dissection inChina[J]．Eur J Vasc Endovasc Surg，2009，37(6)：646-653
8. Eggebrecht H，Nienaber CA，Neuhauser M，et a1．Endovascular stent—graft placement in aorticdissection：a meta—analysis[J]．Eur Heart J,2006，27(4)：489—498.
9. Green, RM, Patient selection for endovascular abdominal aortic aneurysm repair[J]. J Am CollSurg,2002.194(1Suppl): S67-73
10. Kasprzak PM, Muller T, Loibnegger A, et al. Fenestrated and branched stent prostheses in theaortic arch: first experiences [J]. Gefasschirurgie2009,14(3):198-205
11. Yuan LX, Feng X, Jing ZP. Endovascular Repair of a Thoracic Arch Aneurysm With a FenestratedStent-Graft [J]. J Endovasc Ther2008,15(5):539-543
12. Baldwin ZK, Chuter TA, Hiramoto JS, et al. Double-barrel technique for endovascular exclusion ofan aortic arch aneurysm without sternotomy [J]. J Endovasc Ther2008,15(2):161-165
13. Ohrlander T, Sonesson B, Ivancev K, et al. The chimney graft: a technique for preserving orrescuing aortic branch vessels in stent-graft sealing zones [J]. J Endovasc Ther2008,15(4):427-432
14. Wei G, Xin J, Yang D, et al. A new modular stent graft to reconstruct aortic arch [J]. Eur J VascEndovasc Surg2009,37(5):560-565
15. Chen LW, Wu XJ, Lu L, et al. Total arch repair for acute type A aortic dissection with2modifiedtechniques: open single-branched stent graft placement and reinforcement of the dissected archvessel stump with stent graft [J]. Circulation2011,123(22):2536-2541
16. Inoue K, Hosokawa H, Iwase T, et al. Aortic arch reconstruction by transluminally placedendovascular branched stent graft [J]. Circulation1999,100(19Suppl):II316-321
17.顾恺时,朱洪生,吴松昌,等.顾恺时胸心外科手术学.上海科学技术出版社，454-455
18.段志泉，张强.实用血管外科「M].沈阳:辽宁科学技术出版社，1999
19. Kannan RY, Salacinski HJ, Butler PE et al. Current status of prosthetic bypass grafts: a review[J]. JBiomed Mater Res B Appl Biomater.2005;74(1):570-581
20.刘国惠.膨体聚四氟乙烯医用制品的研究[J].上海化工,1994;3(19):1-3
21. Bordenave L, Fernandez P, Remy-Zolghadri M, et al. In vitro endothelialized ePTFE prostheses:clinical update20years after the first realization[J]. Clin Hemorheol Microcirc.2005;33(3):227-234
22. Kannan RY, Salacinski HJ, Butler PE et al. Current status of prosthetic bypass grafts: a review[J]. JBiomed Mater Res B Appl Biomater.2005;74(1):570-815
23. Ryhanen J, Niemi E, Serlo W, et al. Biocompatibility of nickeltitanium shape memory metal and itscorrosion behavior in human cell cultures[J]. J Biomed Mater Res,1997,35(4):451-457
24. Kapanen A, Ryhanen J, Danilov A, et al. Effect of nickeltitanium shape memory alloy on boneformation[J]. Biomaterials,2001,22(18):2475-2480
25.史振宇符伟国王玉琦.人工血管内支架与腹主动脉的生物相容性[J].中华实验外科杂志2005;22:57-658
26.夏亚一,陈峰,王天民.镍钛形状记忆合金性能及生物相容性研究进展[J].生物骨科材料与临床研究,2004,1(2):31-33
27.汪光晔,张春才.镍钛形状记忆合金生物相容性的概况[J].中华创伤骨科杂志,2006,8(4):367-370
28.赵维彪.镍钛形状记忆合金的材料学特征与医学应用[J].中国组织工程研究与临床康复,2007,11(22):4376-4379
29.薛淼,潘家琛,陈希贤等.镍钛合金的基础研究—模拟腐蚀试验及组织学观察[J].中华医学杂志,1982,62:7
30.曾光廷，李静缓，罗学厚，非金属夹杂物与钢的韧性研究,材料科学与工程[J]，2002,18（2）：87-99
1.施新酞:上海实验动物科学,1984,4(1):53
2. Massoud TF, Guglielmi G, Ji C, et al. Experimental saccular aneurysms: Review ofsurgically-constructed models and their laboratory application[J]. Neuroradiology,1994,36:537
3.钟品仁,哺乳类实验动物.人民卫生出版社1983
4.苏荣胜,王荣梅,陈义洲.犬在诊治过程中体温异常升高的预防与急救[J],中国兽医杂志.2010,6(46):77-78
5. Tan ME，Dossche KM，Morshuis WJ，et a1．Operative risk factors of type A aortic dissection：analysis of252consecutive patients[J]．J Cardiovasc Surg，2003，11：277-285
6.尚蔚，刘楠，闫晓蕾，等．A型主动脉夹层手术后早期并发症分析[J]．心肺血管病杂志，2011，30：183-186.
7. Chiappini B，Schepens M，Tan E，et a1．Eady and late outcomes of acute type A aortic dissection：Analysis of risk factors in487consecutive patients[J]．Eur Hcart J．2005．26：180-186．
8.康凯,张宇南,谢宝栋.等22例Stanford A型主动脉夹层手术止血技巧体会[J].心肺血管病杂.2011,6(30):521-523
9. Sundt TM, Orszulak TA, Cook DJ, et al. Improving results of open arch replacement [J]. AnnThorac Surg2008,86(3):787-796, discussion787-796.
10. Szeto WY, Bavaria JE, Bowen FW, et al. The hybrid total arch repair: brachiocephalic bypass andconcomitant endovascular aortic arch stent graft placement [J]. J Card Surg2007,22(2):97-102,discussion103-104.
11. Innes W, Gianni A, Alan B, et al. Prevention of spinal cord ischaemia during descending thoracicand thoracoabdominal aortic surgery[J]. European Journal of Cardio-thoracic Surgery.2001;19:203-213.
12. Reich DL, Uysal S, Sliwinski M, et al. Neuropsychologic outcome after deep hypothermiccirculatory arrest in adults[J]. J Thorac Cardiovasc Surg1999;117:156-63.
13. Svensson LG, Crawford ES, Hess KR, et al. Deep hypothermia with circulatory arrest.Determinants of stroke and early mortality in656patients[J]. J Thorac Cardiovasc Surg1993;106:19-28; discussion28-31.
14. Ye J, Yang L, Del Bigio MR, et al, Retrograde cerebral perfusion provides limited distribution ofblood to the brain: a study in pigs[J]. J Thorac Cardiovasc Surg,1997,114(4):660-665
15. Elmistekawy. E M,Rubens. F D, Deep hypothermie circulatory arrest：alternative strategies forcerebral perfusion．A renew article[J]．Perfusion，2011，26Suppl1：27—34.
16.景在平．包俊敏，周颖奇，等腔内隔绝术治疗胸主动脉夹层动脉瘤[J],第二军医大学学报，1999，20(11)：828-830.
17.景在平．赵珺，赵志青．等, Stanford B型夹层动脉瘤的微创腔内隔绝术治疗[J]．中国实用外科杂志，2000．20(6)：340
18.景在平,赵珺,赵志青,等胸主动脉夹层腔内隔绝术后内漏的分型及意义[J]中华实用外科杂志2002,22(3):154-156
19. Green RM. Patient selection for endovascular abdominal aortic aneurysm repair.[J] J Am Coll Surg2002;194:S67-73.
20.景在平,梅志军.主动脉夹层腔内隔绝术后内漏的处理[J],中国普外基础与临床杂,2006,13(6):632-633
21.张真，卢晓风．生物材料有效性和安全性评价的现状与趋势[J]．生物医学工程学杂志，2002，19(1)：117-121
22.粟爽，李万甫,三种不同材料血管内支架的生物相容性[J],中国组织工程研究与临床康复,2008,12(17),3293-3296
23. Hoffmann R，Mintz GS，Dussaillant GR，et a1．Patterns and mechanisms of in-stent restenosis. Aserial intravascular ultrasound study[J]. Circulation,1996.94(6):1247-54
24. Gordon PC，Gibson M，Cohen DJ，et a1．Mechanisms of restenosis and redilation within coronarystents~uantitative angiographic assessment[J]．J Am Coll Cardiol，1993，21(5)：1166-1174
25.吴婷,滕皋军,覆膜支架防治血管再狭窄的研究进展[J],国外医学临床放射学分册,2003Jul；26(4):244-246
26.刘晋，徐克，张曦彤，等．自制被覆聚氨酯膜与非覆膜不锈钢支架在动脉系统应用的实验对照研究[J]．中国医学影像技术，2003，19(2)：129-132
27.皇甫强，于振涛，罗丽娟，等．钛合金血管内支架研究进展[J]．钛工业进展，2007，24(1)：29-31
28.郑春霞,刘志红,血管内皮细胞损伤及其检测[J],肾脏病与透析肾移植杂志,2007,16(1):64-69
29. Rogers C，Parikh S，Seifert P，et a1．Endogenous cell seeding．Remnant endothelium after stentingenhances vascular repair[J]．Circulation，1996，94(11)：2909-2914
30.孙立忠，刘志刚，常谦，等．主动脉弓替换加支架“象鼻”手术治疗Stanford A型主动脉夹层[J]．中华外科杂志，2004，42：812-816．
31. Nienaber CA，Eagle KA．Aortic dissection：new frontiers in diagnosis and management：Part II：therapeutic management and follow—up[J]．Circulation，20o3，108：772-778
32. Moil Y，Hirose H，Takagi H，et a1．Aortic arch repair for Stanford type A aortic dissection withdistal anastomosis so the proximal level of the distal aortic arch[J]．J Thorac Cardiovasc Surg，2003，126：415-419
33. Uchida N，Shibamura H，Katayama A，et a1．Operative strategy for acute type a aortic dissection：ascending aortic or hemiarch versus total arch replacement with frozen elephant trunk[J]．AnnThorac Surg，2009，87：773-777．
34. Geirsson A，Bavaria JE，Swarr D，et a1．Fate of the residual distal and proximal aorta after acutetype a dissection repair using a contemporary surgical reconstruction algorithm[J]．Ann ThoracSurg，2007，84(6)：1955-1964
35. Poehetino A，Brinkman WT，MoeUer P，et a1．Antegrade thoracic stent grafting during repair ofacute DeBakey I dissection prevents development of thoracoabdominal aortic aneurysms[J]．AnnThorac Surg，2009，88(2)：482-489．
36. Tsagakis K，Kamler M，Kuehl H，et a1．Avoidance of proximal endoleak using a hybrid stent graftin arch replacement and descending aorta stenting[J]．Ann Thorac Surg，2009，88(3)：773-779．
37. Sun L, Qi R, Zhu J, et a1. Total arch replacement combined with stented elephant trunkimplantation: a new "standard" therapy for type a dissection involving repair of the aortic arch[J]?Circulation2011;123:971-978.
38. Hagan PG，Nienaber CA，Isselbacher EM，et a1．The international registry of acute aorticdissection(IKAD)：new insights into an old disease [J]．JAMA，2000，283(7)：897-903
39. Sinatra R，Melina G，Pulitani I，et a1．Emergency operation for acute type A aortic dissection：neurologie complications and earlymortality [J]．Ann Thorac，2001，71(1)：33-38
40. Liu ZG，Sun LZ，Chang Q．et a1．Should the“elephant trunk”be skeletonized?Total archreplacement combined with stented elephant trunk implantation for stanford type A aorticdissection[J]．J Thorac Cardiovasc Surg，2006，131：107-113
41. Ergin MA, Galla JD, Lansman L, et al., Hypothermic circulatory arrest in operations on the thoracicaorta. Determinants of operative mortality and neurologic outcome[J]. J Thorac Cardiovasc Surg1994;107(3):788-797; discussion797-789
42. Bogdan, Y. and G.L. Hines, Management of acute complicated and uncomplicated type B dissectionof the aorta: focus on endovascular stent grafting[J]. Cardiol Rev,2010.18(5):234-239
43. Eggebrecht H，Nienaber CA，Neuhauser M，et a1． Endovascular stent—graft placement in aorticdissection：a meta—analysis[J]．Eur Heart J,2006，27(4)：489-498．
44. Chang GQ，Li ZL．Endovascular stent-graft placement in Stanford type B aortic dissection inChina[J]．Eur J Vasc Endovasc Surg，2009，37(6)：646-653
45. Mestres CA, Fernandez C, Josa M, et al. Hybrid antegrade repair of the arch and descendingthoracic aorta with a new integrated stent-Dacron graft in acute type A aortic dissection: a look intothe future with new devices[J]. Interact Cardiovasc Thorac Surg2007;6:257-259.
46. Chavan A, Karck M, Hagl C, et al. Hybrid endograft for one-step treatment of multisegment diseaseof the thoracic aorta[J]. J Vasc Interv Radiol2005;16:823-829.
47. Szeto WY, Bavaria JE, Bowen FW, et al. The hybrid total arch repair: brachiocephalic bypass andconcomitant endovascular aortic arch stent graft placement[J]. J Card Surg2007;22:97-102;discussion103-104.
48. Greenberg, R.K., Haulon, S., O'Neill, S., et al., Primary endovascular repair of juxtarenalaneurysms with fenestrated endovascular grafting[J]. Eur J Vasc Endovasc Surg,2004.27(5): p.484-91
49. Baldwin, Z.K., Chuter, T. A., Hiramoto, J. S. et al., Double-barrel technique for preservation ofaortic arch branches during thoracic endovascular aortic repair[J]. Ann Vasc Surg,2008.22(6): p.703-709.
50. Chen LW，Dai XF，Lu L，et a1．Extensive primary repair of the thoracic aorta in acute type a aorticdissection by means of ascending aorta replacement combined with open placement oftriple-branched stent graft：early results[J]．Circulation，2010，122(14)：1373-1378．
51. Sun, L., Li, M., Zhu, J., et al., Surgery for patients with Marfan syndrome with type A dissectioninvolving the aortic arch using total arch replacement combined with stented elephant trunkimplantation: the acute versus the chronic[J]. J Thorac Cardiovasc Surg,2011.142(3): p. e85-91
52. Kim, J.B., Chung, C. H., Moon, D. H., et al., Total arch repair versus hemiarch repair in themanagement of acute DeBakey type I aortic dissection[J]. Eur J Cardiothorac Surg,2011.40(4): p.881-887
53. Erbel R, Alfonso F, Boileau C, Task Force on Aortic Dissection, European Society of Cardiology.Diagnosis and management of aortic dissection[J]. Eur Heart J,2001.22(18): p.1642-81.
54. Hebballi R, Swanevelder J (2009) Diagnosis and management of aortic dissection[J]. ContinuingEducation in Anaesthesia, Critical Care&Pain9:14-18
55. Ince H, Nienaber CA (2007) Diagnosis and management of patients with aortic dissection[J]. Heart93:266-270
56. Greenberg, R.K., Haulon, S., O'Neill, S., et al., Primary endovascular repair of juxtarenalaneurysms with fenestrated endovascular grafting[J]. Eur J Vasc Endovasc Surg,2004.27(5): p.484-91.
57. Green, R.M., Patient selection for endovascular abdominal aortic aneurysm repair[J]. J Am CollSurg,2002.194(1Suppl): p. S67-73
1. Moil Y，Hirose H，Takagi H，et a1．Aortic arch repair for Stanford type A aortic dissection withdistal anastomosis so the proximal level of the distal aortic arch[J]．J Thorac Cardiovasc Surg，2003，126：415-419
2. Szeto WY, Bavaria JE, Bowen FW, et al. The hybrid total arch repair: brachiocephalic bypass andconcomitant endovascular aortic arch stent graft placement [J]. J Card Surg2007,22(2):97-102,discussion103-104.
3. Sundt TM, Orszulak TA, Cook DJ, et al. Improving results of open arch replacement [J]. AnnThorac Surg2008,86(3):787-796, discussion787-796.
4.孙立忠，刘志刚，常谦，等．主动脉弓替换加支架“象鼻”手术治疗Stanford A型主动脉夹层[J]．中华外科杂志，2004，42：812-816
5. Uchida N，Shibamura H，Katayama A，et a1．Operative strategy for acute type a aortic dissection：ascending aortic or hemiarch versus total arch replacement with frozen elephant trunk[J]．AnnThorac Surg，2009，87：773—777
6. Shiono M, Hata M, Sezai A, Niino T, Yagi S, Negishi N. Validity of a limited ascending andhemiarch replacement for acute type A aortic dissection. Ann Thorac Surg.2006;82(5):1665-1669.
7. Ohtsubo S, Itoh T, Takarabe K, Rikitake K, Furukawa K, Suda H, Okazaki Y. Surgical results ofhemiarch replacement for acute type A dissection. Ann Thorac Surg.2002;74(5):S1853-S1856.
8. Geirsson A，Bavaria JE，Swarr D，et a1．Fate of the residual distal and proximal aorta after acutetype a dissection repair using a contemporary surgical reconstruction algorithm[J]．Ann Thorac Surg，2007，84(6)：1955-1964．
9. Fattouch K, Sampognaro R, Navarra E, et al. Long-term results after repair of type A acute aorticdissection according to false lumen patency. Ann Thorac Surg2009;88:1244-50.
10. Park K-H, Lim C, Choi JH, et al. Midterm change of descending aortic false lumen after repair ofacute type I dissection. Ann Thorac Surg2009;87:103-108.
11. Jakob H, Tsagakis K, Tossios P, et al. Combining classic surgery with descending stent grafting foracute DeBakey type I dissection. Ann Thorac Surg2008;86:95-101.
12. Fann JI, Smith JA, Miller DC, et al. Surgical management of aortic dissection during a30-yearperiod. Circulation.1995;92(suppl):II-113–II-121.
13. Ergin MA, Philips RA, Galla JD, et a1. Significance of distal false lumen after type A dissectionrepair. Ann Thorac Surg.1994;57:820–825.
14. Poehetino A，Brinkman WT，MoeUer P，et a1．Antegrade thoracic stent grafting during repair ofacute DeBakey I dissection prevents development of thoracoabdominal aortic aneurysms[J]．AnnThorac Surg，2009，88(2)：482-489
15. Sun L, Qi R, Zhu J, Liu Y, Zheng J. Total arch replacement combined with stented elephant trunkimplantation: a new "standard" therapy for type a dissection involving repair of the aortic arch?Circulation.2011;123(9):971-978.
16. Tsagakis K, Pacini D, Di Bartolomeo R, Benedik J, Cerny S, Gorlitzer M, et al. Arch replacementand downstream stent grafting in complex aortic dissection: first results of an international registry.Eur J Cardiothorac Surg.2011;39:87-93.
17. Kim JB, Chung CH, Moon DH, Ha GJ, Lee TY, Jung SH, et al. Total arch repair versus hemiarchrepair in the management of acute DeBakey type I aortic dissection. Eur J Cardiothorac Surg.2011;40(4):881-887
18. Sabik JF, Lytle BW, Blackstone EH, McCarthy PM, Loop FD, Cosgrove DM. Long-termeffectiveness of operations for ascending aortic dissections. J Thorac Cardiovasc Surg.2000;119:946-62.
19. Dobrilovic N, Elefteriades JA. Stenting the descending aorta during repair of type A dissection:technology looking for an application? J Thorac Cardiovasc Surg.2006;131:777-778.
20. Tsagakis K，Kamler M，Kuehl H，et a1．Avoidance of proximal endoleak using a hybrid stent graftin arch replacement and descending aorta stenting[J]．Ann Thorac Surg，2009，88(3)：773-779
21.薛松，急性主动脉夹层的治疗策略[J].中国综合临床，2011，12(27)：1233-123
22. Liu ZG, Sun LZ, Chang Q, et al. Should the "elephant trunk" be skeletonized? Total archreplacement combined with stented elephant trunk implantation for Stanford type A aorticdissection [J]. J Thorac Cardiovasc Surg2006,131(1):107-113
23. Kato M, Kuratani T, Kaneko M, et al. The results of total arch graft implantation with openstent-graft placement for type A aortic dissection [J]. J Thorac Cardiovasc Surg2002,124(3):531-540
24. Schumacher H, Bockler D, Bardenheuer H, et al. Endovascular aortic arch reconstruction withsupra-aortic transposition for symptomatic contained rupture and dissection: early experience in8high-risk patients [J]. J Endovasc Ther2003,10(6):1066-1074
25. Younes HK, Davies MG, Bismuth J, et al. Hybrid thoracic endovascular aortic repair: pushing theenvelope [J]. J Vasc Surg2010,51(1):259-266
26. Gottardi R, Seitelberger R, Zimpfer D, et al. An alternative approach in treating an aortic archaneurysm with an anatomic variant by supraaortic reconstruction and stent-graft placement [J]. JVasc Surg2005,42(2):357-360
27. Bergeron P, Mangialardi N, Costa P, et al. Great vessel management for endovascular exclusion ofaortic arch aneurysms and dissections [J]. Eur J Vasc Endovasc Surg2006,32(1):38-45
28. Desai ND, Szeto WY. Complex aortic arch aneurysm and dissections: hybrid techniques for surgicaland endovascular therapy [J]. Curr Opin Cardiol2009,24(6):521-527
29.张宏鹏，郭伟，刘小平，尹太，贾鑫，熊江，等，杂交技术治疗主动脉弓部病变的近远期结果，中国普外基础与临床杂志，2011,18（10）:1039-1042
30. Schumacher H，Von Tengg Kobligk H，Ostovic M，et a1．Hybrid aortic procedures forendoluminal arch replacement in thoracic aneurysms and type B dissections[J]．JCardiovasc Surg(Torino)，2006，47(5)：509—517
31. Melissano G，Civilini E，Bertoglio L，et a1．Results of endografting of the aortic archin different landing zones [J]．Eur J Vasc Endovasc Surg，2007，33(5)：561-566．
32. Chen LW, Dai XF, Lu L, et al. Extensive primary repair of the thoracic aorta in acute type a aorticdissection by means of ascending aorta replacement combined with open placement oftriple-branched stent graft: early results [J]. Circulation2010,122(14):1373-1378
33.华菲，沈振亚，余云生，叶文学，黄浩岳，主动脉弓三分支覆膜支架在Stanford A型急性主动脉夹层外科治疗中的应用，中华外科杂志，2011，49（8）：720-723
34.徐根兴，刘冀东，王维俊，谢波，康丹凤，薛松，三分支型主动脉弓腔内覆膜支架治疗DeBakey I型主动脉夹层一例，中国综合临床，2011，27（12）：1259
35.刘胜中，曾富春，甘崇志，丛伟，应用新型三分支主动脉弓覆膜支架治疗急性Stanford A型主动脉夹层的临床研究，四川医学，2011，32(2)：165-167
36. Crawford ES, Svensson LG, Coselli JS, et al. Surgical treatment of aneurysm and/or dissection ofthe ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch. Factorsinfluencing survival in717patients [J]. J Thorac Cardiovasc Surg1989,98(5Pt1):659-673;discussion673-654
37. Okita Y, Takamoto S, Ando M, et al.Mortality and cerebral outcome in patients who underwentaortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion:no relation of early death, stroke, and delirium to the duration of circulatory arrest [J]. J ThoracCardiovasc Surg1998,115(1):129-138
38. Kurimoto Y, Ito T, Harada R, et al. Fenestrated stent-graft placement can be an alternativemanagement for distal aortic arch disease [J]. Circulation2006,114(18):755-755
39. Yuan LX, Feng X, Jing ZP. Endovascular Repair of a Thoracic Arch Aneurysm With a FenestratedStent-Graft [J]. J Endovasc Ther2008,15(5):539-543
40. Kasprzak PM, Muller T, Loibnegger A, et al. Fenestrated and branched stent prostheses in the aorticarch: first experiences [J]. Gefasschirurgie2009,14(3):198-205
41. Sonesson B, Resch T, Allers M, et al. Endovascular total aortic arch replacement by in situ stentgraft fenestration technique [J]. J Vasc Surg2009,49(6):1589-1591
42. Inoue K, Hosokawa H, Iwase T, et al. Aortic arch reconstruction by transluminally placedendovascular branched stent graft [J]. Circulation1999,100(19Suppl):II316-321
43. Malina M, Resch T, Sonesson B. Evar and complex anatomy: An update on fenestrated andbranched stent grafts [J]. Scand J Surg2008,97(2):195-204
44. Wei G, Xin J, Yang D, et al. A new modular stent graft to reconstruct aortic arch [J]. Eur J VascEndovasc Surg2009,37(5):560-565
45. Ohrlander T, Sonesson B, Ivancev K, et al. The chimney graft: a technique for preserving orrescuing aortic branch vessels in stent-graft sealing zones [J]. J Endovasc Ther2008,15(4):427-432
46. Baldwin ZK, Chuter TA, Hiramoto JS, et al. Double-barrel technique for endovascular exclusion ofan aortic arch aneurysm without sternotomy [J]. J Endovasc Ther2008,15(2):161-165
47. Baldwin ZK, Chuter TA, Hiramoto JS, et al. Double-barrel technique for preservation of aortic archbranches during thoracic endovascular aortic repair [J]. Ann Vasc Surg2008,22(6):703-709
48. Kuratani T, Sawa Y. Current strategy of endovascular aortic repair for thoracic aortic aneurysms [J].General Thoracic and Cardiovascular Surgery2010,58(8):393-398.
2. Anagnostopoulos CE, Prabhar MJS, Kittle CF. Aortic dissection and dissecting aneurysms. Am JCardiol1972;30:263-273.
3. Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, Rakowski H, Struyven J, RadegranK, Sechtem U, Taylor J, Zollikofer C, Klein WW, Mulder B, Providencia LA. Diagnosis andmanagement of aortic dissection. Eur Heart J.2001;22:1642-1681
4. Tsai, T.T., C.A. Nienaber, and K.A. Eagle, Acute aortic syndromes [J]. Circulation,2005.112(24):p.3802-13.
5. Borst HG, Heinemann MK, Stone CD. Surgical treatment of aortic dissection. New York: ChurchillLivingstone;1996:357.
6. Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB. Kirklin/Barratt-Boyes CardiacSurgery,3rd ed. Salt Lake City: Churchill Livingstone;2003:1938.
7. Fleck T, Hutschala D, Czerny M, et al. Combined surgical and endovascular treatment of acuteaortic dissection type A:preliminary results. Ann Thorac Surg2002;74:761–6.
8. Cohn LH, Edmunds LH Jr, et al. Cardiac Surgery in the Adult. New York: McGraw-Hill,2003:1095-1122.
9. Fann JI, Smith JA, Miller DC, Mitchell RS, Moore KA, Grunkemeier G, Stinson EB, Oyer PE,Reitz BA, Shumway NE. Surgical management of aortic dissection during a30-year period.Circulation.1995;92:II113-121
10. Ehrlich M, Fang WC, Grabenwoger M, Cartes-Zumelzu F, Wolner E, Havel M. Perioperative riskfactors for mortality in patients with acute type a aortic dissection. Circulation.1998;98:II294-298
11. Bachet J, Goudot B, Dreyfus GD, Brodaty D, Dubois C, Delentdecker P, Guilmet D. Surgery foracute type a aortic dissection: The hopital foch experience (1977-1998). Ann Thorac Surg.1999;67:2006-2009; discussion2014-2009
12. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, Evangelista A,Fattori R, Suzuki T, Oh JK, Moore AG, Malouf JF, Pape LA, Gaca C, Sechtem U, Lenferink S,Deutsch HJ, Diedrichs H, Marcos y Robles J, Llovet A, Gilon D, Das SK, Armstrong WF, DeebGM, Eagle KA. The international registry of acute aortic dissection (irad): New insights into an olddisease. JAMA: the journal of the American Medical Association.2000;283:897-903
13. Chiappini B, Schepens M, Tan E, Dell' Amore A, Morshuis W, Dossche K, Bergonzini M, CamurriN, Reggiani LB, Marinelli G, Di Bartolomeo R. Early and late outcomes of acute type a aorticdissection: Analysis of risk factors in487consecutive patients. Eur Heart J.2005;26:180-186
14. Trimarchi S, Nienaber CA, Rampoldi V, Myrmel T, Suzuki T, Mehta RH, Bossone E, Cooper JV,Smith DE, Menicanti L, Frigiola A, Oh JK, Deeb MG, Isselbacher EM, Eagle KA. Contemporaryresults of surgery in acute type a aortic dissection: The international registry of acute aorticdissection experience. J Thorac Cardiovasc Surg.2005;129:112-122
15. Kawahito K, Adachi H, Yamaguchi A, et al. Long-Term surgical outcomes following intraluminalsutureless graft insertion for type A aortic dissection. Surg Today.2001;31(10):866-71.
16. Sun LZ, Qi RD, Chang Q, Zhu JM, Liu YM, Yu CT, Lv B, Zheng J, Tian LX, Lu JG. Surgery foracute type a dissection using total arch replacement combined with stented elephant trunkimplantation: Experience with107patients. J Thorac Cardiovasc Surg.2009;138:1358-1362
17.薛松，急性主动脉夹层的治疗策略.中国综合临床，2011，12(27):1233-35
18.孙立忠，刘志刚，常谦，等．主动脉弓替换加支架“象鼻”手术治疗Stanford A型主动脉夹层．中华外科杂志，2004，42:812-816．
19. Nienaber CA，Eagle KA．Aortic dissection：new frontiers in diagnosis and management：Part II：therapeutic management and foHow—up．Circulation，2003，108:772—778．
20. Moil Y，Hirose H，Takagi H，et a1．Aortic arch repair for Stanford type A aortic dissection withdistal anastomosis so the proximal level of the distal aortic arch．J Thorac Cardiovasc Surg，2003，126:415—419
21. Uchida N，Shibamura H，Katayama A，et a1．Operative strategy for acute type a aortic dissection：ascending aortic or hemiarch versus total arch replacement with frozen elephant trunk．Ann ThoracSurg，2009，87:773—777．
22.汪忠镐.微创外科在胸主动脉瘤治疗中的作用.中国微创外科杂志,2002;2(suppl):13-16.
23. Ehrlich MP, Dumfarth J, Schoder M, Gottardi R, Holfeld J, Juraszek A, Dziodzio T, Funovics M,Loewe C, Grimm M, Sodeck G, Czerny M. Midterm results after endovascular treatment of acute,complicated type b aortic dissection. Ann Thorac Surg.2010;90:1444-1448
24. White RA, Miller DC, Criado FJ, Dake MD, Diethrich EB, Greenberg RK, Piccolo RS, Siami FS.Report on the results of thoracic endovascular aortic repair for acute, complicated, type b aorticdissection at30days and1year from a multidisciplinary subcommittee of the society for vascularsurgery outcomes committee. J Vasc Surg.2011;53:1082-1090
25. Kim U, Hong SJ, Kim J, Kim JS, Ko YG, Choi D, Lee do Y, Chang BC, Shim WH. Intermediate tolong-term outcomes of endoluminal stent-graft repair in patients with chronic type b aorticdissection. J Endovasc Ther.2009;16:42-47
26. Steuer J, Eriksson MO, Nyman R, Bjorck M, Wanhainen A. Early and long-term outcome afterthoracic endovascular aortic repair (tevar) for acute complicated type b aortic dissection. Eur J VascEndovasc Surg.2011;41:318-323
27. Dake MD, Kato N, Mitchell RS, Semba CP, Razavi MK, Shimono T, Hirano T, Takeda K, Yada I,Miller DC. Endovascular stent-graft placement for the treatment of acute aortic dissection. TheNew England journal of medicine.1999;340:1546-1552
28. Szeto WY, Bavaria JE, Bowen FW, Woo EY, Fairman RM, Pochettino A. The hybrid total archrepair: Brachiocephalic bypass and concomitant endovascular aortic arch stent graft placement. JCard Surg.2007;22:97-102; discussion103-104
29. Mestres CA, Fernandez C, Josa M, Mulet J. Hybrid antegrade repair of the arch and descendingthoracic aorta with a new integrated stent-dacron graft in acute type a aortic dissection: A look intothe future with new devices. Interact Cardiovasc Thorac Surg.2007;6:257-259
30. Chavan A, Karck M, Hagl C, Winterhalter M, Baus S, Galanski M, Haverich A. Hybrid endograftfor one-step treatment of multisegment disease of the thoracic aorta. J Vasc Interv Radiol.2005;16:823-829
31. Schumacher H, Bockler D, Bardenheuer H, Hansmann J, Allenberg JR. Endovascular aortic archreconstruction with supra-aortic transposition for symptomatic contained rupture and dissection:Early experience in8high-risk patients. J Endovasc Ther.2003;10:1066-1074
32. Green RM. Patient selection for endovascular abdominal aortic aneurysm repair. J Am Coll Surg.2002;194:S67-73
1. Auer J，Berent R，Eher B．Aortic dissection：incidence，natural history and impact of surgery [J]．JClinic Basic Cardiol,2000,3(3):151-154
2. Pitt MP, Bonser RS. The natural history of thoracic aortic aneurysm disease: an overview. J CardSurg1997;12(suppl):270–278.
3. Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, Rakowski H, Struyven J, RadegranK, Sechtem U, Taylor J, Zollikofer C, Klein WW, Mulder B, Providencia LA. Diagnosis andmanagement of aortic dissection. Eur Heart J.2001;22:1642-1681
4. Tsai TT, CA Nienaber, and KA Eagle, Acute aortic syndromes [J]. Circulation,2005.112(24): p.3802-3813
5. Sun L, Qi R, Zhu J, et a1. Total arch replacement combined with stented elephant trunkimplantation: a new "standard" therapy for type a dissection involving repair of the aortic arch[J]?Circulation,2011;123:971-978
6. Sun LZ, Qi RD, Chang Q, Zhu JM, Liu YM, Yu CT, Lv B, Zheng J, Tian LX, Lu JG. Surgery foracute type a dissection using total arch replacement combined with stented elephant trunkimplantation: Experience with107patients. J Thorac Cardiovasc Surg.2009;138:1358-1362
7. Chang GQ，Li ZL．Endovascular stent—graft placement in Stanford type B aortic dissection inChina[J]．Eur J Vasc Endovasc Surg，2009，37(6)：646-653
8. Eggebrecht H，Nienaber CA，Neuhauser M，et a1．Endovascular stent—graft placement in aorticdissection：a meta—analysis[J]．Eur Heart J,2006，27(4)：489—498.
9. Green, RM, Patient selection for endovascular abdominal aortic aneurysm repair[J]. J Am CollSurg,2002.194(1Suppl): S67-73
10. Kasprzak PM, Muller T, Loibnegger A, et al. Fenestrated and branched stent prostheses in theaortic arch: first experiences [J]. Gefasschirurgie2009,14(3):198-205
11. Yuan LX, Feng X, Jing ZP. Endovascular Repair of a Thoracic Arch Aneurysm With a FenestratedStent-Graft [J]. J Endovasc Ther2008,15(5):539-543
12. Baldwin ZK, Chuter TA, Hiramoto JS, et al. Double-barrel technique for endovascular exclusion ofan aortic arch aneurysm without sternotomy [J]. J Endovasc Ther2008,15(2):161-165
13. Ohrlander T, Sonesson B, Ivancev K, et al. The chimney graft: a technique for preserving orrescuing aortic branch vessels in stent-graft sealing zones [J]. J Endovasc Ther2008,15(4):427-432
14. Wei G, Xin J, Yang D, et al. A new modular stent graft to reconstruct aortic arch [J]. Eur J VascEndovasc Surg2009,37(5):560-565
15. Chen LW, Wu XJ, Lu L, et al. Total arch repair for acute type A aortic dissection with2modifiedtechniques: open single-branched stent graft placement and reinforcement of the dissected archvessel stump with stent graft [J]. Circulation2011,123(22):2536-2541
16. Inoue K, Hosokawa H, Iwase T, et al. Aortic arch reconstruction by transluminally placedendovascular branched stent graft [J]. Circulation1999,100(19Suppl):II316-321
17.顾恺时,朱洪生,吴松昌,等.顾恺时胸心外科手术学.上海科学技术出版社，454-455
18.段志泉，张强.实用血管外科「M].沈阳:辽宁科学技术出版社，1999
19. Kannan RY, Salacinski HJ, Butler PE et al. Current status of prosthetic bypass grafts: a review[J]. JBiomed Mater Res B Appl Biomater.2005;74(1):570-581
20.刘国惠.膨体聚四氟乙烯医用制品的研究[J].上海化工,1994;3(19):1-3
21. Bordenave L, Fernandez P, Remy-Zolghadri M, et al. In vitro endothelialized ePTFE prostheses:clinical update20years after the first realization[J]. Clin Hemorheol Microcirc.2005;33(3):227-234
22. Kannan RY, Salacinski HJ, Butler PE et al. Current status of prosthetic bypass grafts: a review[J]. JBiomed Mater Res B Appl Biomater.2005;74(1):570-815
23. Ryhanen J, Niemi E, Serlo W, et al. Biocompatibility of nickeltitanium shape memory metal and itscorrosion behavior in human cell cultures[J]. J Biomed Mater Res,1997,35(4):451-457
24. Kapanen A, Ryhanen J, Danilov A, et al. Effect of nickeltitanium shape memory alloy on boneformation[J]. Biomaterials,2001,22(18):2475-2480
25.史振宇符伟国王玉琦.人工血管内支架与腹主动脉的生物相容性[J].中华实验外科杂志2005;22:57-658
26.夏亚一,陈峰,王天民.镍钛形状记忆合金性能及生物相容性研究进展[J].生物骨科材料与临床研究,2004,1(2):31-33
27.汪光晔,张春才.镍钛形状记忆合金生物相容性的概况[J].中华创伤骨科杂志,2006,8(4):367-370
28.赵维彪.镍钛形状记忆合金的材料学特征与医学应用[J].中国组织工程研究与临床康复,2007,11(22):4376-4379
29.薛淼,潘家琛,陈希贤等.镍钛合金的基础研究—模拟腐蚀试验及组织学观察[J].中华医学杂志,1982,62:7
30.曾光廷，李静缓，罗学厚，非金属夹杂物与钢的韧性研究,材料科学与工程[J]，2002,18（2）：87-99
1.施新酞:上海实验动物科学,1984,4(1):53
2. Massoud TF, Guglielmi G, Ji C, et al. Experimental saccular aneurysms: Review ofsurgically-constructed models and their laboratory application[J]. Neuroradiology,1994,36:537
3.钟品仁,哺乳类实验动物.人民卫生出版社1983
4.苏荣胜,王荣梅,陈义洲.犬在诊治过程中体温异常升高的预防与急救[J],中国兽医杂志.2010,6(46):77-78
5. Tan ME，Dossche KM，Morshuis WJ，et a1．Operative risk factors of type A aortic dissection：analysis of252consecutive patients[J]．J Cardiovasc Surg，2003，11：277-285
6.尚蔚，刘楠，闫晓蕾，等．A型主动脉夹层手术后早期并发症分析[J]．心肺血管病杂志，2011，30：183-186.
7. Chiappini B，Schepens M，Tan E，et a1．Eady and late outcomes of acute type A aortic dissection：Analysis of risk factors in487consecutive patients[J]．Eur Hcart J．2005．26：180-186．
8.康凯,张宇南,谢宝栋.等22例Stanford A型主动脉夹层手术止血技巧体会[J].心肺血管病杂.2011,6(30):521-523
9. Sundt TM, Orszulak TA, Cook DJ, et al. Improving results of open arch replacement [J]. AnnThorac Surg2008,86(3):787-796, discussion787-796.
10. Szeto WY, Bavaria JE, Bowen FW, et al. The hybrid total arch repair: brachiocephalic bypass andconcomitant endovascular aortic arch stent graft placement [J]. J Card Surg2007,22(2):97-102,discussion103-104.
11. Innes W, Gianni A, Alan B, et al. Prevention of spinal cord ischaemia during descending thoracicand thoracoabdominal aortic surgery[J]. European Journal of Cardio-thoracic Surgery.2001;19:203-213.
12. Reich DL, Uysal S, Sliwinski M, et al. Neuropsychologic outcome after deep hypothermiccirculatory arrest in adults[J]. J Thorac Cardiovasc Surg1999;117:156-63.
13. Svensson LG, Crawford ES, Hess KR, et al. Deep hypothermia with circulatory arrest.Determinants of stroke and early mortality in656patients[J]. J Thorac Cardiovasc Surg1993;106:19-28; discussion28-31.
14. Ye J, Yang L, Del Bigio MR, et al, Retrograde cerebral perfusion provides limited distribution ofblood to the brain: a study in pigs[J]. J Thorac Cardiovasc Surg,1997,114(4):660-665
15. Elmistekawy. E M,Rubens. F D, Deep hypothermie circulatory arrest：alternative strategies forcerebral perfusion．A renew article[J]．Perfusion，2011，26Suppl1：27—34.
16.景在平．包俊敏，周颖奇，等腔内隔绝术治疗胸主动脉夹层动脉瘤[J],第二军医大学学报，1999，20(11)：828-830.
17.景在平．赵珺，赵志青．等, Stanford B型夹层动脉瘤的微创腔内隔绝术治疗[J]．中国实用外科杂志，2000．20(6)：340
18.景在平,赵珺,赵志青,等胸主动脉夹层腔内隔绝术后内漏的分型及意义[J]中华实用外科杂志2002,22(3):154-156
19. Green RM. Patient selection for endovascular abdominal aortic aneurysm repair.[J] J Am Coll Surg2002;194:S67-73.
20.景在平,梅志军.主动脉夹层腔内隔绝术后内漏的处理[J],中国普外基础与临床杂,2006,13(6):632-633
21.张真，卢晓风．生物材料有效性和安全性评价的现状与趋势[J]．生物医学工程学杂志，2002，19(1)：117-121
22.粟爽，李万甫,三种不同材料血管内支架的生物相容性[J],中国组织工程研究与临床康复,2008,12(17),3293-3296
23. Hoffmann R，Mintz GS，Dussaillant GR，et a1．Patterns and mechanisms of in-stent restenosis. Aserial intravascular ultrasound study[J]. Circulation,1996.94(6):1247-54
24. Gordon PC，Gibson M，Cohen DJ，et a1．Mechanisms of restenosis and redilation within coronarystents~uantitative angiographic assessment[J]．J Am Coll Cardiol，1993，21(5)：1166-1174
25.吴婷,滕皋军,覆膜支架防治血管再狭窄的研究进展[J],国外医学临床放射学分册,2003Jul；26(4):244-246
26.刘晋，徐克，张曦彤，等．自制被覆聚氨酯膜与非覆膜不锈钢支架在动脉系统应用的实验对照研究[J]．中国医学影像技术，2003，19(2)：129-132
27.皇甫强，于振涛，罗丽娟，等．钛合金血管内支架研究进展[J]．钛工业进展，2007，24(1)：29-31
28.郑春霞,刘志红,血管内皮细胞损伤及其检测[J],肾脏病与透析肾移植杂志,2007,16(1):64-69
29. Rogers C，Parikh S，Seifert P，et a1．Endogenous cell seeding．Remnant endothelium after stentingenhances vascular repair[J]．Circulation，1996，94(11)：2909-2914
30.孙立忠，刘志刚，常谦，等．主动脉弓替换加支架“象鼻”手术治疗Stanford A型主动脉夹层[J]．中华外科杂志，2004，42：812-816．
31. Nienaber CA，Eagle KA．Aortic dissection：new frontiers in diagnosis and management：Part II：therapeutic management and follow—up[J]．Circulation，20o3，108：772-778
32. Moil Y，Hirose H，Takagi H，et a1．Aortic arch repair for Stanford type A aortic dissection withdistal anastomosis so the proximal level of the distal aortic arch[J]．J Thorac Cardiovasc Surg，2003，126：415-419
33. Uchida N，Shibamura H，Katayama A，et a1．Operative strategy for acute type a aortic dissection：ascending aortic or hemiarch versus total arch replacement with frozen elephant trunk[J]．AnnThorac Surg，2009，87：773-777．
34. Geirsson A，Bavaria JE，Swarr D，et a1．Fate of the residual distal and proximal aorta after acutetype a dissection repair using a contemporary surgical reconstruction algorithm[J]．Ann ThoracSurg，2007，84(6)：1955-1964
35. Poehetino A，Brinkman WT，MoeUer P，et a1．Antegrade thoracic stent grafting during repair ofacute DeBakey I dissection prevents development of thoracoabdominal aortic aneurysms[J]．AnnThorac Surg，2009，88(2)：482-489．
36. Tsagakis K，Kamler M，Kuehl H，et a1．Avoidance of proximal endoleak using a hybrid stent graftin arch replacement and descending aorta stenting[J]．Ann Thorac Surg，2009，88(3)：773-779．
37. Sun L, Qi R, Zhu J, et a1. Total arch replacement combined with stented elephant trunkimplantation: a new "standard" therapy for type a dissection involving repair of the aortic arch[J]?Circulation2011;123:971-978.
38. Hagan PG，Nienaber CA，Isselbacher EM，et a1．The international registry of acute aorticdissection(IKAD)：new insights into an old disease [J]．JAMA，2000，283(7)：897-903
39. Sinatra R，Melina G，Pulitani I，et a1．Emergency operation for acute type A aortic dissection：neurologie complications and earlymortality [J]．Ann Thorac，2001，71(1)：33-38
40. Liu ZG，Sun LZ，Chang Q．et a1．Should the“elephant trunk”be skeletonized?Total archreplacement combined with stented elephant trunk implantation for stanford type A aorticdissection[J]．J Thorac Cardiovasc Surg，2006，131：107-113
41. Ergin MA, Galla JD, Lansman L, et al., Hypothermic circulatory arrest in operations on the thoracicaorta. Determinants of operative mortality and neurologic outcome[J]. J Thorac Cardiovasc Surg1994;107(3):788-797; discussion797-789
42. Bogdan, Y. and G.L. Hines, Management of acute complicated and uncomplicated type B dissectionof the aorta: focus on endovascular stent grafting[J]. Cardiol Rev,2010.18(5):234-239
43. Eggebrecht H，Nienaber CA，Neuhauser M，et a1． Endovascular stent—graft placement in aorticdissection：a meta—analysis[J]．Eur Heart J,2006，27(4)：489-498．
44. Chang GQ，Li ZL．Endovascular stent-graft placement in Stanford type B aortic dissection inChina[J]．Eur J Vasc Endovasc Surg，2009，37(6)：646-653
45. Mestres CA, Fernandez C, Josa M, et al. Hybrid antegrade repair of the arch and descendingthoracic aorta with a new integrated stent-Dacron graft in acute type A aortic dissection: a look intothe future with new devices[J]. Interact Cardiovasc Thorac Surg2007;6:257-259.
46. Chavan A, Karck M, Hagl C, et al. Hybrid endograft for one-step treatment of multisegment diseaseof the thoracic aorta[J]. J Vasc Interv Radiol2005;16:823-829.
47. Szeto WY, Bavaria JE, Bowen FW, et al. The hybrid total arch repair: brachiocephalic bypass andconcomitant endovascular aortic arch stent graft placement[J]. J Card Surg2007;22:97-102;discussion103-104.
48. Greenberg, R.K., Haulon, S., O'Neill, S., et al., Primary endovascular repair of juxtarenalaneurysms with fenestrated endovascular grafting[J]. Eur J Vasc Endovasc Surg,2004.27(5): p.484-91
49. Baldwin, Z.K., Chuter, T. A., Hiramoto, J. S. et al., Double-barrel technique for preservation ofaortic arch branches during thoracic endovascular aortic repair[J]. Ann Vasc Surg,2008.22(6): p.703-709.
50. Chen LW，Dai XF，Lu L，et a1．Extensive primary repair of the thoracic aorta in acute type a aorticdissection by means of ascending aorta replacement combined with open placement oftriple-branched stent graft：early results[J]．Circulation，2010，122(14)：1373-1378．
51. Sun, L., Li, M., Zhu, J., et al., Surgery for patients with Marfan syndrome with type A dissectioninvolving the aortic arch using total arch replacement combined with stented elephant trunkimplantation: the acute versus the chronic[J]. J Thorac Cardiovasc Surg,2011.142(3): p. e85-91
52. Kim, J.B., Chung, C. H., Moon, D. H., et al., Total arch repair versus hemiarch repair in themanagement of acute DeBakey type I aortic dissection[J]. Eur J Cardiothorac Surg,2011.40(4): p.881-887
53. Erbel R, Alfonso F, Boileau C, Task Force on Aortic Dissection, European Society of Cardiology.Diagnosis and management of aortic dissection[J]. Eur Heart J,2001.22(18): p.1642-81.
54. Hebballi R, Swanevelder J (2009) Diagnosis and management of aortic dissection[J]. ContinuingEducation in Anaesthesia, Critical Care&Pain9:14-18
55. Ince H, Nienaber CA (2007) Diagnosis and management of patients with aortic dissection[J]. Heart93:266-270
56. Greenberg, R.K., Haulon, S., O'Neill, S., et al., Primary endovascular repair of juxtarenalaneurysms with fenestrated endovascular grafting[J]. Eur J Vasc Endovasc Surg,2004.27(5): p.484-91.
57. Green, R.M., Patient selection for endovascular abdominal aortic aneurysm repair[J]. J Am CollSurg,2002.194(1Suppl): p. S67-73
1. Moil Y，Hirose H，Takagi H，et a1．Aortic arch repair for Stanford type A aortic dissection withdistal anastomosis so the proximal level of the distal aortic arch[J]．J Thorac Cardiovasc Surg，2003，126：415-419
2. Szeto WY, Bavaria JE, Bowen FW, et al. The hybrid total arch repair: brachiocephalic bypass andconcomitant endovascular aortic arch stent graft placement [J]. J Card Surg2007,22(2):97-102,discussion103-104.
3. Sundt TM, Orszulak TA, Cook DJ, et al. Improving results of open arch replacement [J]. AnnThorac Surg2008,86(3):787-796, discussion787-796.
4.孙立忠，刘志刚，常谦，等．主动脉弓替换加支架“象鼻”手术治疗Stanford A型主动脉夹层[J]．中华外科杂志，2004，42：812-816
5. Uchida N，Shibamura H，Katayama A，et a1．Operative strategy for acute type a aortic dissection：ascending aortic or hemiarch versus total arch replacement with frozen elephant trunk[J]．AnnThorac Surg，2009，87：773—777
6. Shiono M, Hata M, Sezai A, Niino T, Yagi S, Negishi N. Validity of a limited ascending andhemiarch replacement for acute type A aortic dissection. Ann Thorac Surg.2006;82(5):1665-1669.
7. Ohtsubo S, Itoh T, Takarabe K, Rikitake K, Furukawa K, Suda H, Okazaki Y. Surgical results ofhemiarch replacement for acute type A dissection. Ann Thorac Surg.2002;74(5):S1853-S1856.
8. Geirsson A，Bavaria JE，Swarr D，et a1．Fate of the residual distal and proximal aorta after acutetype a dissection repair using a contemporary surgical reconstruction algorithm[J]．Ann Thorac Surg，2007，84(6)：1955-1964．
9. Fattouch K, Sampognaro R, Navarra E, et al. Long-term results after repair of type A acute aorticdissection according to false lumen patency. Ann Thorac Surg2009;88:1244-50.
10. Park K-H, Lim C, Choi JH, et al. Midterm change of descending aortic false lumen after repair ofacute type I dissection. Ann Thorac Surg2009;87:103-108.
11. Jakob H, Tsagakis K, Tossios P, et al. Combining classic surgery with descending stent grafting foracute DeBakey type I dissection. Ann Thorac Surg2008;86:95-101.
12. Fann JI, Smith JA, Miller DC, et al. Surgical management of aortic dissection during a30-yearperiod. Circulation.1995;92(suppl):II-113–II-121.
13. Ergin MA, Philips RA, Galla JD, et a1. Significance of distal false lumen after type A dissectionrepair. Ann Thorac Surg.1994;57:820–825.
14. Poehetino A，Brinkman WT，MoeUer P，et a1．Antegrade thoracic stent grafting during repair ofacute DeBakey I dissection prevents development of thoracoabdominal aortic aneurysms[J]．AnnThorac Surg，2009，88(2)：482-489
15. Sun L, Qi R, Zhu J, Liu Y, Zheng J. Total arch replacement combined with stented elephant trunkimplantation: a new "standard" therapy for type a dissection involving repair of the aortic arch?Circulation.2011;123(9):971-978.
16. Tsagakis K, Pacini D, Di Bartolomeo R, Benedik J, Cerny S, Gorlitzer M, et al. Arch replacementand downstream stent grafting in complex aortic dissection: first results of an international registry.Eur J Cardiothorac Surg.2011;39:87-93.
17. Kim JB, Chung CH, Moon DH, Ha GJ, Lee TY, Jung SH, et al. Total arch repair versus hemiarchrepair in the management of acute DeBakey type I aortic dissection. Eur J Cardiothorac Surg.2011;40(4):881-887
18. Sabik JF, Lytle BW, Blackstone EH, McCarthy PM, Loop FD, Cosgrove DM. Long-termeffectiveness of operations for ascending aortic dissections. J Thorac Cardiovasc Surg.2000;119:946-62.
19. Dobrilovic N, Elefteriades JA. Stenting the descending aorta during repair of type A dissection:technology looking for an application? J Thorac Cardiovasc Surg.2006;131:777-778.
20. Tsagakis K，Kamler M，Kuehl H，et a1．Avoidance of proximal endoleak using a hybrid stent graftin arch replacement and descending aorta stenting[J]．Ann Thorac Surg，2009，88(3)：773-779
21.薛松，急性主动脉夹层的治疗策略[J].中国综合临床，2011，12(27)：1233-123
22. Liu ZG, Sun LZ, Chang Q, et al. Should the "elephant trunk" be skeletonized? Total archreplacement combined with stented elephant trunk implantation for Stanford type A aorticdissection [J]. J Thorac Cardiovasc Surg2006,131(1):107-113
23. Kato M, Kuratani T, Kaneko M, et al. The results of total arch graft implantation with openstent-graft placement for type A aortic dissection [J]. J Thorac Cardiovasc Surg2002,124(3):531-540
24. Schumacher H, Bockler D, Bardenheuer H, et al. Endovascular aortic arch reconstruction withsupra-aortic transposition for symptomatic contained rupture and dissection: early experience in8high-risk patients [J]. J Endovasc Ther2003,10(6):1066-1074
25. Younes HK, Davies MG, Bismuth J, et al. Hybrid thoracic endovascular aortic repair: pushing theenvelope [J]. J Vasc Surg2010,51(1):259-266
26. Gottardi R, Seitelberger R, Zimpfer D, et al. An alternative approach in treating an aortic archaneurysm with an anatomic variant by supraaortic reconstruction and stent-graft placement [J]. JVasc Surg2005,42(2):357-360
27. Bergeron P, Mangialardi N, Costa P, et al. Great vessel management for endovascular exclusion ofaortic arch aneurysms and dissections [J]. Eur J Vasc Endovasc Surg2006,32(1):38-45
28. Desai ND, Szeto WY. Complex aortic arch aneurysm and dissections: hybrid techniques for surgicaland endovascular therapy [J]. Curr Opin Cardiol2009,24(6):521-527
29.张宏鹏，郭伟，刘小平，尹太，贾鑫，熊江，等，杂交技术治疗主动脉弓部病变的近远期结果，中国普外基础与临床杂志，2011,18（10）:1039-1042
30. Schumacher H，Von Tengg Kobligk H，Ostovic M，et a1．Hybrid aortic procedures forendoluminal arch replacement in thoracic aneurysms and type B dissections[J]．JCardiovasc Surg(Torino)，2006，47(5)：509—517
31. Melissano G，Civilini E，Bertoglio L，et a1．Results of endografting of the aortic archin different landing zones [J]．Eur J Vasc Endovasc Surg，2007，33(5)：561-566．
32. Chen LW, Dai XF, Lu L, et al. Extensive primary repair of the thoracic aorta in acute type a aorticdissection by means of ascending aorta replacement combined with open placement oftriple-branched stent graft: early results [J]. Circulation2010,122(14):1373-1378
33.华菲，沈振亚，余云生，叶文学，黄浩岳，主动脉弓三分支覆膜支架在Stanford A型急性主动脉夹层外科治疗中的应用，中华外科杂志，2011，49（8）：720-723
34.徐根兴，刘冀东，王维俊，谢波，康丹凤，薛松，三分支型主动脉弓腔内覆膜支架治疗DeBakey I型主动脉夹层一例，中国综合临床，2011，27（12）：1259
35.刘胜中，曾富春，甘崇志，丛伟，应用新型三分支主动脉弓覆膜支架治疗急性Stanford A型主动脉夹层的临床研究，四川医学，2011，32(2)：165-167
36. Crawford ES, Svensson LG, Coselli JS, et al. Surgical treatment of aneurysm and/or dissection ofthe ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch. Factorsinfluencing survival in717patients [J]. J Thorac Cardiovasc Surg1989,98(5Pt1):659-673;discussion673-654
37. Okita Y, Takamoto S, Ando M, et al.Mortality and cerebral outcome in patients who underwentaortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion:no relation of early death, stroke, and delirium to the duration of circulatory arrest [J]. J ThoracCardiovasc Surg1998,115(1):129-138
38. Kurimoto Y, Ito T, Harada R, et al. Fenestrated stent-graft placement can be an alternativemanagement for distal aortic arch disease [J]. Circulation2006,114(18):755-755
39. Yuan LX, Feng X, Jing ZP. Endovascular Repair of a Thoracic Arch Aneurysm With a FenestratedStent-Graft [J]. J Endovasc Ther2008,15(5):539-543
40. Kasprzak PM, Muller T, Loibnegger A, et al. Fenestrated and branched stent prostheses in the aorticarch: first experiences [J]. Gefasschirurgie2009,14(3):198-205
41. Sonesson B, Resch T, Allers M, et al. Endovascular total aortic arch replacement by in situ stentgraft fenestration technique [J]. J Vasc Surg2009,49(6):1589-1591
42. Inoue K, Hosokawa H, Iwase T, et al. Aortic arch reconstruction by transluminally placedendovascular branched stent graft [J]. Circulation1999,100(19Suppl):II316-321
43. Malina M, Resch T, Sonesson B. Evar and complex anatomy: An update on fenestrated andbranched stent grafts [J]. Scand J Surg2008,97(2):195-204
44. Wei G, Xin J, Yang D, et al. A new modular stent graft to reconstruct aortic arch [J]. Eur J VascEndovasc Surg2009,37(5):560-565
45. Ohrlander T, Sonesson B, Ivancev K, et al. The chimney graft: a technique for preserving orrescuing aortic branch vessels in stent-graft sealing zones [J]. J Endovasc Ther2008,15(4):427-432
46. Baldwin ZK, Chuter TA, Hiramoto JS, et al. Double-barrel technique for endovascular exclusion ofan aortic arch aneurysm without sternotomy [J]. J Endovasc Ther2008,15(2):161-165
47. Baldwin ZK, Chuter TA, Hiramoto JS, et al. Double-barrel technique for preservation of aortic archbranches during thoracic endovascular aortic repair [J]. Ann Vasc Surg2008,22(6):703-709
48. Kuratani T, Sawa Y. Current strategy of endovascular aortic repair for thoracic aortic aneurysms [J].General Thoracic and Cardiovascular Surgery2010,58(8):393-398.