覆膜血管支架治疗DebakeyⅢ型主动脉夹层临床分析
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摘要
目的:主动脉夹层(Aortic dissection ,AD)是目前临床上较为常见且具有灾难性的疾病,随着综合性无创影像学诊断技术日趋先进,主动脉夹层患者诊断得到不断提高。主动脉夹层在我国的发病率呈现逐年上升趋势,多数病例起病后数小时至数天内死亡,未得到及时治疗者在24小时内死亡为24%[1-2]。目前主动脉夹层的高发病率和高死亡率已经引起我们临床医生的高度重视。通过总结经皮主动脉内覆膜血管支架治疗DebakeyⅢ型主动脉的疗效,使我们今后诊断和治疗DebakeyⅢ型主动脉夹层得到进一步提高。
方法:采用回顾性临床病例分析方法,总结2008年9月～2009年12月河北医科大学第二医院心脏外科18例DebakeyⅢ型主动脉夹层患者,分析经皮主动脉内覆膜支架技术治疗DeBakeyⅢ型主动脉夹层的临床资料,来进一步提高我们对经皮主动脉内覆膜血管支架治疗DebakeyⅢ型主动脉夹层认识。
结果:18例DebakeyⅢ型主动脉夹层患者,17例覆膜支架释放均成功, 1例患者于支架置入后8 h突然死亡,考虑为远端夹层动脉瘤破裂所致。1例患者未成功,原因为该患者股动脉和髂动脉存在狭窄畸形,股动脉和髂动脉的直径无法通过覆膜血管支架传输系统。其余患者主动脉内覆膜血管支架置入后胸背部疼痛消失,无器官缺血、血栓形成等并发症发生。
结论:主动脉夹层临床表现复杂多样,常易误诊,临床医师应充分认识主动脉夹层的特征,及早诊断,迅速治疗,以尽快挽救病人生命。经皮主动脉内覆膜血管支架是治疗DebakeyⅢ型主动脉夹层的有效方法,需合理选择适应证,术前、后应合理控制血压。经皮主动脉内覆膜血管支架治疗DebakeyⅢ型主动脉夹层近期效果满意,但远期效果有待进一步察。
Objective: In the current clinical , Aortic dissection is relatively common and to possess catastrophic disease,As a comprehensive non-invasive imageing diagnostic technology become more advanced,The diagnosis of patients with Aortic dissection has been constantly improving, The incidence of patients with Aortic dissection present an upward trend year by year in our country,Most cases after onset die within a few hours to several days, The patients did not receive timely treatment within 24 hours, the mortality rate was 24% High morbidity and mortality of patients with Aortic dissection have been attached great importance to clinicians,To summarize the efficacy of endovascular stent-graft placement for the treatment of debakeyⅢtype aortic dissection,The diagnosis and treatment of debakeyⅢtype aortic dissection will be further improved in our future.
Methods: To summarize the patient who is in the cardiac surgery of hebei medical university second hospital in the between Septement 2008～December 2009,by the method of retrospective analysis. To analyze the clinical data of 18 cases of endovascular stent-graft placement for the treatment of debakeyⅢtype aortic dissection. To improve the recongnition on endovascular stent-graft placement for the treatment of debakeyⅢtype aortic dissection.
Results: 18 cases patient of debakeyⅢtype aortic dissection, 17 cases patient successfully carry out endovascular stent-graft placement, one case patient suddenly die after 8 houre in endovascular stent-graft placemen, the reason consider distal aortic dissection aneurysm rupture. one case patient unsuccessfully carry out endovascular stent-graft placement,the reason is the exist stenotic malformation of femoral artery and iliac artery, The diameter of femoral artery iliac artery did not pass through system of endovascular stent-graft. others patient pain of dorsal part of chest was obliterate afte endovascular stent-graft placement, No organ ischemia, thrombosis and other complications occurred.
Conclusions: Clinical manifestations of patients with Aortic dissection are diverse and complex often misdiagnosed Clinicians should fully understand the characteristics of patients with aortic dissection, Early diagnosis, Quick treatment, In order to save the patient's life as soon as possible.Endovascular stent-graft placement is effective for the treatment of debakeyⅢtype aortic dissection .however,proper indications should be selected and blood pressure should be appropriately controlled before and after the operation.Short-term effect of percutaneous endovascular stent-graft placement for patient of debakeyⅢtype aortic dissection is satisfactory,However,further studies are needed to evaluate its long-term outcomes.
方法:采用回顾性临床病例分析方法,总结2008年9月～2009年12月河北医科大学第二医院心脏外科18例DebakeyⅢ型主动脉夹层患者,分析经皮主动脉内覆膜支架技术治疗DeBakeyⅢ型主动脉夹层的临床资料,来进一步提高我们对经皮主动脉内覆膜血管支架治疗DebakeyⅢ型主动脉夹层认识。
结果:18例DebakeyⅢ型主动脉夹层患者,17例覆膜支架释放均成功, 1例患者于支架置入后8 h突然死亡,考虑为远端夹层动脉瘤破裂所致。1例患者未成功,原因为该患者股动脉和髂动脉存在狭窄畸形,股动脉和髂动脉的直径无法通过覆膜血管支架传输系统。其余患者主动脉内覆膜血管支架置入后胸背部疼痛消失,无器官缺血、血栓形成等并发症发生。
结论:主动脉夹层临床表现复杂多样,常易误诊,临床医师应充分认识主动脉夹层的特征,及早诊断,迅速治疗,以尽快挽救病人生命。经皮主动脉内覆膜血管支架是治疗DebakeyⅢ型主动脉夹层的有效方法,需合理选择适应证,术前、后应合理控制血压。经皮主动脉内覆膜血管支架治疗DebakeyⅢ型主动脉夹层近期效果满意,但远期效果有待进一步察。
Objective: In the current clinical , Aortic dissection is relatively common and to possess catastrophic disease,As a comprehensive non-invasive imageing diagnostic technology become more advanced,The diagnosis of patients with Aortic dissection has been constantly improving, The incidence of patients with Aortic dissection present an upward trend year by year in our country,Most cases after onset die within a few hours to several days, The patients did not receive timely treatment within 24 hours, the mortality rate was 24% High morbidity and mortality of patients with Aortic dissection have been attached great importance to clinicians,To summarize the efficacy of endovascular stent-graft placement for the treatment of debakeyⅢtype aortic dissection,The diagnosis and treatment of debakeyⅢtype aortic dissection will be further improved in our future.
Methods: To summarize the patient who is in the cardiac surgery of hebei medical university second hospital in the between Septement 2008～December 2009,by the method of retrospective analysis. To analyze the clinical data of 18 cases of endovascular stent-graft placement for the treatment of debakeyⅢtype aortic dissection. To improve the recongnition on endovascular stent-graft placement for the treatment of debakeyⅢtype aortic dissection.
Results: 18 cases patient of debakeyⅢtype aortic dissection, 17 cases patient successfully carry out endovascular stent-graft placement, one case patient suddenly die after 8 houre in endovascular stent-graft placemen, the reason consider distal aortic dissection aneurysm rupture. one case patient unsuccessfully carry out endovascular stent-graft placement,the reason is the exist stenotic malformation of femoral artery and iliac artery, The diameter of femoral artery iliac artery did not pass through system of endovascular stent-graft. others patient pain of dorsal part of chest was obliterate afte endovascular stent-graft placement, No organ ischemia, thrombosis and other complications occurred.
Conclusions: Clinical manifestations of patients with Aortic dissection are diverse and complex often misdiagnosed Clinicians should fully understand the characteristics of patients with aortic dissection, Early diagnosis, Quick treatment, In order to save the patient's life as soon as possible.Endovascular stent-graft placement is effective for the treatment of debakeyⅢtype aortic dissection .however,proper indications should be selected and blood pressure should be appropriately controlled before and after the operation.Short-term effect of percutaneous endovascular stent-graft placement for patient of debakeyⅢtype aortic dissection is satisfactory,However,further studies are needed to evaluate its long-term outcomes.
引文
1 Kieffer E. Dissection of the descending thoracic aorta. In: Rutherford RB.Vasc Surg, 2000,11:10-15
2 Hagan PG,Nienaber CA, Isselbacher EM, et al. The International Registry of A2cute Aortic Dissection ( IRAD) :new insights into an old disease. JAMA,2000,283: 897-903
3 Khan IA. Clinical manifestations of aortic dissection. J Clin Basic Cardiol,2001,4:265-267
4 Kato N, Shimono T, Hirano T, et al. Midterm results of stent-graft repair of acute and chronic aortic dissection with descending tear: thecomp lication2specific app roach. J Thorac Cardiovasc Surg, 2002,124: 306-312
5 JingZP,FengX, BaoJM, et al. Endovascular stent-graft exclusion forstanford B type aortic dissections: a report of 146 patients.Chin JSurg, 2003,7(41):483-486
6 GreenbergR,KhwajaJ,HaulonS,et al.Aorticdissection newpers pective and treatment paradigms.EurJ Vasc Endo- vasc Surg,2003,26:579
7 Nienaber CA , Eagle KA1 Aortic dissection : new frontiers indiagnosis and management:PartI:from etiology to diagnosticst rategies Circulation,2003, 108 (5) :628-635
8景在平,冯翔,包俊敏等.腔内隔绝术治疗Stanford B型主动脉夹层动脉瘤146例临床分析.中华外科杂志,2003,7(41):483-486
9 Leurs LJ ,Bell R ,Degrieck Y,et al. Endovasculart reatment of thoracic aortic disease:combined experience from the EUROSTAR and United King Thoracic Endograf t regist ries. J Vasc Surg ,2004 ,40 :670-679
10黄连军,孙立忠,朱俊明等.带膜血管内支架置入治疗胸主动脉夹层.中华心血管病杂志,2004,32:141-143
11 Bortone AS, De CillisE, D’Agostino D, et al. Endovasculatreatment of thoracic aortic disease: four years of experience.Circulation,2004,110:262
12 Duebener LF,Lorenzen P,Richardt G,et al.Emergency endovascular stent - grafting for life-threatening acute type B aortidissection.Ann ThoracSurg,2004,78:1261
13 Hogan CJ. An aortic dissection in a young weightlifter with non-Marfan fibrillinopat hy 1 Emerg Med J ,2005 ,22 ( 4) :3042-3051
14 Rothwell PM, Giles MF, Flossmann E, et al. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischemic attack.Lancet,2005,366(9479):29-36
15 Wang ZG, Li C. Single2branch endograft for treating stanford type B aortic dissections with entry tears in p roximity to the left subclavian artery . J Endovasc Ther, 2005, 12 (5) : 588-593
16 Tsai TT,Bossone E,Isselbacher EM,et al.Clinical characteristics of hypotension in patients with acute aortic dissection. Am JCardiol ,2005 , 95 :48
17 Eggebrecht H,Nienaber CA,Neuhauser M,et al.Endovascular stent-graft placement in aortic dissection:ameta-analysis .Eur Heart J,2006,27(4):489
18 Sbarzaglia P,Lovato L,Buttazzi K,etal.Interventional techniques in the treatment of aortic dissection[J].Radiol Med, 2006,111(4):585
19李潮,李玉亮,汪忠镐等.分支型腔内支架人工血管治疗B型主动脉夹层[ J ].中华胸心血管外科杂志, 2006, 22 ( 3 ) : 152 -154
20 Ince H , Nienaber CA. Diagnosis and management of patient swith aortic dissection. Heart , 2007 , 93 :266
21刘冬生,叶键烽,赵红磊等.覆膜支架血管腔内置入治疗主动脉夹层12例体会江西医药2008, 43(9),925-926
22沈菲,苏唏,朱汉东等.经皮主动脉内覆膜支架技术治疗DeBakeyⅢ型主动脉夹层内科急危重症杂志,2009,15(2):76-79
1 Carpentier A,Louimet D,Aupeele B,et a1.Computer assisted open heart surgery.First case operated on with SUCCESS[J].CR Aead Sei Ul,1998,321(5):437-442
2 Chu JJ , Chang CH,L in PJ , et al. V ideo-assisted cardiac surgery:p relim inary results in Chan M em irial Ho sp ital[J ]. Ch in M ed J(E ng 1) , 1998, 111 (5) : 422- 427
3 L in PJ, Chang CH, Chu JJ, et a1. minimally invasive cardiac surgical techniques in the clsure of ventricular sep tal defect: an laternative app roach [ J ]. Ann Thorac Surg, 1998, 65 ( 2) : 165-168
4 Laborde F,No irhomme P, Karam J , et al. A new video-assisted thoracop ic surgical techique for interuption of patent ductusarterio susinntants and children. J Thorac Cardiovasc Surg,1999, 105 (2) : 278
5 Liu YL ,Zhang HJ,Sun SH ,etal.Repair of cardiac defects through a shorter right lateral thoracotomy in children:current .Ann Thopa surgy ,2000,70:739-741
6曾建业,电视胸腔镜手术治疗动脉导管未闭的研究进展.广西医学, 2000, 22 (1) : 86-88
7 Miyaji K, Hannan RL , Ojito J , et al. Video - assisted cardioscopyn for intrcuentyicular repair in congenital heart disease. Ann ThoracSurg , 2000 ;70 (3) : 730-737
8梁智星,梁法禹,郭建军等.电视胸腔镜下动脉导管未闭手术.ClinicalM edicine of China, 2001,6(17):438
9 Torracca I,Lsmeno G,Alfieri 0.Totally endoscopic computerenhanced atrial septal defect clousure in six patients[J3.Ann Thor Surg,2001,72(4):1354-1357
10 Felger JE.Chitwoed wR Jr,Nifong LW,et d.Evdutim 0f mitral valve surgery:toward a totally endoscopic approach .Ann Thorac Sllrg,2001,72:1203-1209
11翁国星,谢琦,王欢等,电视胸腔镜下动脉导管钳闭86例. Chin J Thorac Cardiovasc Surg ,December 2002 ,18:374
12 Nifong L W,Chu V F,Bailey B M et a1.Robotic Mitral Valve Repair:experience with the da Vinie system.Ann Thorac Surg,2003,75(2):438-442
13 Mehmanesh H, Henze R, Lange R. Totally endoscopic mitral valve repair. J Thorac Cardiovasc Surg, 2002, 123(1):96- 97
14 Argenziano M Williams MR.Robotic artrial septal defect repair and endoscopic treatment of atrial fibrillation.semin Thoral Cardio Surg,2003,15:130-140
15肖明第.电视胸腔镜发展现状.中国微创外科杂志,2004,4:356-357.
16 Eichenspumer H,Detter C,Deuse T,et at.Video and robotic.assisted minimally invasive mitral valve surgery:a comparison of the Port Access and transthoracic clamp techniques.Ann Thorac Surg,2005,79:485-491
17李乃斌,张宏伟,晁栋等.电视胸腔镜手术治疗动脉导管未闭16例.Ch in J Clin Thorac Cardiovasc Surg, April 2005, 12:127-128
18 Chitwood WR Jr.Current status of endoscopic and robotic mitral valve surgery.Ann Thorac Surg , 2005,79:2248-2253
19程云阁,王跃军,顾剑民等.全胸腔镜下二尖瓣置换术临床经验总结.岭南心血管病杂志,2007,13:321- 323
20程云阁,王跃军,顾剑民等.完全胸腔镜下体外循环心脏手术674例临床分析.中华外科杂志,2007,45:1521- 1523
21段大为,李彤等.国内胸腔镜心脏手术临床应用进展.Medical Innovation of China February 2009.6:100-101
2 Hagan PG,Nienaber CA, Isselbacher EM, et al. The International Registry of A2cute Aortic Dissection ( IRAD) :new insights into an old disease. JAMA,2000,283: 897-903
3 Khan IA. Clinical manifestations of aortic dissection. J Clin Basic Cardiol,2001,4:265-267
4 Kato N, Shimono T, Hirano T, et al. Midterm results of stent-graft repair of acute and chronic aortic dissection with descending tear: thecomp lication2specific app roach. J Thorac Cardiovasc Surg, 2002,124: 306-312
5 JingZP,FengX, BaoJM, et al. Endovascular stent-graft exclusion forstanford B type aortic dissections: a report of 146 patients.Chin JSurg, 2003,7(41):483-486
6 GreenbergR,KhwajaJ,HaulonS,et al.Aorticdissection newpers pective and treatment paradigms.EurJ Vasc Endo- vasc Surg,2003,26:579
7 Nienaber CA , Eagle KA1 Aortic dissection : new frontiers indiagnosis and management:PartI:from etiology to diagnosticst rategies Circulation,2003, 108 (5) :628-635
8景在平,冯翔,包俊敏等.腔内隔绝术治疗Stanford B型主动脉夹层动脉瘤146例临床分析.中华外科杂志,2003,7(41):483-486
9 Leurs LJ ,Bell R ,Degrieck Y,et al. Endovasculart reatment of thoracic aortic disease:combined experience from the EUROSTAR and United King Thoracic Endograf t regist ries. J Vasc Surg ,2004 ,40 :670-679
10黄连军,孙立忠,朱俊明等.带膜血管内支架置入治疗胸主动脉夹层.中华心血管病杂志,2004,32:141-143
11 Bortone AS, De CillisE, D’Agostino D, et al. Endovasculatreatment of thoracic aortic disease: four years of experience.Circulation,2004,110:262
12 Duebener LF,Lorenzen P,Richardt G,et al.Emergency endovascular stent - grafting for life-threatening acute type B aortidissection.Ann ThoracSurg,2004,78:1261
13 Hogan CJ. An aortic dissection in a young weightlifter with non-Marfan fibrillinopat hy 1 Emerg Med J ,2005 ,22 ( 4) :3042-3051
14 Rothwell PM, Giles MF, Flossmann E, et al. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischemic attack.Lancet,2005,366(9479):29-36
15 Wang ZG, Li C. Single2branch endograft for treating stanford type B aortic dissections with entry tears in p roximity to the left subclavian artery . J Endovasc Ther, 2005, 12 (5) : 588-593
16 Tsai TT,Bossone E,Isselbacher EM,et al.Clinical characteristics of hypotension in patients with acute aortic dissection. Am JCardiol ,2005 , 95 :48
17 Eggebrecht H,Nienaber CA,Neuhauser M,et al.Endovascular stent-graft placement in aortic dissection:ameta-analysis .Eur Heart J,2006,27(4):489
18 Sbarzaglia P,Lovato L,Buttazzi K,etal.Interventional techniques in the treatment of aortic dissection[J].Radiol Med, 2006,111(4):585
19李潮,李玉亮,汪忠镐等.分支型腔内支架人工血管治疗B型主动脉夹层[ J ].中华胸心血管外科杂志, 2006, 22 ( 3 ) : 152 -154
20 Ince H , Nienaber CA. Diagnosis and management of patient swith aortic dissection. Heart , 2007 , 93 :266
21刘冬生,叶键烽,赵红磊等.覆膜支架血管腔内置入治疗主动脉夹层12例体会江西医药2008, 43(9),925-926
22沈菲,苏唏,朱汉东等.经皮主动脉内覆膜支架技术治疗DeBakeyⅢ型主动脉夹层内科急危重症杂志,2009,15(2):76-79
1 Carpentier A,Louimet D,Aupeele B,et a1.Computer assisted open heart surgery.First case operated on with SUCCESS[J].CR Aead Sei Ul,1998,321(5):437-442
2 Chu JJ , Chang CH,L in PJ , et al. V ideo-assisted cardiac surgery:p relim inary results in Chan M em irial Ho sp ital[J ]. Ch in M ed J(E ng 1) , 1998, 111 (5) : 422- 427
3 L in PJ, Chang CH, Chu JJ, et a1. minimally invasive cardiac surgical techniques in the clsure of ventricular sep tal defect: an laternative app roach [ J ]. Ann Thorac Surg, 1998, 65 ( 2) : 165-168
4 Laborde F,No irhomme P, Karam J , et al. A new video-assisted thoracop ic surgical techique for interuption of patent ductusarterio susinntants and children. J Thorac Cardiovasc Surg,1999, 105 (2) : 278
5 Liu YL ,Zhang HJ,Sun SH ,etal.Repair of cardiac defects through a shorter right lateral thoracotomy in children:current .Ann Thopa surgy ,2000,70:739-741
6曾建业,电视胸腔镜手术治疗动脉导管未闭的研究进展.广西医学, 2000, 22 (1) : 86-88
7 Miyaji K, Hannan RL , Ojito J , et al. Video - assisted cardioscopyn for intrcuentyicular repair in congenital heart disease. Ann ThoracSurg , 2000 ;70 (3) : 730-737
8梁智星,梁法禹,郭建军等.电视胸腔镜下动脉导管未闭手术.ClinicalM edicine of China, 2001,6(17):438
9 Torracca I,Lsmeno G,Alfieri 0.Totally endoscopic computerenhanced atrial septal defect clousure in six patients[J3.Ann Thor Surg,2001,72(4):1354-1357
10 Felger JE.Chitwoed wR Jr,Nifong LW,et d.Evdutim 0f mitral valve surgery:toward a totally endoscopic approach .Ann Thorac Sllrg,2001,72:1203-1209
11翁国星,谢琦,王欢等,电视胸腔镜下动脉导管钳闭86例. Chin J Thorac Cardiovasc Surg ,December 2002 ,18:374
12 Nifong L W,Chu V F,Bailey B M et a1.Robotic Mitral Valve Repair:experience with the da Vinie system.Ann Thorac Surg,2003,75(2):438-442
13 Mehmanesh H, Henze R, Lange R. Totally endoscopic mitral valve repair. J Thorac Cardiovasc Surg, 2002, 123(1):96- 97
14 Argenziano M Williams MR.Robotic artrial septal defect repair and endoscopic treatment of atrial fibrillation.semin Thoral Cardio Surg,2003,15:130-140
15肖明第.电视胸腔镜发展现状.中国微创外科杂志,2004,4:356-357.
16 Eichenspumer H,Detter C,Deuse T,et at.Video and robotic.assisted minimally invasive mitral valve surgery:a comparison of the Port Access and transthoracic clamp techniques.Ann Thorac Surg,2005,79:485-491
17李乃斌,张宏伟,晁栋等.电视胸腔镜手术治疗动脉导管未闭16例.Ch in J Clin Thorac Cardiovasc Surg, April 2005, 12:127-128
18 Chitwood WR Jr.Current status of endoscopic and robotic mitral valve surgery.Ann Thorac Surg , 2005,79:2248-2253
19程云阁,王跃军,顾剑民等.全胸腔镜下二尖瓣置换术临床经验总结.岭南心血管病杂志,2007,13:321- 323
20程云阁,王跃军,顾剑民等.完全胸腔镜下体外循环心脏手术674例临床分析.中华外科杂志,2007,45:1521- 1523
21段大为,李彤等.国内胸腔镜心脏手术临床应用进展.Medical Innovation of China February 2009.6:100-101