夾層動(dòng)脈瘤雜交手術(shù)弓上分支轉(zhuǎn)流方式探討_1課件

1、夾層動(dòng)脈瘤雜交手術(shù)弓上分支轉(zhuǎn)流方式探討Aortic Arch Bypass in Hybrid Operation for Aortic Dissection Aneurysm,哈爾濱醫(yī)科大學(xué)附屬第二醫(yī)院血管外科姜維良,WEILIANG JIANGDept. of Vascular Surgery, 2nd Teaching Hosp.Harbin Medical University, Harbin, Heilongj

2、iang, China 150086,夾層動(dòng)脈瘤雜交手術(shù)弓上分支轉(zhuǎn)流Aortic Dissection Hybrid Operation with Arch Bypass,涉及主動(dòng)脈弓分支的夾層動(dòng)脈瘤，通過(guò)外科手術(shù)改變供血位置，可以創(chuàng)造出腔內(nèi)修復(fù)的條件，使得腔內(nèi)修復(fù)手術(shù)可以進(jìn)行。 Aortic Dissection involving arch braches can be repaired with the assistanc

3、e of the surgical operations alternating the vessel anatomy and creating optimal settings for endovascular repair.,病例資料 Cases,我科共完成主動(dòng)脈夾層EVAR 112例弓上分支轉(zhuǎn)流 6例5.3%（6/112）Totally 112 cases of TEVAR for aortic dissection we

4、re performed in our unit, 6 (5.3%)of which with auxiliary arch bypass,病例資料Cases,弓上分支轉(zhuǎn)流方式分類(lèi) Type of aortic arch bypass,1.同側(cè)轉(zhuǎn)位 頸動(dòng)脈-鎖骨下動(dòng)脈 目的：重建左側(cè)優(yōu)勢(shì)椎動(dòng)脈血流2.對(duì)側(cè)轉(zhuǎn)位 頸-頸-鎖骨下動(dòng)脈 目的：重建左頸動(dòng)脈\左鎖骨下動(dòng)脈3.升主動(dòng)脈轉(zhuǎn)流

5、 目的：重建弓上血運(yùn)1. Ipsilateral：Carotid A.-SCA. aim：to reconstruct the dominant vertebral A.2. Contralateral： Carotid - Carotid – SCA. aim：to reconstruct LCA. \L. SCA.3. Bypass of arch: aim：to reconst

6、ruct the arch branches,1.同側(cè)轉(zhuǎn)位 頸動(dòng)脈-鎖骨下動(dòng)脈 Ipsilateral bypass: Carotid A.-SCA.,1.鎖骨下動(dòng)脈-頸動(dòng)脈 端側(cè)吻合 （SCA-CA: end-to-side）2.頸動(dòng)脈-鎖骨下動(dòng)脈 人造血管轉(zhuǎn)流（CA-SCA: artificial graft bypass）,2.對(duì)側(cè)轉(zhuǎn)位 頸-頸-鎖骨下動(dòng)脈Contralateral Bypass: CA-CA

7、-SCA,合理的重建方法—盡量縮短頸動(dòng)脈阻斷時(shí)間Ideal methods should shorten the carotid blocking time,2.對(duì)側(cè)轉(zhuǎn)位 頸-頸-鎖骨下動(dòng)脈Contralateral Bypass：CA-CA-SCA,可能延長(zhǎng)頸動(dòng)脈阻斷時(shí)間的重建方式Styles that may prolong blocking time of carotid artery.,3.升主動(dòng)脈轉(zhuǎn)流,3. Bypa

8、ss involving ascending aorta,弓上分支轉(zhuǎn)位病例—同側(cè)轉(zhuǎn)流Case 1: arch branch translocation (Ipsilateral bypass),,,,BYPASS,Case 1,,,BYPASS,Case 1,,,BYPASS,Case 1,,,BYPASS,Case 1,,,BYPASS,Case 1,鎖骨下動(dòng)脈-頸動(dòng)脈轉(zhuǎn)流前后對(duì)比Effect of Bypass,←轉(zhuǎn)流前 Be

9、fore Bypass,轉(zhuǎn)流后→After Bypass,TEVAR手術(shù)后After TEVAR,Case 1,鎖骨下動(dòng)脈-頸動(dòng)脈 對(duì)端吻合(SCA-CA: end-to-end)右位主動(dòng)脈弓夾層動(dòng)脈瘤Case 2: aortic dissection with right sided aortic arch,瘺口位于弓頂，食道受壓，進(jìn)食困難。,Entry at the top of the arch, esophagus co

10、mpressed and dysphasia developed,Case 2,雙側(cè)鎖骨下動(dòng)脈發(fā)自降主動(dòng)脈雙側(cè)頸動(dòng)脈起自升主動(dòng)脈Bilateral SCA arise from descending aorta, bilateral carotid A. from ascending aorta.,Case 2,鎖骨下動(dòng)脈-頸動(dòng)脈同側(cè)轉(zhuǎn)流Ipsilateral Bypass from SCA to CA,Case 2,Angiog

11、raphy of After EVAR,Case 2,術(shù)后1個(gè)月復(fù)查CTA,術(shù)后CTA,CTA Follow-up @ 1m after TEVAR,Case 2,對(duì)側(cè)轉(zhuǎn)位 頸-頸-鎖骨下動(dòng)脈轉(zhuǎn)流Contralateral bypass：Carotid - Carotid – SCA.,頸-頸-鎖骨下動(dòng)脈人造血管轉(zhuǎn)流Carotid - Carotid – SCA：Artificial graft bypass,瘺口位于主動(dòng)脈弓

12、病例Case 3： entry on the arch,降主動(dòng)脈多發(fā)瘺口 左側(cè)血胸Multiple entry on descending aorta with left side hemothorax,,Case 3,弓上瘺口位置Entry on the arch,,Case 3,瘺口位于頸動(dòng)脈開(kāi)口附近Entry near Left Carotid Artery,,Case 3,,,Case 3,BYPASS,頸-頸動(dòng)脈

13、轉(zhuǎn)流+左頸鎖骨下動(dòng)脈側(cè)側(cè)吻合CA-CA bypass+L. CA-SCA side-side anastomosis,,,,Case 3,TEVAR,,,Case 3,Closed hemothorax drainage,主動(dòng)脈夾層伴左側(cè)頸動(dòng)脈受累病例Case 4: aortic dissection with left carotid artery involvement,瘺口位置 entry position,,Case 4,

14、,,Case 4,BYPASS,頸頸轉(zhuǎn)流+頸鎖骨下對(duì)端吻合CA-CA bypass + CA-SCA end-end anastomosis,,Case 4,總結(jié)summary,1.頸部雜交手術(shù)可以對(duì)瘺口位于主動(dòng)脈弓的夾層進(jìn)行TEVAR手術(shù)2.手術(shù)并發(fā)癥發(fā)生率相對(duì)較低3.轉(zhuǎn)流方式可以根據(jù)患者情況個(gè)體化選擇4.防止并發(fā)癥發(fā)生的要點(diǎn)是盡量縮短頸動(dòng)脈阻斷時(shí)間①Carotid hybrid operations make TE

15、VAR procedure safe and possible for the aortic dissections with arch entries. ②With relatively low complication rate, ③the procedure can be customized for individual patient.④Key point for complication prevention is t