主動(dòng)脈疾病的治療進(jìn)展與挑戰(zhàn)劉永民

1、主動(dòng)脈疾病的治療進(jìn)展與挑戰(zhàn),升主動(dòng)脈_根部主動(dòng)脈弓_頭臂動(dòng)脈胸降主動(dòng)脈_肋間動(dòng)脈腹主動(dòng)脈_四大分支,正常主動(dòng)脈的解剖,主動(dòng)脈疾病分類(lèi),狹窄性主動(dòng)脈疾病先天性－ 瓣上狹窄 主動(dòng)脈縮窄 后天性 －大動(dòng)脈炎 動(dòng)脈硬化擴(kuò)張性主動(dòng)脈疾病真性主動(dòng)脈瘤主動(dòng)脈夾層假性主動(dòng)脈瘤,主動(dòng)脈縮窄,嬰兒型主動(dòng)脈縮窄 合并心臟畸形成人型主動(dòng)脈縮窄 合并主動(dòng)脈弓部

2、、根部病變,主動(dòng)脈夾層的傳統(tǒng)分型,,Stanford A, B DeBakey Ⅰ Ⅱ Ⅲ,根部細(xì)化分型的方法,A1型：竇部正常型 竇管交界及近端正常 無(wú)主動(dòng)脈瓣關(guān)閉不全A2型：根部輕度受累型 竇部小于3.5cm 夾層累及右冠狀動(dòng)脈 主動(dòng)脈瓣交界撕脫致主動(dòng)脈瓣關(guān)閉不全A3型：根部重度受累型 竇部大于5cm 或3.5--5厘米但竇管交界結(jié)構(gòu)破壞 有嚴(yán)重主動(dòng)脈瓣關(guān)閉不全,7,主動(dòng)脈

3、弓部的細(xì)化分型方法,C型(復(fù)雜型) 逆行剝離 弓/弓遠(yuǎn)端動(dòng)脈瘤 頭臂動(dòng)脈夾層 馬凡氏綜合征S型(單純型) 原發(fā)內(nèi)膜破口—升主動(dòng)脈,新分型的臨床意義（ 1 ）,確定手術(shù)時(shí)機(jī)A型夾層___積極進(jìn)行手術(shù)治療A1型 病情較緩 多不需要緊急手術(shù)A2和A3型病人 多需緊急手術(shù) 心包積血 —心臟壓塞—低心排 冠狀動(dòng)脈受累—急性心肌供血障礙

4、 嚴(yán)重主動(dòng)脈瓣關(guān)閉不全—急性左心衰竭,新分型的臨床意義（2）,確定手術(shù)方式 A1型：保留竇部 升主動(dòng)脈及其遠(yuǎn)端的替換,,新分型的臨床意義（2）,確定手術(shù)方式 A2型：根部成形為最佳選擇： David手術(shù) 單竇或兩個(gè)竇替換 +/- 冠狀動(dòng)脈開(kāi)口移植 或CABG,,新分型的臨床意義（2）,確定手術(shù)方式A3型—主動(dòng)脈根部替換術(shù),,12,新分型的臨床意義（2）,確定手術(shù)方

5、式C型—主動(dòng)脈弓替換+支架象鼻手術(shù)S型—保留主動(dòng)脈弓,13,全弓替換術(shù),14,,升主動(dòng)脈替換,新分型的臨床意義（3）,初步判定預(yù)后 A1型 A2型 A3型 C型 S型 手術(shù)難度 + +++ + +++ + 手術(shù)風(fēng)險(xiǎn) + +++ + +++ + 假性動(dòng)脈瘤 - + - 抗凝 -

6、 - + 生存質(zhì)量 好 較好 較差 好 較差,B型主動(dòng)脈夾層的改良分型,分型依據(jù)主動(dòng)脈弓部有無(wú)受累降主動(dòng)脈的擴(kuò)張部位,弓部有無(wú)受累,BC型（Complicated） 夾層累及左鎖骨下動(dòng)脈及遠(yuǎn)端主動(dòng)脈弓部 BS型（Simple） 遠(yuǎn)端主動(dòng)脈弓部未受累 夾層位于左鎖骨下動(dòng)脈開(kāi)口遠(yuǎn)端,根據(jù)降主動(dòng)脈擴(kuò)張部位將其分成三個(gè)亞型,B1型（降主動(dòng)脈近端型）B2型（全胸降主動(dòng)脈型）

7、B3型（全胸降主動(dòng)脈、腹主動(dòng)脈型）,,該分型的臨床意義,,主動(dòng)脈外科的治療進(jìn)展,----雜交技術(shù),弓部分支間搭橋升主動(dòng)脈—弓部分支搭橋,+,帶膜支架植入,,主動(dòng)脈外科的治療進(jìn)展,介入材料開(kāi)發(fā)--開(kāi)孔和分支帶膜支架,可用于有重要分支部位 操作復(fù)雜 成功率低 推廣受限,基礎(chǔ)研究方面----臟器保護(hù)和血液保護(hù)外科手術(shù)----手術(shù)時(shí)機(jī)的選擇

8、 適應(yīng)證擴(kuò)展 手術(shù)方式的改進(jìn)介入治療----適應(yīng)證擴(kuò)展 材料研制,主動(dòng)脈外科的熱點(diǎn)問(wèn)題,23,主動(dòng)脈外科面臨的挑戰(zhàn),發(fā)病率上升----夾層最突出急性期夾層比例增加二次或多次手術(shù)比例增加巨大和廣泛動(dòng)脈瘤比例增加老年患者比例增加血液和血制品減少止血藥物減少,Surgical Repair of 2500 Aortic Diseases,(Jan.19

9、94－Dec.2008) 劉永民Center of Aortic Surgery,,,,the UK cardiac surgical register reported mortality rates in 200014.6% for aortic root operation28% for aortic arch replacement31.5% for descending aorta repair,Nati

10、onal adult cardiac surgical database report 2000–001. http://www.scts.org/sections/audit/Cardiac/index.html. Accessed June 1, 2006.,History of aortic surgery,In 1950’s Surface hypothermia：replacement of partial or

11、total aortic arch,In 1960CPB: resection of aortic aneurism,History of aortic surgery,Clinic data of aortic dissection,(10/48),(29/581),(8/29),(9/376),Type A,Type B,Clinic data of aortic aneurysm,(12/76),(6/392),(4/43)

12、,(2/136),(8/45),(8/216),AR,AA,DA,Center of Aortic Surgery,Half of this year: 240 aortic operations The total number: > 2,000 (since 1994)Total mortality: about 3%,Open surgical repair of 1782 Aortic disease pa

13、tients,1782 aortic disease patients (55/1782 3.09%),,survivors,death,False aneurysm （2/64 3.02%）,True aneurysm （15/741 2.02%）,dissection（38/977 3.89%）,54%,939,38,4%,42%,726,15,62,2,,,,977 aortic dissections,977 patie

14、nts (38/977 3.89%),survivors,death,38%,62%,572,29,367,9,(29/581 4.83%),Stanford type B,Stanford type A,(9/376 2.39%),,,,,Stanford type Ac (Complex subtype),Total aortic replacement,Stanford type B1s Dissection intervent

15、ional treatment,,Stanford type B1 and B2 Dissection,Descending aortic replacement + mini stented elephant trunk,Partial descending aortic replacement combined with stented ET,Pre,Post,The operation for Failed Interv

16、entional Therapy,Endovascular treatment for Stanford type B1S dissection Using proper stent-graft；Soft hand and preventing endoleak,741 True Aneurysms Operation,Root and extensive aneurysm, most see in Marfan syndrom

17、eascending aneurysm, most see in aortic valve diseaseArch aneurysm, most see in congenital disease and valve diseaseDescending and abdominal aneurysm , most see in hypertension and arteriosclerosis disease,Resul

18、ts 5-year survival (unoperated pts) 54% Aneurysms > 6 cm, yearly rupture/dissection 6.4% yearly mortality

19、 10.8% Elective/preemptive surgery restored life-expectancy to normal,Yearly Rupture/Dissection Rates forThoracic Aortic Aneurysms,,Davies et al, Presented at 2001 ST

20、S,,Size Criteria of Surgical Intervention for Asymptomatic Aortic Aneurysms,Elefteriades ATS 2002,Aortic Root Replacement by Ministernotomy,,,Pseudoaneurysm Operation Data,TAAR：total aortic arch replacement; TH-AR:

21、Thoracoabdominal aortic replacement；STT：stented technique;AAR: ascending aortic replacement; TAR: total aortic replacement; IT：interventional therapy; STAAR：subtotal aortic arch replacement; DAR: descending aortic repla

22、cement,16 patients, no death , two minor endoleak,Interventional Therapy,less invasive, effective, and safety,,,,,,,Pseudo-aneurysm,,,closure using 10/7mm Plug device,Milestones in China,Aortic arch replacement with sten

23、ted elephant trunk,Entire aortic replacement in one stage,,,Milestones in China,,,,,David procedure,Jacket of aortic root,Milestones in China,,,Bentall procedure by micro-incision,Stanford type A dissectionAortic root c

24、hange: A1、A2、A3Aortic arch: type C、 SStanford type B dissectionDilated range: B1、B2、B3Aortic arch: type C、type S,Modified classification of aortic dissection,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Nearly half of aorti

25、c operations in china were done,,超聲在主動(dòng)脈外科中的作用,二維超聲和多普勒技,以及經(jīng)食道超聲探頭等綜合超聲技術(shù)對(duì)主動(dòng)脈各段及其主要分支的系統(tǒng)觀察，使超聲這種簡(jiǎn)便的，可用于床旁的技術(shù)從特定的檢查室走進(jìn)了急診室、導(dǎo)管室與手術(shù)室，全面介入了主動(dòng)脈疾病的術(shù)前診斷、術(shù)中監(jiān)測(cè)及術(shù)后隨訪(fǎng),50,主動(dòng)脈瘤的超聲診斷,特征性改變是某段主動(dòng)脈腔的擴(kuò)張（> 50％為動(dòng)脈瘤)升主動(dòng)脈瘤以竇部擴(kuò)張為主，蒜頭樣改變常為馬凡

26、， 伴有主動(dòng)脈瓣或二尖瓣脫垂更有利于診斷主動(dòng)脈瓣異常如二瓣化，交界粘連，瓣口狹窄或偏心動(dòng)脈硬化或大動(dòng)脈炎所致動(dòng)脈瘤以胸腹主動(dòng)脈較多見(jiàn)先天性或后天性主動(dòng)脈峽部狹窄后擴(kuò)張形成的動(dòng)脈瘤升主動(dòng)脈直徑大于50mm者應(yīng)考慮手術(shù)治療馬凡，或合并明顯瓣膜損害時(shí)，>45mm應(yīng)積極處理,51,假性動(dòng)脈瘤的超聲診斷,假性動(dòng)脈瘤的瘤壁為機(jī)化血栓與周?chē)鞴倩蚪M織粘連的纖維組織，瘤口即動(dòng)脈管壁上的破口，一般較小超聲上的特征是發(fā)現(xiàn)在動(dòng)脈旁

27、的異常搏動(dòng)性團(tuán)塊，有較確切邊界，瘤體內(nèi)部回聲與病程有關(guān)假性動(dòng)脈瘤與囊狀動(dòng)脈瘤在超聲影像上需要鑒別：瘤徑和血流主動(dòng)脈假性動(dòng)脈瘤多發(fā)生在弓降部，對(duì)假性動(dòng)脈診斷的敏感性及特異性均低于CT或MRI,52,主動(dòng)脈夾層的超聲診斷,無(wú)創(chuàng)診斷夾層動(dòng)脈瘤的主要方法之一，在急診情況下，快速甄別急性胸疼主動(dòng)脈內(nèi)探及搏動(dòng)性剝脫內(nèi)膜，膜片將受累血管分為真假兩腔TTE多可獲得滿(mǎn)意的圖像，胸降主動(dòng)脈經(jīng)胸探查不能獲得滿(mǎn)意圖像時(shí)，TEE檢查可獲得良好圖像，但對(duì)重

28、癥患者，需慎用TEE檢查提供主動(dòng)脈腔徑，瓣膜，心肌運(yùn)動(dòng)，心包和胸腔積液等信息，有利于分型，手術(shù)時(shí)機(jī)和方式選擇，預(yù)后的判斷等,53,大動(dòng)脈炎的超聲診斷,大動(dòng)脈炎是一種以中膜損害為主的非特異性全層動(dòng)脈炎，病變主要累及主動(dòng)脈及其分支，肺動(dòng)脈可被累及升主動(dòng)脈累及時(shí)多表現(xiàn)為動(dòng)脈擴(kuò)張胸主動(dòng)脈累及造成管腔狹窄時(shí)，超聲發(fā)現(xiàn)與主動(dòng)脈縮窄類(lèi)似的血流動(dòng)力學(xué)改變頸動(dòng)脈被累及時(shí)主要累及頸總動(dòng)脈，頸內(nèi)動(dòng)脈及頸外動(dòng)脈較少被累及,54,術(shù)中超聲的應(yīng)用,對(duì)動(dòng)脈管

29、壁結(jié)構(gòu)的觀察：動(dòng)脈硬化斑塊并確定其位置及范圍對(duì)主動(dòng)脈瓣的觀察：主動(dòng)脈瓣成形者，術(shù)后即刻觀察主動(dòng)脈瓣反流的矯正效果其他：包括人工血管是否存在吻合口漏，評(píng)價(jià)心臟功能，對(duì)進(jìn)行了冠狀動(dòng)脈吻合者，可評(píng)價(jià)室壁運(yùn)動(dòng)狀態(tài),55,小結(jié)：,與其他影像技術(shù)相比，對(duì)主動(dòng)脈疾患累及的范圍及主動(dòng)脈主要分支是否受累的觀察，超聲心動(dòng)圖不及 UFCT及MRI對(duì)真腔與假腔之間的血流交通、對(duì)判斷主動(dòng)脈瓣受累的程度及心臟的功能狀態(tài)有明顯的優(yōu)勢(shì)術(shù)中監(jiān)測(cè)及手術(shù)后的長(zhǎng)期隨訪(fǎng)