夾層動脈瘤雜交手術(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,涉及主動脈弓分支的夾層動脈瘤，通過外科手術(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 Type of aortic arch bypass,1.同側(cè)轉(zhuǎn)位 頸動脈-鎖骨下動脈 目的：重建左側(cè)優(yōu)勢椎動脈血流2.對側(cè)轉(zhuǎn)位 頸-頸-鎖骨下動脈 目的：重建左頸動脈\左鎖骨下動脈3.升主動脈轉(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 頸動脈-鎖骨下動脈 Ipsilateral bypass: Carotid A.-SCA.,1.鎖骨下動脈-頸動脈 端側(cè)吻合 （SCA-CA: end-to-side）2.頸動脈-鎖骨下動脈 人造血管轉(zhuǎn)流（CA-SCA: artificial graft bypass）,2.對側(cè)轉(zhuǎn)位 頸-頸-鎖骨下動脈Contralateral Bypass: CA-CA

7、-SCA,合理的重建方法—盡量縮短頸動脈阻斷時間Ideal methods should shorten the carotid blocking time,2.對側(cè)轉(zhuǎn)位 頸-頸-鎖骨下動脈Contralateral Bypass：CA-CA-SCA,可能延長頸動脈阻斷時間的重建方式Styles that may prolong blocking time of carotid artery.,3.升主動脈轉(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,鎖骨下動脈-頸動脈轉(zhuǎn)流前后對比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,鎖骨下動脈-頸動脈 對端吻合(SCA-CA: end-to-end)右位主動脈弓夾層動脈瘤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)鎖骨下動脈發(fā)自降主動脈雙側(cè)頸動脈起自升主動脈Bilateral SCA arise from descending aorta, bilateral carotid A. from ascending aorta.,Case 2,鎖骨下動脈-頸動脈同側(cè)轉(zhuǎn)流Ipsilateral Bypass from SCA to CA,Case 2,Angiog

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

12、病例Case 3： entry on the arch,降主動脈多發(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,瘺口位于頸動脈開口附近Entry near Left Carotid Artery,,Case 3,,,Case 3,BYPASS,頸-頸動脈

13、轉(zhuǎn)流+左頸鎖骨下動脈側(cè)側(cè)吻合CA-CA bypass+L. CA-SCA side-side anastomosis,,,,Case 3,TEVAR,,,Case 3,Closed hemothorax drainage,主動脈夾層伴左側(cè)頸動脈受累病例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)可以對瘺口位于主動脈弓的夾層進(jìn)行TEVAR手術(shù)2.手術(shù)并發(fā)癥發(fā)生率相對較低3.轉(zhuǎn)流方式可以根據(jù)患者情況個體化選擇4.防止并發(fā)癥發(fā)生的要點(diǎn)是盡量縮短頸動脈阻斷時間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