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【关键词】 升主动脉
随着血管腔内技术的迅猛发展和日趋成熟,主动脉疾病腔内修复术因其出色稳定的疗效、微创且低并发症而应用范围越来越广泛。从20世纪90年代初Volodos和Parodi[1~3]将其应用于临床至今将近20年,治疗病种更是从最初的腹主动脉瘤[4~6]发展到胸主动脉夹层、急性夹层、创伤性主动脉疾病、主动脉-支气管瘘、主动脉缩窄、感染性动脉瘤、主动脉-消化道瘘等多种疑难重症[7~16]。由于主动脉疾病患者多全身状况差、病情变化凶险,对开放性手术的耐受性差,故低死亡率、低副损伤的腔内技术[9,17~24]的确为患者和医生提供了一种更好的治疗方案选择。但是升主动脉和主动脉弓部却因为其解剖特点的特殊性一直是腔内技术的雷区。升主动脉起始部由主动脉瓣和冠状动脉发出,主动脉弓部有头臂干、左颈总、左锁骨下三大重要分支发出,支架移植物在这一区域的应用因而受到限制。但是每年胸主动脉瘤的发病率约为6/21万,有文献报道其中发生在根部及升主动脉的占45%,弓部占10%,降主动脉占35%,并且患者多高龄、合并多种疾病[23~25];胸主动脉夹层的年发病率约为100/10万人,其中累及升主动脉及主动脉弓的占2/3,在我国以40岁左右的青壮年急症患者居多,病情变化多凶险。面对如此高发病率以及患病人群的特点,如何能将腔内修复技术应用于升主动脉及弓部病变就成了世界血管外科学界研究的热点所在。总结目前世界上用以重建主动脉弓的腔内技术,可以归纳为两大类:(1)开放性手术与腔内修复相结合的“杂交”术式,该大类目前文献报道较多,又可划分为两支:①主动脉置换杂交术式;②非主动脉置换杂交术式;(2)单纯腔内重建术式,该大类由于技术难度高,对医者和病例选择性较强,故相关文献报道偏少。
1 开放性手术与腔内修复相结合的“杂交”术式
1.1 主动脉置换杂交术式 此种手术方式多为使用支架移植物重建弓的后半部和(或)降主动脉段,同时经过正劈胸骨等术式开胸进行全弓置换。1999年日本Koyanagi等[26]报道了1例Debaky Ⅲ型夹层累及弓部的62岁老年男性病例使用该种术式获得成功,当时他们选择开胸暴露的降主动脉段为支架移植物入路,并且需要全麻、低体温、停循环和选择性脑血管灌注。2005年Carroccio等[27]提出二期“象鼻”置换术,即先一期进行“象鼻”置换术,二期进行降主动脉腔内修复术,短期内收效良好。同年Greenberg等[28]报道了22例同步行象鼻置换术及腔内修复术的病例,其选择支架移植物入路为股动脉或髂动脉,该术式的死亡率及并发症率明显低于单纯外科手术组。此后该种技术日趋成熟,其死亡率及手术并发症率较全主动脉弓置换手术偏低[29,30],成为一种值得选择的治疗方案。但该术式仍需要进行开胸、低体温、停循环、选择性脑灌注等操作,相对于EVR来说其创伤和手术不良反应仍偏大。
1.2 非主动脉置换杂交术式 该大类主要手术方式是对妨碍支架移植物释放的重要脏器供血动脉,如头臂干、左颈总、左锁骨下等,进行解剖外旁路重建,在保证重要脏器血供的基础上同期对胸主动脉进行腔内修复术[31,32]。2000年Macierewicz等[33]报道了复杂肾上腹主动脉瘤的64岁老年男性病例成功应用腔内修复及脾脏、肠系膜上血管旁路重建术两步治疗,他们提出杂交术式对于因累及内脏动脉而不能单纯行EVR的复杂主动脉瘤来说是一个满意的选择。2001年Yano等[34]报道了2例同期进行左锁骨下动脉旁路术及胸主动脉腔内修复术的病例,技术成功、疗效满意。Schumacher等[35]报道了8例平均年龄71岁的高危主动脉弓部病变患者接受该种杂交术式的经验,所有患者均接受弓上重要分支的选择性旁路重建,为支架移植物释放创造适合的锚定区,技术成功率100%,无支架移位及锚定区漏,旁路通畅率满意。2004年Melissano等[36]报道了1例71岁老年男性病例,同时患有头臂干、主动脉弓、腹主动脉瘤,一期行腹主动脉瘤切除术后,二期行杂交手术:首先开胸暴露升主动脉,将分叉血管移植物与升主动脉行端侧吻合,然后分别将左锁骨下动脉、头臂干与两分叉行端端吻合,最后使用直径定做的Zenith主动脉支架进行腔内修复,术中使用全麻加硬膜外麻醉,实时脑电波描记监测脑灌注情况,没有使用深低温停循环操作,支架移植物形态好,将动脉瘤完全隔绝,无内漏发生,旁路通畅,术后2~3天时发生房颤和肺不张,保守治疗好转。上述手术方式以及目前经常提到的杂交术式[37~39]均使用的是无分叉型胸主动脉支架移植物,旁路重建头臂干时需要进行开胸操作,创伤仍偏大。Chuter等[40,41]2003年报道了1例使用分支型支架移植物成功治疗主动脉弓病变的病例。在该病例中,首先进行右颈总动脉-左颈总动脉转流以及左锁骨下-左颈总动脉转流术,而后以右颈总动脉为入路释放1枚分支型支架,支架的细长臂深入无名干,短粗臂进入主动脉内,再由股动脉导入一支架移植物与短粗臂连接,从而使用分叉支架移植物重建了主动脉弓[40,41]。2005年Guo W等[42]对1例B型夹层腔内修复术后逆行撕裂发生A型夹层的患者成功地进行了首例Standford A型夹层腔内重建主动脉弓的治疗。而由于使用分叉支架移植物的杂交术式相对于使用无分叉支架移植物的杂交术式创伤小、技术简洁,故我科研小组对其进行了深入的科研研究,并成功地完成了“模块分叉支架型血管重建主动脉弓的犬试验研究”[43],进一步的研究仍在进行当中。
2 单纯腔内重建术式该类术式
完全借助腔内技术及器械对主动脉弓进行血管内重建,对设计思路及术者有较严格的要求。1999年Kanji Inoue等[44]报道了通过使用带三个分支的支架移植物重建主动脉弓的病例15例。他们通过套圈器将导引导丝通过各个分支引入主动脉弓的主要分支血管内,有14例使用的是带一个分支的支架移植物,1例为三个分支支架移植物,该种重建方式全部使用定做支架,有着较强的个体性,虽然创伤小,但操作方式复杂,手术耗时长,推广性差。2004年Williams等[45]报道了使用原位开窗技术重建弓部的病例。支架移植物完全覆盖了左锁骨下动脉后,再经左肱动脉导入一切割球囊,于左锁骨下动脉开口处打开支架移植物的覆膜,并置入裸支架支撑,从而恢复左锁骨下动脉的供血,达到重建弓部的目的。该种术式对腔内器材的改进依赖度较高,但却不会破坏弓部原有生理特点,若技术可行,则将会是一种很有潜力的重建方式。2007年我们的试验小组完成了模块分叉支架型血管重建主动脉弓的犬试验研究,并正式提出模块分叉支架型血管重建人主动脉弓的概念。此概念提出将人主动脉弓由三个独立模块进行重建,其中模块一、二负责重建升主动脉、及前半弓,为分叉支架血管;模块三负责重建后半弓及降主动脉,为非分叉支架血管[43]。因为三个模块是互相独立的,所以此方案的灵活性大,个体性小,同时微创、操作复杂度相对低,是一个较好的理念。而且随着对正常中国人群主动脉腔内技术相关解剖特点研究的完成,相应的模块型号即将出炉,相信该项技术会有一定的发展前景。虽然上述的大部分手术方式还不能在临床上得到广泛的开展,但相信随着腔内技术、器械及医师技术的不断进步,腔内技术参与重建主动脉弓会得到更进一步的肯定和发展。
【参考文献】
1 Volodos NL,Karpovich IP,Shekhanin VE,et al.A case of distant transfemoral endoprosthesis of the thoracic artery using a selffixing synthetic prosthesis in traumatic aneurysm.Grudn Khir,1988,6:84-86.
2 Parodi JC,Palmaz JC,Barone HD.Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.Ann Vasc Surg,1991,5:491-499.
3 Volodos NL,Karpovich IP,Troyan VI,et al.Clinical experience of the use of selffixing synthetic prostheses for remote endoprosthetics of the thoracic and the abdominal aorta and iliac arteries through the femoral artery and as intraoperative endoprosthesis for aorta reconstruction.Vasa Suppl,1991,33:93-95.
4 Edwards WH,Naslund TC,Edwards WH,et al.Endovascular grafting of abdominal aortic aneurysms.A preliminary study.Ann Surg,1996,223(5):568-573;discussion 573-575.
5 May J,White GH,Yu W,et al.Early experience with the Sydney and EVT prostheses for endoluminal treatment of abdominal aortic aneurysms.J Endovasc Surg,1995,2(3):240-247.
6 Lumsden AB,Allen RC,Chaikof EL,et al.Delayed rupture of aortic aneurysms following endovascular stent grafting.Am J Surg,1995,170(2):174-178.
7 Boudghène F,Sapoval M,JM,et al.Endovascular graft placement in experimental dissection of the thoracic aorta.J Vasc Interv Radiol,1995,6(4):501-507.
8 Nienaber CA,Fattori R,Lund G,et al.Nonsurgical reconstruction of thoracic aortic dissection by stentgraft placement.N Engl J Med,1999,340(20):1539-1545.
9 Lachat M,Pfammatter T,Turina M.Transfemoral endografting of thoracic aortic aneurysm under local anesthesia:a simple,safe and fast track procedure.Vasa,1999,28(3):204-206.
10 Ruchat P,Capasso P,CholletRivier M,et al.Endovascular treatment of aortic rupture by blunt chest trauma.J Cardiovasc Surg(Torino),2001,42(1):77-81.
11 Dorweiler B,Dueber C,Neufang A,et al.Endovascular treatment of acute bleeding complications in traumatic aortic rupture and aortobronchial fistula.Eur J Cardiothorac Surg,2001,19(6):739-745.
12 Alcibar J,Pena N,Onate A,et al.Primary stent implantation in aortic coarctation:midterm followup.Rev Esp Cardiol,2000,53(6):797-804.
13 Hinchliffe RJ,Yung M,Hopkinson BR.Endovascular exclusion of a ruptured pseudoaneurysm of the infrarenal abdominal aorta secondary to pancreatitis.J Endovasc Ther,2002,9(5):590-592.
14 Corso JE,Kasirajan K,Milner R.Endovascular management of ruptured,mycotic abdominal aortic aneurysm.Am Surg,2005,71(6):515-517.
15 Bozinovski J,Coselli JS.Outcomes and survival in surgical treatment of descending thoracic aorta with acute dissection.Ann Thorac Surg,2008,85(3):965-970.
16 De Loos ER,Lim RF,Teijink JA.Endovascular aortic occlusion for a secondary aortoenterocutaneous fistula:44month followup.J Endovasc Ther,2008,15(2):237-240.
17 Greenhalgh RM,Brown LC,Kwong GP,et al.EVAR trial participants.Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm(EVAR tial 1),30days operative mortality results:randomised controlled trial.Lancet,2004,364:843-848.
18 Greenberg RK,Chuter TA,Sternbergh WC 3rd,et al.Zenith Investigators.Zenith AAA endovascular graft:Intermediateterm results of the US multicenter trial.J Vasc Surg,2004,39:1209-1218.
19 Bettex DA,Lachat M,Pfammatter T,et al.To compare general,epidural and local anaesthesia for endovascular aneurysm repair(EVAR).Eur J Vasc Endovasc Surg,2001,21:179-184.
20 Davis M,Taylor PR.Endovascular infrarenal abdominal aortic aneurysm repair.Heart,2008,94(2):222-228.
21 Caronno R,Piffaretti G,Tozzi M,et al.Endovascular repair for thoracic aortic arch aneurysms.Int Angiol,2006,25(3):249-255.
22 Ramaiah V,RodriguezLopez J,Diethrich EB.Endografting of the thoracic aorta.J Card Surg,2003,18(5):444-454.
23 Bortone AS,De Cillis E,DAgostino D,et al.Endovascular treatment of thoracic aortic disease:four years of experience.Circulation,2004,110(11 Suppl 1):II262-267.
24 Chuter TA,Schneider DB.Endovascular repair of the aortic arch.Perspect Vasc Surg Endovasc Ther,2007,19(2):188-192.
25 Olsson C,Thelin S,Sthle E,et al.Thoracic aortic aneurysm and dissection:increasing prevalence and improved outcomes reported in a nationwide populationbased study of more than 14,000 cases from 1987 to 2002.Circulation,2006,114(24):2611-2618.
26 Koyanagi T,Sakurada T,Kikuchi Y,et al.Graft replacement from ascending aorta to descending aorta with endovascular stent graft under median sternotomy.Kyobu Geka,1999,52(12):1029-1031.
27 Carroccio A,Spielvogel D,Ellozy SH,et al.Aortic arch and descending thoracic aortic aneurysms:experience with stent grafting for secondstage“elephant trunk”repair.Vascular,2005,13(1):5-10.
28 Greenberg RK,Haddad F,Svensson L,et al.Hybrid approaches to thoracic aortic aneurysms:the role of endovascular elephant trunk completion.Circulation,2005,112(17):2619-2626.
29 Liu JC,Zhang JZ,Yang J,et al.Combined interventional and surgical treatment for acute aortic type a dissection.Int J Surg,2008,6(2):151-156.
30 AbouZamzam AM Jr.Endovascular repair of a ruptured descending thoracic aortic aneurysm in a patient with an ascending aortic aneurysm:hybrid open arch reconstruction with simultaneous thoracic stentgraft deployment within elephant trunk.Ann Vasc Surg,2008,22(2):168-172.
31 Matsuzaki K.Reconstruction of neck vessels in endovascular repair of aortic arch aneurysms.Kyobu Geka,2006,59(10):887-892.
32 Keshava SN,Falk A.Revascularization of aortic arch branches and visceral arteries using minimally invasive endovascular techniques.Mt Sinai J Med,2003,70(6):401-409.
33 Macierewicz JA,Jameel MM,Whitaker SC,et al.Endovascular repair of perisplanchnic abdominal aortic aneurysm with visceral vessel transposition.J Endovasc Ther,2000,7(5):410-414.
34 Yano OJ,Faries PL,Morrissey N,et al.Ancillary techniques to facilitate endovascular repair of aortic aneurysms.J Vasc Surg,2001,34(1):69-75.
35 Schumacher H,Bckler D,Bardenheuer H,et al.Endovascular aortic arch reconstruction with supraaortic transposition for symptomatic contained rupture and dissection:early experience in 8 highrisk patients.J Endovasc Ther,2003,10(6):1066-1074.
36 Melissano G,Civilini E,MarroccoTrischitta MM,et al.Hybrid endovascular and offpump open surgical treatment for synchronous aneurysms of the aortic arch,brachiocephalictrunk,and abdominal aorta.Tex Heart Inst J,2004,31(3):283-287.
37 Mangino D,Terrini A,Grassi G,et al.Off pump treatment of aortic arch rupture:extraanatomic hybrid reconstruction.Eur J Cardiothorac Surg,2005,27(1):156-158.
38 Wirthlin DJ,Alcocer F,Whitley D,et al.Use of hybrid aortic stent grafts for endovascular repair of abdominal aortic aneurysms:indications and outcomes.J Surg Res,2002,108(1):14-19.
39 Donas KP,Czerny M,Guber I,et al.Hybrid openendovascular repair for thoracoabdominal aortic aneurysms:current status and level of evidence.Eur J Vasc Endovasc Surg,2007,34(5):528-533.
40 Chuter TA,Buck DG,Schneider DB,et al.Development of a branched stentgraft for endovacular repair of aortic arch aneurysm.J Endovasc Ther,2003,10:940-945.
41 Chuter TA,Schneider DB,Reilly LM,et al.Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection.J Vasc Surg,2003,38:859-863.
42 Guo W,Liu X,Liang F,et al.Transcarotid artery endovascular reconstruction of the aortic arch by modified bifurcated stent graft for Stanford type A dissection.Asian J Surg,2007,30(4):290-295.
43 Yang DH,Guo W,Liu XP,et al.The feasibility study of endovascular reconstruction of aortic arch with modular branched stentgraft system in canine.Zhonghua Wai Ke Za Zhi,2007,45(19):1346-1349.
44 Inoue K,Hosokawa H,Iwase T,et al.Aortic arch reconstruction by transluminally placed endovascular branched stent graft.Circulation,1999,100(19 Suppl):II316-321.
45 Mc Williams RG,Murphy M,Hartley D,et al.In situ stentgraft fenestration to preserve the left subclavian artery.J Endovasc Ther,2004,11(2):170-174.
作者单位:100853 北京,解放军总医院血管外科(△通讯作者)