胸主动脉真性、假性和夹层动脉瘤行主动脉腔内修复术的临床和影像学研究

A Clinical and Imageological Study on Endo-vascular Repair of Thoracic Aortic Aneurysm,Thoracic Pseudo-aneurysm and Aortic Dissection

目的总结胸主动脉真性、假性和夹层动脉瘤的术前诊断和腔内修复的要点,对术前、术后的主动脉CT血管造影(CTA)影像进行评估和比较,以探讨用统一的影像学指标在术前、术中、术后和随访中对病变演变和疗效进行系统评价和动态观察。方法48例胸主动脉瘤和夹层动脉瘤患者在术前CTA图象指导下行主动脉腔内修复术(EVR),植入覆膜支架,植入前、后做数字减影血管造影(DSA),术后定期多次做CTA随访评价疗效。所有CTA和DSA图象输入e-FilmTM软件中建立影像数据库,筛选关键层面,测量分析对比。结果48例共行EVR49次,准确植入长、短支架54枚,夹层内膜破口封闭42例,胸主动脉真性动脉瘤完全隔绝2例,假性动脉瘤颈口封闭4例。术后发生不同程度的内漏9例,经相应的处理消除;因导入动脉出血抢救成功,但发生弥漫性血管内凝血、多器官功能衰竭死亡1例。随访47例,随访时间6～51个月。所有患者恢复良好,临床效果满意。结论EVR治疗胸降主动脉真、假性和夹层动脉瘤效果良好;夹层动脉瘤的早期诊断要点为胸痛和CTA扫描;CTA特定层面和左前斜位图象是术前评估和术后疗效评定的重要参考。

Objective To summarize the critical point of diagnosis and endo-vascular repairment （EVR） to thoracic aortic aneurysm （TAA）, thoracic pseudo-aneurysm （TPA） and aortic dissection （AD）, by comparison the computerized tornography angiography （CTA） images before and after EVR to observe effects, so as to explore a unique index of imageology to assess the pathological development and evaluate therapeutically effect in dynamic and systemic reviews in pre-, intra-, post-EVR and follow-up period. Methods Forty-eight patients involving aneurysm or dissection of thoracic aorta were treated with EVR based on the pre-operative CTA imaging. Before and after the introducing of stem-graft, digital substation angiography （DSA） was taken place and sequential enhanced CTA was followed to evaluate the effects of the treatment. All imagings of CTA and DSA were collected and induced into e-FilmTM database to select key sections for analyses and measurement. Results Forty-nine EVR were preformed and 54 stent grafts were implanted in 48 cases, with endothelial tears sealed in 42 cases of dissection, aneurismal cavities excluded in 2 cases of aortic aneurysm, and rupture site closed in 4 cases of pseudo-aneurysm. Endo-leakage happened in 9 cases, which were treated successfully by appropriate measures. One case suffered hemorrhage from introducing artery （iliac） which was controled by surgery, but he died of disseminated intravascular coagulation and then multiple organs failure. Forty-seven cases were followed up in 6--51 months with a satisfied clinical effect. Conclusion EVR is favorable in the effect of repairment to true, false and dissection of thoracic descending aorta. Chest pain and CTA scan is the key of early diagnosis of aortic dissection. Certain sections and left- anterior oblique viewing are the crucial profile for assessment and evaluation before and after operation.