慢性胸腹主动脉夹层动脉瘤杂交手术进展

Advance in hybrid repair of chronic thoracoabdominal aortic dissecting aneurysm

慢性胸腹主动脉夹层动脉瘤的手术治疗被称为血管外科技术领域的最具有挑战性的手术之一。近60年来,以人工血管置换为主的开放修复术一直是慢性胸腹主动脉夹层动脉瘤的首选治疗方式。随着血管微创腔内技术的发展,产生了两种新的手术方式:全腔内覆膜支架修复术和逆向去分支内脏动脉重建联合腔内覆膜支架修复杂交手术(简称杂交手术)。尽管全腔内覆膜支架修复术创伤小、恢复快,但由于对主动脉解剖形态要求高、费用高昂、缺乏通用腔内覆膜支架产品等问题,在临床应用方面仍存在一定局限性。杂交手术结合了主动脉腔内修复微创的治疗理念与内脏动脉区去分支重建技术,逐渐成为治疗胸腹主动脉瘤的重要术式之一,尤其针对不能承受开放手术和由于主动脉扭曲、夹层真腔狭小等解剖形态不适合全腔内治疗的慢性胸腹主动脉夹层动脉瘤。近年根据杂交手术血流动力学分析不断优化内脏动脉重建策略,以及探索分期及同期手术的优劣。

Surgical intervention for chronic thoracoabdominal aortic dissecting aneurysms(cTAADA)is regarded as one of the most challenging procedures in the field of vascular surgery.For nearly six decades,open repair predominantly utilizing prosthetic grafts has been the treatment of choice for cTAADA.With advances in minimally invasive endovascular technologies,two novel surgical approaches have emerged:total endovascular stent-graft repair and hybrid procedures combining retrograde debranching of visceral arteries with endovascular stent-graft repair(abbreviated as hybrid procedure).Although total endovascular stent-graft repair offers reduced trauma and quicker recovery,limitations persist in clinical application due to hostile anatomical requirements of the aorta,high costs,and the lack of universally available stent-graft products.Hybrid repair,integrating the minimally invasive ethos of endovascular repair with visceral artery debranching techniques,has increasingly become a significant surgical modality for managing thoracoabdominal aneurysms,especially in cases unsuitable for open surgery or total endovascular treatment due to anatomical constraints such as aortic tortuosity or narrow true lumens in dissections.Recent enhancements in hybrid surgical approaches include ongoing optimization of visceral artery reconstruction strategies based on hemodynamic analyses,and exploration of the comparative benefits of staged versus concurrent surgical interventions.