主动脉疾病治疗现状及思考

Current status and reflections on the treatment of aortic disease

主动脉瘤和主动脉夹层是血管外科常见疾病。随着腔内技术的发展,主动脉疾病的治疗进入了一个崭新的阶段。由于主动脉不同部位的解剖条件和血流动力学特点不同,治疗中存在的难点、解决方案亦不同。本文对主动脉瘤和主动脉夹层在不同解剖部位的难点和解决方案进行了综述。关于升主动脉的动脉瘤或夹层的腔内治疗,其难点在于在收缩期和舒张期中主动脉管径变化大、锚定困难、锚定区短以及缺少适宜的支架。主动脉弓部疾病的腔内治疗中,目前由一些专科医师参与研发的分支支架或开窗技术在临床腔内治疗中总体取得较满意结果,但还存在技术难度高及与支架的分支数量呈正相关的神经系统并发症发生率的限制。另外,关于支架原位或预开窗技术是否对主动脉疾病腔内治疗的远期效果存在影响还需继续观察。对于累及胸腹主动脉的病变,其难点在于大量内脏分支血管的存在及支架术后并发内漏的问题,相关分支支架已经进入多中心临床实验阶段,其远期结果还需观察;对于解剖条件不满足的患者,如果全身状况允许,开放手术仍然是可靠的治疗方法。因此,未来关于主动脉瘤及主动脉夹层疾病的腔内治疗,一方面,在支架材料上还需要研发柔顺性更好的合适的支架材料;另一方面,要严格把握手术适应证,谨慎选择腔内治疗。

Aortic aneurysm and aortic dissection are common diseases in vascular surgery.With the development of endovascular technology,the treatment of aortic diseases has entered a brand-new stage.Due to the different anatomical conditions and hemodynamic characteristics of lesions in different parts of aorta,the difficulties and solutions are also different.Therefore,this article reviews the difficulties and solutions for aortic aneurysm and aortic dissection at different anatomical sites.Regarding endovascular treatment of aneurysms or dissection in the ascending aorta,the difficulty lies in the large variation in the diameter of the aortic during systole and diastole,which makes anchoring difficult.On the other hand,there is a lack of suitable stents for patients with a short anchoring zone.In aortic arch disease,branch stenting or fenestration techniques have achieved overall satisfactory results,but there are still limitations in the occurrence of neurological complications due to high technical difficulty and positive correlation with the number of branches of the stent.Additionally,the in situ or pre-opening stenting technique may have potential impacts on the long-term treatment of aortic disease,which needs to been further observed.For lesions involving the thoracic and abdominal aorta,the difficulty lies in the presence of a large number of visceral branch vessels and the complication of endovascular fistulas after stenting.Relevant branch stents have already entered the stage of multicenter clinical trials,and their long-term results need to be observed.For patients whose anatomical conditions do not meet the requirements of endovascular treatment,open surgery remains a reliable method,if systemic conditions allow.Therefore,for future endovascular treatment of aortic aneurysm and aortic dissection,more flexibal stents are needed first;additionauy,vascular surgeons should strictly follow the indications and carefully select the endovascular treatment.