Custom Made Fenestrated Stent Graft Collapse after Thoracic Endovascular Aortic Repair: A Case Report

We present a case of stent graft collapse after performing thoracic endovascular aortic repair with a custom-made fenestrated stent graft. The patient was a 70-year-old woman with an asymptomatic aneurysm of the distal aortic arch, and thoracic endovascular aortic repair was performed. The patient showed a blood pressure difference between the left arm and the right arm on postoperative day (POD) 17 prompting the performance of a chest computed tomography scan which revealed stent graft collapse. She then underwent staged debranching of thoracic endovascular aortic repair. Stent graft collapse is a rare but well-described complication of thoracic endovascular repair. Therefore, patients who undergo such a procedure should be carefully monitored for signs and symptoms, which suggest the possibility of stent collapse.

Total endovascular repair of an intraoperative stent-graft deployed in the false lumen of Stanford type A aortic dissection: A case report

BACKGROUND A 46-year-old male underwent ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection in 2016.However,an intraoperative stent-graft was deployed in the false lumen inadvertently.This caused severe iatrogenic thoracic and abdominal aortic dissection,and the dissection involved many visceral arteries.CASE SUMMARY The patient had pain in the chest and back for 1 mo.A computed tomography scan showed that the patient had secondary thoracic and abdominal aortic dissection.The ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection were performed 2 years prior.An intraoperative stent-graft was deployed in the false lumen.Endovascular aneurysm repair was performed to address this intractable situation.An occluder was used to occlude the proximal end of the true lumen,and a covered stent was used to direct blood flow back to the true lumen.A three-dimensional printing technique was used in this operation to guide prefenestration.The computed tomography scan at the 1stmo after surgery showed that the thoracic and abdominal aortic dissection was repaired,with all visceral arteries remaining patent.The patient did not develop renal failure or neurological complications after surgery.CONCLUSION The total endovascular repair for false lumen stent-graft implantation was feasible and minimally invasive.Our procedures provided a new solution for stent-graft deployed in the false lumen,and other departments may be inspired by this case when they need to rescue a disastrous stent implantation.

Carotid-subclavian bypass and endovascular aortic repair of Kommerell’s diverticulum with aberrant left subclavian artery:A case report

BACKGROUND Kommerell’s diverticulum(KD)with aberrant left subclavian artery is a rare congenital deformity and also has very little research literature about it(35%of case study).There are three types of aortic arch diverticulum.Even literature concerning the treatment options are limited.CASE SUMMARY We present a case report of a 50-year-old male with KD in the right aortic arch with aberrant left subclavian artery.We conducted a total endovascular repair procedure,which is innovative and will spread more light in the medical world.Our patient has no past medical history and is a non-smoker and non-alcoholic.Patient presented with shortness of breath,chest pain and dizziness for six months.Blood tests were done and computerized tomography(CT)angiogram of the chest confirmed the diagnosis,illustrating showed a 3.9 cm KD.On Day 1,the CT angiogram showed mild dilatation of the thoracic aorta,adjacent esophagus,trachea was compressed and displaced.Surgery was planned as the treatment modality.Carotid-Subclavian artery bypass and endovascular aortic repair was conducted.We used prolene 5-0 C1 sutures to precisely anastomose a 6-mm Dacron graft to the left subclavian artery.Haemostasis was secured and wounds were closed.Protamine was administered and patient was shifted to intensive care unit.Post-operative,patient responded favorably and was discharged.Regular follow-up is done.CONCLUSION The procedure we performed is novel.This will help the cardio-thoracic surgeons a better insight about the full procedures we conducted,thereby bringing more light and better treatment options in managing KD with aberrant subclavian artery.

胸主动脉腔内隔绝术在破裂性胸降主动脉瘤治疗中的应用

目的 评价破裂性胸降主动脉瘤腔内治疗的效果,并总结治疗经验。方法 回顾性分析2016年1月至2023年6月张家界市人民医院血管介入外科收治的8例破裂性胸降主动脉瘤患者的临床资料。其中男性4例,女性4例,中位年龄70.5岁(61~78岁)。8例术前均行主动脉CTA检查明确胸降主动脉瘤且存在胸腔或(和)纵隔血肿,均急诊行胸主动脉腔内隔绝术。结果 6例患者胸降主动脉瘤隔绝彻底,其中2例患者采用烟囱支架技术重建左锁骨下动脉。另外2例患者存在少量Ⅰa型内漏,在近端植入CUFF支架后内漏消失。住院期间1例患者发生食管主动脉瘘导致脓毒性休克死亡,3例患者术后出现呼吸衰竭,行胸腔穿刺引流、抗感染、呼吸机辅助呼吸治疗后恢复。2例患者术后出现缺血性脑卒中,1例表现为患侧肢体肌力3级伴语言障碍,1例表现为患侧肢体肌力4级伴语言障碍。随访期间1例术后7个月再次突发胸痛死亡,1例未植入烟囱支架的患者于术后18个月出现Ⅰa型内漏,近端植入CUFF支架后内漏消失。其余5例病例随访期间情况良好。结论 破裂性胸降主动脉瘤行腔内治疗安全、有效。

Stanford B型主动脉夹层腔内修复术后主动脉扩张性病变的研究进展

胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)目前是Stanford B型主动脉夹层(type B aortic dissection,TBAD)的主要治疗方法,当下治疗原则以封堵近端破口为主,而旷置远端破口导致假腔血栓化受阻;主动脉形态及支架远端弹性应力变化,导致管腔局部点压力扩大,形成新发破口或再发夹层导致假腔瘤样扩张,甚至急性破裂致死。术后应通过定期CTA随访,严密监测支架远端管径变化、残留破口直径及假腔血栓化程度。本文通过总结国内外文献,对TEVAR后主动脉扩张性病变的发病原因、机制及处理方法等进行归纳并作综述。

外泌体介导的组织工程在骨修复中的作用

严重创伤、骨肿瘤等导致的骨不连及骨缺损治疗是骨科医生面临的难题,以细胞为基础的骨组织工程技术为骨缺损修复治疗提供有效方法。随着对干细胞在骨组织再生中作用的深入理解,研究人员发现干细胞外泌体释放是其引导骨再生的治疗机制之一。外泌体能够通过旁分泌信号在细胞间发挥通讯作用,调节骨形成过程中的骨再生和血管生成。本文阐述外泌体的生物学来源、成分及功能,从分子生物学角度探讨外泌体在骨修复中的调控作用,同时对外泌体在骨组织工程中促进骨缺损修复的研究成果进行总结,以期更加深入理解外泌体的作用机制,为骨缺损修复提供新的治疗思路。

Old canalicular laceration repair:a retrospective study of the curative effects and prognostic factors

AIM： To investigate the epidemiology and surgical outcomes of old canalicular laceration and analyze the variables impacting on the prognosis of reparation. METHODS： A retrospective review of all old canalicular laceration repairs from Jan. 1, 2008 to Dec. 30, 2015 was performed. Analyzed data included demographics, mechanisms of injury, the time from injury to repair, causes for delayed repair, old associated injuries, the types of surgery, and the effects of repair using canaliculus anastomosis combined with bicanalicular stent intubation. RESULTS： Totally 148 patients with old canalicular laceration received surgical repair and were enrolled. The mean age at presentation was 32.52 years old （ranged from 3 to 63 years old）. The 110 patients （74.32%） were male and 127 patients （85.81%） were adults （__.18 years old）. The old upper, lower, and bicanalicular lacerations were found in 5 （3.38%）, 39 （26.35%）, and 104 patients （70.27%）, respectively. The mechanism of old injury was primarily due to motor vehicle accidents （n=53, 35.81%）. The mean time from injury to repair was 43.61mo （ranged from 1 to 360mo）. Associated old ocular and orbit injuries were found in 65 patients （43.92%）, and chronic dacryocystitis in 18 patients （12.16%）. The main cause of delayed repair was that doctors or patients didn＇t pay attention to the canalicular laceration because of the concurrent severe injuries （n=71, 47.97%）. Totally 136 patients （91.89%） with old canalicular laceration underwent canaliculus anastomosis combined with bicanalicular stent intubation. In all of them, 20 patients （13.51%） were combined with dacryocystorhinostomy. In these cases, 132 patients （97.06%） attained anatomic success, 121 patients （88.97%）reported no epiphora （functional success）, 11 patients （8.09%） reported significant epiphora anesis （functional improvement）, and 4 （2.94%） reported no significant anesis （functional failure）. Rates of anatomic success and functional success were significantly correlated with different canaliculus involved. However, rates of anatomic success and functional success were not significantly affected by the time from injury to repair. CONCLUSION： The canalicular anastomosis combined with bicanalicular stent intubation could act as an effective therapeutics for old canalicular laceration.

Endovascular stent-grafts for acute and chronic type B aortic dissection: comparison of clinical outcomes

Objective To evaluate the early and mid-term results of endovascular repair for acute and chronic type B aortic dissection, and to compare the clinical outcomes between the 2 groups. Methods From May 2002 to December 2006, 50 patients with type B aortic dissection were treated by endovascular stent-graft. There were 23 patients in the acute aortic dissection (AAD) group and 27 patients in the chronic aortic dissection (CAD) group. All patients were followed up from 1 to 54 months (average, 17±16 months).The immediate and follow-up clinical outcomes were documented and compared between the 2 groups. Results Placement of endovascular stent-grafts across the primary entry tears was technically successful in all 50 patients. Compared to the CAD group, the AAD group had a higher percentage of pleural effusion (17.4% vs. 0%, P=0.04) and visceral /leg ischemia (26.1% vs 3.7%, P=0.04). Procedure related complications, including endoleak and post-implantation syndrome, occurred more frequently in the AAD group than in the CAD group (21.7% vs 3.7% and 30.4% vs 11.1%, respectively; P=0.08 and P=0.04). Kaplan–Meier analysis showed no difference in the survival rate at 4 years between the 2 groups (86.4% vs 92.3%, P=0.42 by log-rank test). However, the event-free survival rate was higher in patients with chronic dissection than in patients with acute aortic dissection(96.2% vs 73.9%; P=0.02 by log-rank test). Conclu- sions Endovascular repair with stent-graft was safe and effective for the treatment of both acute and chronic type B aortic dissection. However, both immediate and long term major complications occurred more frequently in patients with acute dissection than in those with chronic dissection.

Endovascular treatment of aortoiliac aneurysms: From intentional occlusion of the internal iliac artery to branch iliac stent graft

Approximately 20%-40% of patients with abdominal aortic aneurysms can have unilateral or bilateral iliac artery aneurysms and/or ectasia. This influences and compromises the distal sealing zone during endovascular aneurysm repair. There are a few endovascular techniques that are used to treat these types of aneurysms, including intentional occlusion/over-stenting of the internal iliac artery on one or both sides, the "bell-bottom" technique, and the more recent method of using an iliac branch stent graft. In some cases, other options include the "snorkel and sandwich" technique and hybrid interventions. Pelvic ischemia, represented as buttock claudication, has been reported in 16%-55% of cases; this is followed by impotence, which has been described in 10%-17% of cases following internal iliac artery occlusion. The bellbottom technique can be used for a common iliac artery up to 24 mm in diameter given that the largest diameter of the stent graft is 28 mm. There is a paucity of data and evidence regarding the "snorkel and sandwich" technique, which can be used in a few clinical scenarios. The hybrid intervention is comprised of a surgical operation, and is not purely endovascular. The newest branch stent graft technology enables preservation of the anterograde flow of important side branches. Technical success with the newest technique ranges from 85%-96.3%, and in some small series, technical success is 100%. Buttock claudication was reported in up to 4% of patients treated with a branch stent graft at 5-year follow-up. Mid- and short-term follow-up results showed branch patency of up to 88% during the 5-6-year period. Furthermore, branch graft occlusion is a potential complication, and it has been described to occur in 1.2%-11% of cases. Iliac branch stent graft placement represents a further development in endovascular medicine, and it has a high technical success rate without serious complications.

Short-term efficacy of unibody single-branched stent in the treatment of lesions involving the left subclavian artery:two-year follow-up outcomes

The development of thoracic endovascular aortic repair(TEVAR)technology avoids the risk of patients opening the chest and is widely used in Stanford B-type dissection.[1–3]However,because TEVAR technology has clear requirements for vascular anatomy of the lesion,it limits its application to some patients.In the shortcomings of the proximal anchor zone,coverage of the left subclavian artery(LSA)origin without revascularization during TEVAR appears to have increased risk of stroke,upper extremity ischemia and paraplegia.[4]

Angioscopic Observation of an Endoluminal Stent Graft: CT Imaging versus Angioscopic Imaging

We could observe the endoluminal stent graft (SG) following thoracic endovascular aneurysm repair (TEVAR) by a coronary artery angioscope and establish intravascular visualization of SG. The patient was a 70-year-old woman with the distal aortic arch aneurysm and the descending aortic aneurysm, and debranching TEVAR were performed. After 12 months follow up, urgent hospitalization was required for chest pain, and cardiac catheter examination with a coronary artery angioscope was performed. The endoluminal SG was observed. The observation in angioscope which is a video image is better than CT that is a still image, and observation in blood vessel or SG is possible. It may be possible to observe the endoluminal SG, allowing potential investigation of an endoleak, or the covering status of the SG with the native aortic vessel wall, or the state of intimal membrane formation in the endoluminal graft.

Endovascular Repair for Abdominal Aortic Aneurysm Reduces Postoperative Blood Endotoxin Levels Assayed by the EAA Method Compared with Open Abdominal Surgery

Introduction: We hypothesized to demonstrate whether there are significant differences in blood endotoxin (Et) levels after abdominal aortic surgery between endovascular aortic repair (EVAR) and open abdominal surgery. Methods: The patients who underwent the surgical treatment for abdominal aortic aneurysm were divided into two groups according to the procedures: open abdomen surgery (OP) and EVAR (SG). The value of Endotoxin Activity Assay (EAA) was compared between groups. Results: After surgery, Et level was significantly higher in the OP group than in the SG group on postoperative day 3. Neutrophil count was significantly higher in the OP group immediately after treatment, but no significant difference was seen thereafter. There were no differences between the groups in other inflammatory markers. Conclusions: This study indicated that EVAR was less invasive compared to an open abdominal surgery from the standpoint of assessing postoperative endotoxin activity (EA) levels measured by EAA.

Endovascular repair of type B aortic dissection: a study by computational fluid dynamics

Aortic dissection is a dangerous pathological condition where blood intrudes into the layers of the arterial walls, creating an artificial channel (false lumen). In the absence of thrombosis or surgical intervention, blood will enter the false lumen through the proximal tear, and join the true lumen again through a distal tear. Rupture of the weakened outer wall will result in extremely high mortality rates. Type B thoracic aortic dissection (TAD), occurring along the descending aorta, can be repaired surgically by the deployment of an endovascular stent graft, concealing the proximal entry tear. Blood might still flow into the false lumen (FL) through the distal tear. The domain of such flow should be minimized, as complete thrombosis of the FL is generally believed to be more beneficial for the patient. The dependence on the area ratios of the lumens and size of these tears is studied by computational fluid dynamics.

单分支支架重建与单纯封闭左锁骨下动脉术在锚定区不足的Stanford B型主动脉夹层腔内修复术中的临床疗效

目的 探讨单分支支架重建与单纯封闭左锁骨下动脉(LSA)术在锚定区不足的Stanford B型主动脉夹层(TBAD)腔内修复术中的临床疗效。方法 收集2019年1月至2021年9月于潍坊市人民医院行胸主动脉腔内修复术(TEVAR)的48例TBAD患者的临床资料,按照手术方式的不同将其分为A组(n=25,采用Castor单分支支架重建LSA)与B组(n=23,直接封闭LSA),比较两组患者的手术成功率、手术时间、出血量、住院时间、并发症、假腔血栓化、手术前后真假腔直径变化等指标。结果 两组患者术区血管测量数据比较,差异无统计学意义(P﹥0.05)。A组患者支架长度大于B组患者,支架远端直径小于B组患者,差异均有统计学意义(P﹤0.05)。A组患者手术成功率100%,与B组患者的95.6%比较,差异无统计学意义(P﹥0.05)。两组患者手术时间、出血量、住院时间、并发症发生率比较,差异均无统计学意义(P﹥0.05)。两组患者支架覆盖段假腔均完全血栓化。术前、术后3个月,两组患者主动脉真、假腔直径比较,差异均无统计学意义(P>0.05);术后3个月,两组患者主动脉峡部、穿膈处真腔直径均大于本组术前,假腔直径均小于本组术前,差异均有统计学意义(P﹤0.05)。结论 对于锚定区不足的TBAD使用Castor单分支主动脉支架重建LSA安全有效,单纯封闭LSA术可在部分患者中选择使用。

逆行性A型主动脉夹层腔内隔绝治疗效果观察

目的观察逆行性A型主动脉夹层的腔内隔绝治疗效果,探讨逆行性A型主动脉夹层腔内隔绝治疗的策略。方法选取湖南中医药大学第一附属医院2016年10月至2020年11月近端内膜破口位于降主动脉的逆行性A型主动脉夹层患者19例,行主动脉覆膜支架植入术,并于术后1周、3个月、半年、1年随访观察治疗效果。结果全组随访无一例患者死亡,2例患者支架近端主动脉弓部出现局限性溃疡,2例出现升主动脉夹层,1例支架远端出现夹层,其余14例患者均恢复良好,无相关并发症。结论近端内膜破口位于降主动脉的逆行性A型主动脉夹层患者,经保守治疗后择期行腔内隔绝手术的治疗策略近中期效果理想。

单分支支架治疗Stanford B型主动脉夹层安全性和有效性的Meta分析

目的比较单分支支架(single-branched stent graft,SBSG)与其他胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)治疗Stanford B型主动脉夹层(type B aortic dissection,TBAD)患者的安全性和有效性。方法系统性检索PubMed、Embase、Cochrane Library、Web of Science、万方数据、中国知网从建库至2022年9月发表的比较SBSG和其他TEVAR相关技术治疗TBAD患者的中英文文献,对技术成功率、手术时间、早期Ⅰ型内漏、围术期神经系统并发症、术后30 d死亡和随访期分支血管阻塞等数据进行Meta分析。结果共纳入9篇文献986例患者,其中SBSG组338例,对照组637例。Meta分析结果显示,SBSG组有更低的早期Ⅰ型内漏(OR=0.47,95%CI=0.22~0.99,P=0.046)和随访期分支血管阻塞发生率(OR=0.46,95%CI=0.21~0.97,P=0.041)。两组技术成功率、手术时间、围术期神经系统并发症和术后30 d死亡发生率的差异无统计学意义。结论SBSG在治疗TBAD的应用中是安全有效的,能有效降低早期Ⅰ型内漏和随访期分支血管阻塞的发生率。

Stanford B型急性主动脉夹层947例临床分析

目的:探讨Stanford B型急性主动脉夹层(AAD)的临床特点及不同治疗方式对预后的影响。方法:回顾性分析947例Stanford B型主动脉夹层患者的临床资料,根据治疗方式分为非介入手术组(单纯药物治疗457例)和介入手术组(490例)。统计并比较2组院内死亡率。结果:947例患者中,男789例,平均年龄(55.9±12.6)岁,女158例,平均年龄(56.8±11.4)岁。住院死亡40例(4.22%);其中非介入手术组死亡39例;介入手术组死亡1例;非介入手术组院内病死率明显高于介入手术组(8.53%vs 0.20%,P<0.01)。结论:Stanford B型AAD患者病情急,进展快,死亡风险大,尽早确诊并行适宜的介入手术治疗可明显提高患者的生存率。

原位开窗在胸主动脉的应用与研究进展

原位开窗是一种超适应证技术,其打破了胸主动脉腔内修复的原有禁区,将治疗范围拓展到了主动脉弓。由于主动脉弓具有复杂的解剖结构,其弓上分支的重建依然是胸主动脉腔内修复术(TEVAR)应用的难点,复杂的血管解剖、支架覆膜及结构因素、术中及术后卒中并发症等问题是决定原位开窗技术能否成功的关键。与其他技术相比,原位开窗技术具有操作难度低、治疗效果好、并发症风险低等优势,发展潜力较大。因此,本文根据原位开窗的应用、研究进展等问题进行综述。

良性输尿管狭窄的诊疗进展

良性输尿管狭窄指由输尿管管腔缩窄引起的梗阻性病变,可导致严重的肾功能损伤甚至衰竭,其发病主要与嵌顿结石、输尿管碎石术以及盆腹腔手术等因素有关。良性输尿管狭窄以手术治疗为主,但其治愈率与狭窄特征密切相关。既往采用修复重建手术治疗,虽治愈率较高,但创伤大、风险高、术后恢复慢。目前腔内手术治疗因创伤小、风险低、恢复快等特点,大量应用于狭窄长度短、病程时间短、肾功能情况良好、非缺血性的良性输尿管狭窄患者的治疗中。同时长期留置输尿管支架的维持性治疗也能有效保护肾功能。因此,在良性输尿管狭窄的治疗中,应充分结合患者的身体情况以及狭窄特征为患者提供最合适的个体化治疗方案。

Viabahn VBX球囊扩张式覆膜支架的初步应用体会

目的探讨Viabahn VBX球囊扩张式覆膜支架的短期临床应用结果。方法收集2022年6~10月在天津医科大学总医院行VBX支架植入术的27例患者临床资料,对释放成功率、技术成功率、术后30 d临床成功率等治疗结果进行回顾性分析。结果共植入29枚VBX支架,包括治疗狭窄闭塞性病变23处,扩张性病变6处。VBX支架治疗狭窄闭塞病变的器械释放成功率、技术成功率和30 d临床成功率均为100%,治疗扩张性病变的器械释放成功率和30 d临床成功率为100%,技术成功率83.3%。1例肾动脉瘤患者出现内漏,其余患者无狭窄、内漏出现,未发生器械或手术相关的严重不良事件。结论VBX支架应用于既需充分扩张又可能破裂出血造成生命危险的病变部位以及解剖条件适宜的扩张性病变作为主支架以及桥接支架时,均能显示出较好的近期结果。