Mid-term outcomes of left subclavian artery revascularization with Castor stent graft in treatment of type B aortic dissection in left subclavian artery

Background:Here we analyzed mid-term data of thoracic endovascular aneurysm repair(TEVAR)surgery with Castor single-branched stent graft placement for the management of Stanford type B aortic dissection(STBAD)involving the left subclavian artery(LSA).Methods:Between April 2014 and February 2019,32 patients with STBAD involving a Castor single-branched stent graft were included.We analyzed their outcomes,including technical success rate(TSR),surgical duration(SD),presence of ischemia,perioperative complications,LSA patency,and survival rate(SR),using computed tomography angiography and clinical evaluation during mid-term follow-up.Results:The mean patient age was 54.63±12.37 years(range,36–83 years).The TSR was 96.88%(n=31/32).The mean SD was 87.44±10.89 with a mean contrast volume of 125.31±19.30 mL.No neurological complications or deaths occurred during the study period.The patients had a mean hospital stay of 7.84±3.20 days.At a mean follow-up of 68.78±11.26 months,four non-aortic deaths(12.5%)were observed.The LSA patency rate was 100%(n=28/28).There was only one case of type I endoleak immediately after surgery(3.12%)(type I from LSA).However,none of the patients experienced type II endoleaks,and there were no cases of retrograde type A aortic dissection or stent graft-driven new distal entry.Finally,all patients exhibited good LSA patency.Conclusion:TEVAR using a Castor single-branched stent graft may be a highly feasible and efficient procedure for the management of STBAD involving the LSA.

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

Within the recent months, endovascular repair of aortic aneurysms has become a rather interesting alternative to patients considering open surgery. In the past, the procedure was typically and more solely reserved to a selected group of elderly patients with several co-morbidities.……

Successful treatment of aortic dissection with pulmonary embolism:A case report

BACKGROUND Aortic dissection(AD)and pulmonary embolism(PE)are both life-threatening disorders.Because of their conflicting treatments,treatment becomes difficult when they occur together,and there is no standard treatment protocol.CASE SUMMARY A 67-year-old man fell down the stairs due to syncope and was brought to our hospital as a confused and irritable patient who was uncooperative during the physical examination.Further examination of the head,chest and abdomen by computed tomography revealed a subdural hemorrhage,multiple rib fractures,a hemopneumothorax and a renal hematoma.He was admitted to the Emergency Intensive Care Unit and given a combination of oxygen therapy,external rib fixation,analgesia and enteral nutrition.The patient regained consciousness after 2 wk but complained of abdominal pain and dyspnea with an arterial partial pressure of oxygen of 8.66 kPa.Computed tomography angiograms confirmed that he had both AD and PE.We subsequently performed only nonsurgical treatment,including nasal high-flow oxygen therapy,nonsteroidal analgesia,amlodipine for blood pressure control,beta-blockers for heart rate control.Eight weeks after admission,the patient improved and was discharged from the hospital.CONCLUSION Patients with AD should be alerted to the possibility of a combined PE,the development of which may be associated with aortic compression.In patients with type B AD combined with low-risk PE,a nonsurgical,nonanticoagulant treatment regimen may be feasible.

The clinical study of modified total aortic arch replacement and stent elephant trunk technique treatment for patients with DeBakey Ⅰ thoracic aortic dissection

Objective To summarize the clinical study of modified total aortic arch replacement and stent elephant trunk technique treatment to patients with DeBakey Ⅰ thoracic aortic dissection. Methods From January 2006 to October 2010,101 cases of DeBakeyⅠaortic dissection were treated by modified total arch replacement and stent elephant trunk technique,in which emergencey surgery were performed on 73 cases. There were 76 male and 25

Use of three dimensional-printing in the management of floating aortic thrombus due to occult aortic dissection:A case report

BACKGROUND Floating thrombus within the thoracic aorta is a rare entity but may cause systemic embolism.The pathogenesis of floating aortic thrombi is not yet fully understood.No definitive guidelines are available for the management of floating aortic thrombus.CASE SUMMARY We report a 48-year-old patient,without a history of trauma and infection,who presented with sudden severe back pain.A floating thrombus within the aortic arch was found by computed tomography angiography(CTA).No evidence of coagulopathies was found.However,with the assistance of a three dimensionalprinted model,this floating thrombus was identified to be caused by occult aortic dissection(AD).Subsequently,an emergency thoracic endovascular repair was performed.The patient’s back pain was rapidly alleviated postoperatively.CTA at 1 year showed no filling defect in the stent-graft and aorta.CONCLUSION Occult AD is a potential factor causing floating aortic thrombi,endovascular stent-graft exclusion may be an optimal therapeutic choice with promising results.Moreover,the combination of CTA and three dimensional-printed models can contribute to the diagnosis and treatment of floating aortic thrombi due to occult AD.

Percutaneous coronary intervention following repair of type B aortic dissection:a report of 8 cases

Objective Patients with aortic dissection have a significant incidence of coronary artery disease. The purpose of this study is to evaluate the safety and feasibility of percutaneous coronary stent in patients who have undergone endovascular stent, and to assess the effect of anti-coagulant and anti-platelet treatment on patients' thrombosis process. Methods From January 2005 to July 2007, 8 patients who had undergone endovascular stent-graft during the past 1 to 7 months for type B aortic dissection repair, underwent percutaneous coronary intervention (PCI) because of coexisting coronary artery disease. Anti-coagulant and anti-platelet treatments were administrated after PCI according to the standard protocol. Patients were followed up for a mean period of 23 months. Clinical and false lumen status data were collected during the follow-up. Results PCI were technically successful in all 8 patients and no severe complications such as death, paraplegia, renal failure occurred during hospitalization. Complete false lumen thrombosis was observed in 5 patients and incomplete false lumen thrombosis in the remained 3 patients at the end of follow up. There were no major complications such as death, dissection rupture or aneurysm development occurred during the follow-up period. Conclusion Our data implied that PCI can be safely performed in patients with type B aortic dissection who have undergone endovascular stent-graft, without interrupt- ing the thrombosis process.

The Impact of the Morphologic Characteristics of Type B Aortic Dissection in the Acute Phase on the Aortic Enlargement in the Late Stage

Objectives: According to the International Registry of Acute Aortic Dissection, >70% of patients with type-B aortic dissection (AD) have delayed aortic growth. The objective of this study was to investigate the morphologic characteristics of aortic enlargement in type-B AD. Methods: A total of 120 patients with uncomplicated acute type-B aortic dissection (uATBAD) were divided into 4 groups according to the presence of a patent or thrombosed false lumen (FL) with or without aortic enlargement. In all groups, the area of the true lumen (TL) and the FL were measured on axial computed tomography images. Results: A total of 120 uATBAD patients were evaluated: patent FL with (PE, N = 28, 23%) or without aortic enlargement (PU, N = 17, 14%) and thrombosed FL with (TE, N = 34, 28%) or without enlargement (TU, N = 41, 34%). The initial aortic diameter was not significantly different among the 4 groups (PE vs. PU = 39 ± 8 vs. 37 ± 10 (p = 0.354);TE vs. TU = 38 ± 6 vs. 37 ± 6 (p = 0.391)). The area of the FL tended to be larger in the PE group. In contrast, the area of the TL was significantly larger in the TE group. Late outcomes of uATBAD treated with optimal medical treatment were acceptable. Conclusions: In patients with uATBAD and a thrombosed FL, the patients with aortic enlargement tended to be increased TL size. In contrast, in patients with a patent FL, the patients with aortic enlargement tended to be increased FL size.

Aortic dissection with epileptic seizure: A case report

BACKGROUND Aortic dissection(AoD)is a life-threatening disease.Its diversified clinical manifestations,especially the atypical ones,make it difficult to diagnose.The epileptic seizure is a neurological problem caused by various kinds of diseases,but AoD with epileptic seizure as the first symptom is rare.CASE SUMMARY A 53-year-old male patient suffered from loss of consciousness for 1 h and tonicclonic convulsion for 2 min.The patient performed persistent hypomania and chest discomfort for 30 min after admission.He had a history of hypertension without regular antihypertensive drugs,and the results of his bilateral blood pressure varied greatly.Then the electroencephalogram showed the existence of epileptic waves.The thoracic aorta computed tomography angiography showed the appearance of AoD,and it originated at the lower part of the ascending aorta.Finally,the diagnosis was AoD(DeBakey,type I),acute aortic syndrome,hypertension(Grade 3),and secondary epileptic seizure.He was given symptomatic treatment to relieve symptoms and prevent complications.Thereafter,the medical therapy was effective but he refused our surgical advice.CONCLUSION The AoD symptoms are varied.When diagnosing the epileptic seizure etiologically,AoD is important to consider by clinical and imaging examinations.

Changes of Clinical Features of Aortic Dissection Over Ten Years

Objectives To investigate changes of clinical features of aortic dissection （AD） in recent years in Guangzhou. Methods Retrospective analysis of consecutive patients with AD over 10 years in Guangdong Cardiovascular Institute. Demographic features and outcomes in cases presenting with acute dissection were compared between patients admitted in two five-year periods. Results 339 patients with AD were admitted during the recent ten years. Their mean age was 55.7 ± 11.2 years. Male verse female ratio was 4.8. Surgery was performed in 37 % of cases with acute type A and 7 % with acute type B dissection. Apart from a fast increase in number of patients admitted each year, there were no significant changes in demographic characteristics over these ten years. Survival of patients with acute dissection showed a trend of improvement, though it had not been statistically confirmed. Conclusions The number of admitted patients with AD has been fast increasing in Guangzhou. These patients were about ten years younger than previously reported by foreign researchers. Surgery was much less frequently performed than it was in western countries. Survival in acute cases showed a trend of improvement. These data support urgent improvement in prevention and management of aortic dissection.

The interactions between bloodstream and vascular structure on aortic dissecting aneurysmal model: A numerical study

Stent-graft implantation is an important means of clinical treatment for aortic dissecting aneurysm （ADA）. However, researches on fluid dynamics effects of stent were rare. Computer simulation was used to investigate the interactions between bloodstream and vascular structure in a stented ADA, which endures the periodic pulse velocity and pressure. We obtained and analyzed the flow velocity distribution, the wall displacement and wall stress in the ADA. By comparing the different results between a non-stented and a stented ADA, we found that the insertion of a vascular graft can make the location of maximum stress and displacement move from the aneurysm lumen wall to the artery wall, accompanied with a greatly decrease in value. These results imply that the placement of a stent-graft of any kind to oc-clude ADA will result in a decreased chance of rupture.

Research and clinical translation of trilayer stent-graft of expanded polytetrafluoroethylene for interventional treatment of aortic dissection

The aortic dissection(AD)is a life-threatening disease.The transcatheter endovascular aortic repair(EVAR)affords a minimally invasive technique to save the lives of these critical patients,and an appropriate stent-graft gets to be the key medical device during an EVAR procedure.Herein,we report a trilayer stent-graft and corresponding delivery system used for the treatment of the AD disease.The stent-graft is made of nitinol stents with an asymmetric Z-wave design and two expanded polytetrafluoroethylene(ePTFE)membranes.Each of the inner and outer surfaces of the stent-graft was covered by an ePTFE membrane,and the two membranes were then sintered together.The biological studies of the sintered ePTFE membranes indicated that the stent-graft had excellent cytocompatibility and hemocompatibility in vitro.Both the stent-graft and the delivery system exhibited satisfactory mechanical properties and operability.The safety and efficacy of this stent-graft and the corresponding delivery system were demonstrated in vivo.In nine canine experiments,the blood vessels of the animals implanted with the stent-grafts were of good patency,and there were no thrombus and obvious stenosis by angiography after implantation for 6months.Furthermore,all of the nine clinical cases experienced successful implantation using the stent-graft and its postrelease delivery system,and the 1-year follow-ups indicated the preliminary safety and efficacy of the trilayer stent-graft with an asymmetric Z-wave design for interventional treatment.

主动脉夹层病理病因及临床治疗的研究进展

主动脉夹层是一种高度致死性的心血管急症。近年来研究表明,分子的异常表达和共存疾病可增加主动脉夹层的发病风险并加重其病情,而腔内技术改进、新型器械迭代研发及新夹层分期分型的提出有助于患者的精准化治疗和改善预后。因此,本文就主动脉夹层的临床分类、病理机制、危险因素和治疗方案做一综述。

急性Stanford A型主动脉夹层的临床带教策略

急性Stanford A型主动脉夹层是心血管外科的危急重症,病情凶险,进展快速,临床表现和主动脉夹层撕裂的范围及程度相关,因而误诊率较高。此类患者一经确诊,尽早进行外科手术是成功救治的唯一途径。兰州大学第一医院是一家三级甲等教学医院,每年收治急诊及外院转诊的急性Stanford A型主动脉夹层约100例。对于首诊医师而言,如何进行快速正确的诊断、鉴别诊断、并完善术前相关准备,需要在熟练掌握理论知识的基础上,进行临床经验的积累和总结。文章针对外科规范化培训的医师、住院医师及进修医师,就近年来在心血管外科临床带教的教学体会,从急性Stanford A型主动脉夹层的正确诊断(症状和体征、人群分布特点、时间生物模式及辅助检查几个方面)、鉴别诊断及术前准备等方面进行总结,提高初学者对该病的临床辨别能力、初步救治能力及转诊能力,进而提高临床医师对此类患者的整体救治能力,尽可能减少漏诊和误诊。

IMB护理模式对主动脉夹层动脉瘤手术患者负性情绪、疼痛和生活质量的影响

目的 探讨信息-动机-行为模型(IMB)护理模式对主动脉夹层动脉瘤手术患者负性情绪、疼痛和生活质量的影响。方法 选取2022年2—12月河南省胸科医院收治的60例主动脉夹层动脉瘤手术患者为研究对象,按照随机数字表法将其分为对照组(30例)和观察组(30例)。对照组进行常规护理模式,观察组进行IMB护理模式。比较两组血压水平、负面情绪、疼痛评分、生活质量。结果 护理4周观察组的血压水平较对照组更优(P<0.05)。护理4个月后,两组患者的医院焦虑抑郁量表评分均降低,且观察组较对照组更低(P<0.05)。护理4周两组数字疼痛强度量表评分均逐渐降低,且观察组疼痛缓解较对照组更优(P<0.05)。护理6周,观察组生活质量自评量表各项评分均比对照组高(P<0.05)。结论 IMB护理模式不仅可以减轻主动脉夹层动脉瘤患者焦虑,平衡血压,还可以缓解疼痛,提高生活质量,具有显著疗效,值得临床推广应用。

急性A型主动脉夹层合并肠系膜低灌注致肠缺血坏死的治疗策略

急性A型主动脉夹层是一种严重的心血管疾病,起病快,病死率高,传统上通常在患者入院后紧急进行开放性主动脉修复术,以防止主动脉破裂而导致死亡。然而,若合并灌注不良综合征引起肠系膜上动脉低灌注会进一步导致肠坏死,严重影响手术预后甚至引起不良后果,在治疗上带来极大困难。本文结合近年来国内外研究文献,从急性A型主动脉夹层造成器官灌注不良的机制、治疗现状、手术方式的选择进行综述。文献复习结果表明,目前针对急性A型主动脉夹层合并肠系膜上动脉灌注不良的手术方式选择可采用中心型主动脉修复术;对肠系膜上动脉先进行开窗和/或支架置入,再对主动脉进行延迟开放修复;优先进行肠系膜上动脉血运重建,再行主动脉中心型修复术;中心型主动脉修复的同时,对肠系膜上动脉的远端真腔进行直接血流灌注,并且都可以取得良好的治疗效果。但在外科主动脉修复术后,仍可能出现肠缺血坏死,此时需要积极进行剖腹探查并做出相应坏死肠切除处理,才能挽救患者的生命。

急性Stanford A型主动脉夹层合并灌注不良综合征术后死亡的危险因素分析

[目的]探究急性Stanford A型主动脉夹层(ATAAD)合并灌注不良综合征(MPS)术后死亡的危险因素。[方法]选取2020年6月—2023年6月南充市中心医院收治的244例ATAAD合并MPS患者为研究对象,追踪患者术后生存情况,分为存活组(156例)和死亡组(88例)。采用倾向性评分匹配(PSM)法按1∶1匹配后,两组均为54例,单因素和Logistic回归分析ATAAD合并MPS患者术后死亡的危险因素,受试者工作特征(ROC)曲线下面积(AUC)对ATAAD合并MPS患者进行预后分析。利用y=1-1/(1+e^(-z))回归方程建立预测模型,十字交叉验证法验证模型的稳定性。[结果]匹配后,与存活组(n=54)比,死亡组(n=54)的男性占比、饮酒史占比、急性生理学和慢性健康状况评价Ⅱ(APACHEⅡ)评分、序贯器官功能衰竭(SOFA)评分、谷丙转氨酶(ALT)、谷草转氨酶(AST)、总胆红素(TSB)、胆碱酯酶、血清肌酐(SCr)、血尿素氮(BUN)、氨基末端脑钠肽前体(NT-proBNP)、D-二聚体(D-D)、白细胞计数(WBC)、中性粒细胞计数(NEU)、纤维蛋白原降解产物(FDP)、血小板(PLT)、纤维蛋白原(FIB)、C反应蛋白(CRP)、高敏肌钙蛋白、手术时间、ICU滞留时间、呼吸机带机时间、住院时间、肢体远端灌注不良、肾灌注不良方面均明显升高(P<0.05)。Logistic回归分析显示,性别(男)、有饮酒史、NT-proBNP≥271.86 ng/L、D-D≥0.74 mg/L和NEU≥13.06×10^(9)L^(-1)是ATAAD合并MPS患者术后死亡的独立危险因素(P<0.05)。NT-proBNP、D-D、性别(男)、饮酒史和NEU(简称“五因素”)联合预测ATAAD合并MPS患者的价值最高,其AUC为0.979(95%CI:0.937~0.984),灵敏度为94.3%,特异度为91.8%,高于独立预测指标。五因素联合预测的最佳临界值为5.02,>5.02组的生存率显著高于≤5.02组,Log Rank检验P<0.01。以ATAAD合并MPS患者术后死亡的重要因素建立预测模型,结果显示,模型具有良好的预测精准度。[结论]NT-proBNP≥271.86 ng/L、D-D≥0.74 mg/L、性别(男)、有饮酒史、NEU≥13.06×10^(9)L^(-1)是ATAAD合并MPS患者长期预后的独立危险因素,其联合应用可有效增加预后评估的准确性。

分步定位释放技术在Stanford B型主动脉夹层开窗治疗中的应用效果

目的探讨分步定位释放技术在缺乏近端锚定区的Stanford B型主动脉夹层开窗治疗中的疗效与安全性。方法收集2018年1月至2022年12月滨州医学院烟台附属医院收治的43例Stanford B型主动脉夹层患者的临床资料,所有患者的近心端第一破口累及左锁骨下动脉(LSA)或距离LSA小于15 mm。按照治疗方法的不同将Stanford B型主动脉夹层患者分为A组(n=18,采用传统定位方法重建弓上血运)和B组(n=25,采用分步定位释放技术重建弓上血运)。所有患者出院后随访3~12个月,比较两组患者围手术期和术后随访相关指标。结果所有患者均成功采用开窗技术处理主动脉弓部病变并保留弓上动脉。两组患者手术成功率均为100%,均未出现手术入路相关并发症。两组患者术前双侧肱动脉血压差比较,差异无统计学意义(P>0.05)。A组患者的手术时间短于B组患者,造影剂用量少于B组患者,差异均有统计学意义(P<0.05)。术后即刻造影显示,两组患者术后急性肾功能损伤、内漏的发生率比较,差异均无统计学意义(P>0.05)。A组患者术后双上肢肱动脉血压差明显大于B组患者,差异有统计学意义(P<0.01)。两组患者术后脊髓缺血、脑卒中、夹层复发、破溃死亡的发生率比较,差异均无统计学意义(P>0.05)。结论分步定位释放技术指导的开窗技术术后短期内患者脑卒中、脊髓缺血、复发、死亡的发生风险低。该术式对LSA的重建效果良好,术后双侧肱动脉血压差改善明显,现阶段值得在临床推广应用。

长途转移措施应用于主动脉夹层的临床效果

目的探讨长途转移措施应用于动脉夹层的临床效果及对患者心理状态的影响。方法选取连云港市急救中心2021年2月—2022年2月长途转运的41例主动脉夹层患者纳入本研究。按照不同的转运方式分为观察组与对照组。对照组21例行常规转运措施,观察组20例应用长途转移措施。观察2组转运成功率,比较2组治疗前后的焦虑自评量表(self rating anxiety scale,SAS)与抑郁自评量表(self-rating depressive scale,SDS)。结果干预后,2组患者SAS、SDS评分有所下降,观察组低于对照组(P<0.05)。对照组的转运成功率为70.00%,观察组的转运成功率为100%,2组比较差异有统计学意义(P<0.05)。结论长途转移措施应用于主动脉夹层中的临床效果确切,可以改善患者的心理状态,提高转运成功率,临床值得推广。

Hybrid treatment of recurring thoracoabdominal aortic aneurysm concomitant with retrograde type A aortic dissection

So far, standard therapy of complex thoracoabdominal aortic disease is open surgical repair requiring aortic clamping and replacement of the-involved segment. Despite significant improvements, morbidity and mortality of open surgery remain high. As a result, open surgery is often withheld owing to severe comorbidities of the patients. Endovascular technique has emerged as an alternative for treatment of these diseases in high risk patients,