Central nervous injury risk factors after endovascular repair of a thoracic aortic aneurysm with type B aortic dissection

Aortic dissection is the deadliest disease of the cardiovascular system.Type B aortic dissection accounts for 30%-60%of aortic dissections and is mainly treated by endovascular repair of thoracic endovascular aneurysm repair(TEVAR).However,patients are prone to various complications after surgery,with central nervous system injury being the most common,which seriously affects their prognosis and increases the risk of disability and death.Therefore,exploring the risk factors of central nervous system injury after TEVAR can provide a basis for its prevention and control.AIM To investigate the risk factors for central nervous system injury after the repair of a thoracic endovascular aneurysm with type B aortic dissection.METHODS We enrolled 306 patients with type B aortic dissection who underwent TEVAR at our hospital between December 2019 and October 2022.The patients were categorized into injury(n=159)and non-injury(n=147)groups based on central nervous system injury following surgery.The risk factors for central nervous system injury after TEVAR for type B aortic dissection were screened by comparing the two groups.Multivariate logistic regression analysis was performed.RESULTS The Association between age,history of hypertension,blood pH value,surgery,mechanical ventilation,intensive care unit stay,postoperative recovery times on the first day after surgery,and arterial partial pressure of oxygen on the first day after surgery differed substantially(P<0.05).Multivariate logistic regression analysis indicated that age,surgery time,history of hypertension,duration of mechanical ventilation,and intensive care unit stay were independent risk factors for central nervous system injury after TEVAR of type B aortic dissection(P<0.05).CONCLUSION For high-risk patients with central nervous system injury after TEVAR of type B aortic dissection,early intervention measures should be implemented to lower the risk of neurological discomfort following surgery in high-risk patients with central nervous system injury after TEVAR for type B aortic dissection.

Value of digital subtraction angiography in endovascular graft exclusion for abdominal aortic aneurysms

Objective: To evaluate the value of digital subtraction angiography (DSA) in management of endovascular graft exclusion (EVGE) for abdominal aortic aneurysms. Methods: Monitored by DSA and fluoroscopy, stent-graft complex were introduced into the aneurysm sac via femoral arteries and were deployed at the proximal and distal necks to exclude the sac from circulation. Results: The success rate of deployment was 94. 74% (36/38). Endoleaks occurred in 4 cases. One converted to open surgery because of sac rupture 4 days after deployment. Thrombosis and stenosis occurred in 2 cases. Three patients died shortly after the operation (< 3 months). Conclusion: DSA can monitor EVCE on real-time throughout the whole procedure. It can meet the needs of measurement, location, evaluating, detecting, and also can be much helpful in correcting complications. Moreover, it provides large visual field and operating space, and is a very important monitoring method for EVGE.

Standards of endovascular graft exclusion for abdominal aortic aneurysms

Objective: To discuss the standards of endovascular graft exclusion (EVGE) for abdominal aortic aneurysms (AAAs). Methods: The results of our primary experiences for the evidence of standards was summarized. Results: Standards of operating success, cure and procedure failure were put forward. Some relative questions on EVGE were also answered. Conclusion: EVGE is a kind of new conceptive therapy for AAAs in China. More cases should be evaluated in the future to modify it.

Endovascular treatment of intracranial dissecting aneurysm

Objective To analyze the clinical features of intracranial dissecting aneurysm and summarize the experience of its endovascular embolization. Methods 16 cases of intracranial dissecting aneurysm were treated by endovascular embolization. Among these 16 patients,3 patients were treated with single stent or double

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.

Relationship between acute kidney injury before thoracic endovascular aneurysm repair and in-hospital outcomes in patients with type B acute aortic dissection

Objective Acute kidney injury （AKI） frequently occurs after catheter-based interventional procedures and increases mortality. However, the implications of AKI before thoracic endovascular aneurysm repair （TEVAR） of type B acute aortic dissection （AAD） remain unclear. This study evaluated the incidence, predictors, and in-hospital outcomes of AKI before TEVAR in patients with type B AAD. Methods Between 2009 and 2013, 76 patients were retrospectively evaluated who received TEVAR for type B AAD within 36 h from symptom onset. The patients were classified into no-AKI vs. AKI groups, and the severity of AKI was further staged according to kidney disease： im- proving global outcomes criteria before TEVAR. Results The incidence of preoperative AKI was 36.8%. In-hospital complications was significantly higher in patients with preoperative AKI compared with no-AKI （50.0% vs. 4.2%, respectively; P 〈 0.001）, including acute renal failure （21.4% vs. O, respectively; P 〈 0.001）, and they increased with severity of AKI （P 〈 0.001）. The maximum levels of body tem- perature and white blood cell count were significantly related to maximum serum creatinine level before TEVAR. Multivariate analysis showed that systolic blood pressure on admission （OR： 1.023; 95% CI： 1.003-1.044; P ： 0.0238） and bilateral renal artery involvement （OR： 19.076; 95% CI： 1.914 190.164; P = 0.0120） were strong predictors of preoperative AKI. Conclusions Preoperative AKI frequently occurred in patients with type B AAD, and correlated with higher in-hospital complications and enhanced inflammatory reaction. Systolic blood pressure on admission and bilateral renal artery involvement were major risk factors for AKI before TEVAR.

Endovascular graft exclusion for descending thoracic aortic dissections

Objective: To assess the operation indications, preoperative evaluation, technique essential and clinical prospective of Endovascular Graft Exclusion for thoracic aortic dissection. Methods: Since September 1998, Endovascular Graft Exclusion for thoracic aortic dissection has been performed on 10 patients. Graft was constructed from self-expanding Z-stents covered with a woven Dacron polyester fabric graft. Ged dimensions were determined ftom spiral computed tomographic scans. All operations were performed under DSA guidance. Results: There was one early death resulting from endoleaks. Proedures in the other 9 patients succeeded. No complications such as myocardial infarction, lung failure, kidney failureand paralysis that commonly occurred ther conventional operations were obsered. Immediate thrombosis in false lumen was achieved in 6 patients, and late thrombosis occurred in 3 patients. Mean follow-up duration was 3 months, the aneurysmal diameter was decreased obviously. Conclusion: These early results support the hypothesis that Endovascular Graft Exclusion may be a safe and durable treatment for selected patients with theracic aortic dissection. Endoleak may allow continued aneurysmal expansion and rupture. Further follow-up is necessary to evaluate the true long-term effectiveness of this procedure.

Reconstructive treatment of symptomatic vertebral artery dissecting aneurysms with Willis covered stent: Initial experience

Background:Symptomatic vertebral artery dissecting aneurysm(VADA)is a challenging disease with controversy on treatment strategy due to anatomic configuration and their nature.Moreover,the outcomes of reconstructive treatment have not been well established.Objective:To evaluate the safety and efficacy of reconstructive endovascular treatment(EVT)for symptomatic VADAs with Willis covered stent.Methods:We evaluated retrospectively 13 patients with symptomatic VADAs who treated with Willis covered stent,compared with stent-assisted coiling(SAC)on the characteristics,posttreatment course,angiographic and clinical follow-up outcomes at an average of 14.4 months(range,3-48 months).Results:A total of 33 patients with symptomatic VADAs were reviewed,23 of these patients with ruptured VADAs.The technical successful rate is 100%respectively in Willis covered stent(Group A)and SAC(Group B,n=20).The initial complete occlusion rate was significant higher in group A(100%)than group B(30%)(p<0.01).Major procedure-related complications were not significant different in the two groups.Serial follow-up angiograms revealed 5 recurrent VADAs in group B and no recurrence in group A(p>0.05).No obvious in-stent stenosis and no re-hemorrhage and delayed ischemic symptoms during the follow-up period.The final angiograms of all survived patients demonstrated the complete occlusion rate was higher in group A(100%)than group B(80%),but no significant statistical difference(p>0.05).Clinical outcomes were favorable in 31(93.9%),severe disability occurred in one in group B,and only one death in group A.The final clinical outcomes were also not significant difference in the two groups(p>0.05).Conclusions:Our initial result demonstrated reconstructive EVT with Willis covered stent provides a viable approach for selected symptomatic VADAs involving the intracranial and extracranial segments,which is similar to favorable results with SAC.However,an expanded clinical experiences and larger cohort studies are needed.

Surgical Treatment of Aortic Aneurysm and Aortic Dissection:A Retrospective Analysis of 122 Cases

The study summarizes the clinical experience of surgical treatments of various types of thoracic aneurysm and aortic dissection. Clinical data of 122 patients with thoracic aneurysm and aortic dissection during July 2005 to July 2008 were retrospectively analyzed. The elective operations were performed in 107 patients while emergency surgery was done in 15 cases. Different surgical strategies were employed on the basis of diseased region, including simple ascending aortic replacement （n=3）, aortic root replacement （n=43）, hemi-arch replacement/total arch replacement ＋ elephant trunk technique （n=32）, thoracic/thoracoabdominal aortic replacement （n=8） and endovascular repair （n=36）. In this series, there is 4 cases of perioperative death due to massive cerebral hemorrhage （n=1）, respiratory failure （n=1） and multiple organ dysfunction syndrome （MODS） （n=2）. Three cases developed post-operative massive cerebral infarction and the relatives of the patients abandoned treatment. Instant success rate of endovascular repair was 100%. The intimal rupture was sealed. Blood flow was unobstructed in true lumen and no false lumen was visualized. It was concluded that aggressive surgery should be considered in the patients with thoracic aneurysm and aortic dissection. Surgical procedures should vary with the location and the nature of the lesions.

A Case of Thoracic Aortic Aneurysm with Hemoptysis as the First Symptom

This article reports a case of thoracic aortic aneurysm with hemoptysis as the first clinical manifestation, hemoptysis as the first clinical manifestation is very uncommon and to the best of our knowledge, only twenty of such cases have been previously reported. The case report presented here constitutes the longest course of the disease reported in medical literature, and good recovery after thoracic endovascular aortic repair, may help us to increase the understanding and diagnosis of the disease.

血管内治疗小脑后下动脉瘤24例临床经验

目的 探讨血管内治疗小脑后下动脉(PICA)瘤的治疗策略、安全性及临床疗效。方法 回顾性分析安徽医科大学第一附属医院2017年7月至2022年1月行血管内治疗的24例PICA动脉瘤病人的临床资料(其中,PICA近端13例、过渡段1例、远端10例;以蛛网膜下腔出血首诊的21例、未破裂动脉瘤3例),单纯栓塞12例、动脉瘤及载瘤动脉闭塞7例(闭塞材料使用弹簧圈3例、Onyx胶4例)、支架辅助弹簧圈栓塞5例。术后随访3~24个月。结果 24例PICA动脉瘤病人术中动脉瘤均栓塞顺利。23例病人无近期并发症,1例出血病人合并严重脑血管痉挛自动出院(临床预估死亡)。随访结果:19病人远期随访无复发;4例复发,其中2例二期行支架辅助栓塞,后期随访良好、未再复发;1例首次支架辅助栓塞病人再次行穿支架网孔弹簧圈单纯栓塞,后期随访良好、未再复发;1例首次单纯栓塞病人再次行弹簧圈栓塞,后期随访良好、未再复发。结论 血管内治疗PICA动脉瘤安全、可行,疗效可靠。根据动脉瘤血管解剖位置,对于破裂出血的PICA动脉瘤首次治疗倾向单纯栓塞或载瘤动脉闭塞术。首次单栓病例术后复发,可二期行支架辅助栓塞能取得满意效果。对于复发动脉瘤经再次血管内治疗可获得满意效果。

3D打印联合影像融合技术在主动脉腔内治疗教学中的应用

探讨3D打印联合影像融合技术在血管外科主动脉疾病腔内治疗教学中应用的效果。2020年3月至2023年10月在解放军总医院第一医学中心血管外科进行住院医师规范化轮转培训的60名学员的教学结果显示,该方法能提升学员学习兴趣,使其快速掌握主动脉瘤的解剖结构,了解腔内治疗的基本原理和技能,为血管外科临床教学模式改进提供新的思路。

B型主动脉夹层患者TEVAR术中应用股动脉穿刺预置缝合技术与股动脉切开技术的效果对比分析

目的:对比在B型主动脉夹层患者胸主动脉腔内修复术(Thoracic Endovascular Aneurysm Repair,TEVAR)术中应用股动脉穿刺预置缝合技术与股动脉切开技术的效果。方法:回顾性收集2020年4月至2023年4月期间于本院血管外科行TEVAR术治疗的137例B型主动脉夹层患者的临床资料。根据手术方式不同,将患者分为切开组(采用股动脉切开术,68例)和缝合组(采用股动脉穿刺预置缝合术,69例)。分析比较两组的手术指标及康复情况、生活质量及并发症(术后住院期间)发生情况。结果:缝合组的手术时间、术后下床活动时间及住院时间均显著短于切开组,术中出血量显著少于切开组(P<0.05)。缝合组术后6 m及1 y的生活质量评分均显著高于切开组(P<0.05)。两组的术后并发症发生率无显著差异(P>0.05)。结论:与股动脉切开技术比较,EVAR术中应用股动脉穿刺预置缝合技术可缩短B型主动脉夹层患者手术时间、术后下床活动时间及住院时间,减少术中出血量,改善生活质量,且安全性较高。

血流导向装置治疗椎动脉夹层动脉瘤疗效分析

目的探讨Pipeline血流导向装置(pipeline embolization divice,PED)治疗椎动脉夹层动脉瘤(vertebral artery dissecting aneurysm,VADA)的安全性及疗效。方法回顾性收集2019年1月至2023年6月新疆医科大学第一附属医院神经外科采用PED治疗的21例VADA患者的临床资料,记录手术方式、围手术期并发症、影像学结果并进行随访。以改良Rankin量表评分(mRS)评估患者预后,影像学随访采用Kamran分级。结果21例患者中未破裂动脉瘤17例,破裂动脉瘤4例。共置入22枚PED,其中13例患者接受单纯PED置入,8例患者接受PED联合弹簧圈栓塞,技术成功率21/21。3例破裂动脉瘤患者近端合并有狭窄,1例患者狭窄率>50%,因此额外放置了1枚Solitaire支架进行支架内后扩张。术后即时Kamran分级1级16例,2级1例,3级4例。围手术期并发症2例,1例患者发生动脉瘤术后破裂,1例患者肺部重症感染最终死亡。出院时mRS评分1分15例,2分2例,3分1例,4分1例,6分2例。18例患者获得随访,中位随访时间为12.5(6~30)个月,其中mRS评分0分13例,1分4例,2分1例;Kamran分级2级2例,3级4例,4级12例。结论采用PED治疗VADA手术成功率高、安全性好,但围手术期并发症不可忽视,未来仍需大量样本进一步研究。

血管内治疗椎动脉夹层动脉瘤的疗效分析

目的对椎动脉夹层动脉瘤(VADA)进行血管内治疗的安全性和有效性进行综合分析。方法回顾性纳入2020年1月至2022年12月期间在苏州大学附属第一医院神经外科接受血管内治疗的45例颅内段椎动脉夹层动脉瘤患者,收集一般资料和临床资料,其中一般资料包括年龄、性别和血管危险因素等,临床资料包括动脉瘤的基本特征(动脉瘤的长径、是否位于椎动脉优势侧、与同侧小脑后下动脉的关系)、治疗结果和随访资料等。随访资料包括CT血管成像(CTA)和/或数字减影血管造影(DSA)等影像学资料以及门诊及电话进行的临床预后资料。术后6个月进行脑血管造影术,随后每1-2年进行影像学及临床随访。结果在45例椎动脉夹层动脉瘤患者中,方案包括载瘤动脉闭塞治疗3例、单纯支架置入术2例、支架辅助弹簧圈栓塞治疗28例、密网孔支架置入术12例。2例VADA破裂患者(均累及小脑后下动脉)行支架辅助弹簧圈栓塞治疗,术后1周内因动脉瘤再次破裂而死亡,死亡率为4.4%。42例患者完成了术后6个月的影像学(DSA)随访,随访时间为6-12个月,中位随访时间为7个月。DSA随访结果显示,38例患者动脉瘤治愈(占90.5%),4例改善(9.5%);43例患者完成了术后6个月的临床随访,结果显示43例(100%)患者均预后良好。结论以上数据表明,VADA患者采用血管内治疗方案安全、有效,但该结论还需在更大规模的队列中进一步验证。

急性Stanford A型主动脉夹层患者术后脊髓损伤的危险因素分析

目的分析急性Stanford A型主动脉夹层患者接受全主动脉弓部人工血管替换(total aortic arch replacement,TAAR)联合冷冻象鼻技术(frozen elephant trunk,FET)治疗后脊髓损伤(spinal cord injury,SCI)的危险因素。方法回顾性收集2017年9月至2023年6月广东省人民医院接受TAAR联合FET治疗的698例急性Stanford A型主动脉夹层患者临床资料,其中48例术后发生SCI的患者设置为SCI组,其余650例患者为非SCI组,使用多因素Logistic回归分析术后SCI的危险因素。结果单因素分析结果显示,两组在糖尿病史、脑血管病史、纤维蛋白原含量、发自假腔肋间动脉数量、第6、9、12胸椎水平真腔面积、体外循环前乳酸水平、主动脉阻断时间、体外循环时间、手术时间、重症监护病房停留时间、总住院时间以及术后发生急性肺损伤、急性肾损伤、消化道出血、多器官功能障碍综合征、死亡/自动出院比例等方面的差异有统计学意义。多因素分析结果显示,糖尿病史(OR=7.539,95%CI=2.303~24.683,P<0.001)和脑血管病史(OR=4.494,95%CI=1.639~12.325,P=0.004)是患者接受TAAR联合FET术后发生SCI的独立危险因素。结论对于有糖尿病和脑血管病史的急性Stanford A型主动脉夹层患者,应避免术后低血压,预防SCI的发生。

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。

胸腹主动脉瘤精准外科诊疗体系构建及应用

胸腹主动脉瘤(TAAA)累及主动脉及胸腹段多支内脏动脉和脊髓供血动脉,但因动脉病变受累范围广、异质性高,手术重建主动脉及多支内脏动脉难度较大,围手术期病死率及截瘫、脏器缺血等严重并发症发生率较高,因此,TAAA患者需要制定个体化的临床诊治策略。本述评归纳总结中国医学科学院北京协和医学院北京协和医院TAAA精准外科诊疗体系的构建与应用,通过改良传统术式建立TAAA全腔内治疗体系,应用血流仿真模型制定手术策略,优化特殊病因TAAA的诊疗策略,从而提升TAAA的诊治水平,改善患者的预后情况,以期为TAAA的诊治提供参考。

腹主动脉腔内修复术栓塞单侧髂内动脉术后臀肌跛行危险因素及步行锻炼的效果分析

目的探索腹主动脉瘤腔内修复术(endovascular aortic repair,EVAR)联合髂内动脉栓塞术后患者出现臀肌跛行的危险因素,以及运动锻炼对臀肌跛行的治疗效果。方法回顾性分析2020年1月至2022年12月南京大学医学院附属鼓楼医院119例行EVAR联合髂内动脉栓塞术患者的临床资料。术后随访判断臀肌跛行相关情况,并结合患者情况和术前影像资料分析EVAR术后出现臀肌跛行的危险因素。鼓励2021年2月之后出现臀肌跛行的患者进行为期6个月的步行锻炼,通过与未进行步行锻炼的患者比较分析步行锻炼对臀肌跛行症状的治疗效果。结果47例(39.5%)患者术后出现臀肌跛行症状。多因素Logistic回归分析显示,髂内动脉合并附壁血栓(OR=2.244,95%CI=1.035~4.868,P=0.041)和髂内动脉远端分支数量<2支(OR=2.361,95%CI=1.060~5.258,P=0.035)是EVAR联合髂内动脉栓塞术后臀肌跛行的独立危险因素。完整参与步行锻炼和未参与步行锻炼的患者报告臀肌跛行症状好转的比例分别为52.9%和50.0%,差异无统计学意义(χ2=0.029,P=0.866);完整参与步行锻炼患者的恢复时间为(6.2±2.2)个月,显著短于未参与步行锻炼患者的(9.4±3.7)个月,差异有统计学意义(t=2.159,P=0.047)。结论髂内动脉合并血栓形成及髂内动脉远端分支数量不足2支是EVAR联合髂内动脉栓塞术后出现臀肌跛行的独立危险因素。规律的运动锻炼并不能改变臀肌跛行的治愈率,但能加快部分患者的恢复时间。

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。