主动脉夹层腔内修复的现状与问题.ppt

Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital主动脉夹层腔内修复的现状与问题 Still waters run deep.流静水深流静水深,人静心深人静心深 Where there is life,there is hope。有生命必有希望。有生命必有希望Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital1999年年Dake和和Nienaber分别分别报道报道TEVAR技术治疗技术治疗急性急性B型主动脉夹层。型主动脉夹层。Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalTEVAR治疗15年来，在治疗理念、操作技术及支架器具方面都取得了较大进展，如在升主动脉夹层及弓部夹层领域也逐渐应用。长期的随访结果证实了TEVAR已成为B型夹层的首先治疗方式。内漏及逆撕等仍是需要继续攻克的难题。Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital 既往：急性期：发病14d内 慢性期：发病14d后 目前提出亚急性期，但定义不一：INSTEAD：2w-6w VIRTUE：14d-28d IRAD：8d-30d 目前基于安全性倾向于在亚急性期行TEVAR术临床分期临床分期Steuer,J.,Bjorck,M.,Mayer,D.,et al.,Distinction between acute and chronic type B aortic dissection:is there a sub-acute phase?Eur J Vasc Endovasc Surg,2013.45(6):627-31.Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital复杂性与非复杂性复杂性与非复杂性急性期复杂性：胸痛组织器官低灌注难治性高血压进行性主动脉周或胸膜腔血肿2周内主动脉直径增加1cm 慢性期复杂性：夹层动脉瘤直径大于5.5cm 复杂性复杂性AD如不处理有较高的死亡率，被认如不处理有较高的死亡率，被认为是为是TEVAR的绝对手术指征的绝对手术指征!Fattori,R.,Tsai,T.T.,Myrmel,T.,et al.,Complicated acute type B dissection:is surgery still the best option?:a report from the International Registry of Acute Aortic Dissection.JACC Cardiovasc Interv,2008.1(4):395-402.Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital非复杂非复杂TBAD中也有因假腔通畅而预后差的亚中也有因假腔通畅而预后差的亚群，所谓非复杂性可能是误称，还需要仔细群，所谓非复杂性可能是误称，还需要仔细分出真正稳定的分出真正稳定的AD！Augoustides,J.G.,Szeto,W.Y.,Woo,E.Y.,et al.,The complications of uncomplicated acute type-B dissection:the introduction of the Penn classification.J Cardiothorac Vasc Anesth,2012.26(6):1139-44.Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital临床分型4040多年前多年前De BakeyDe Bakey分型和分型和StanfordStanford分型分型20052005年景在平年景在平 “3N3V”“3N3V”分型分型 20092009年年AugoustidesAugoustides提出提出 Penn Penn分型分型 20132013年年DakeDake教授提出教授提出DISSECTDISSECT分类分类 Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalInstitute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalN:裸区裸区V：内脏区：内脏区Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalPenn classification of ischemic presentations in acute type A aortic dissectionNo ischemia(Penn class Aa)Localized ischemia(Penn class Ab)Generalized ischemia(Penn class Ac)Combined ischemia(Penn class Ab&c)localized and generalized ischemia togetherInstitute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalUniversity of Pennsylvania Classification of Acute Stanford Type-B Aortic DissectionClinical PresentationDefinition of Clinical Presentation ClassClass A(Uncomplicated)Absence of branch-vessel ischemia or circulatory compromiseType I high risk for future aortic complicationsType II low risk for future aortic complicationsClass B(Complicated)Branch-vessel malperfusionClass C(Complicated)Circulatory compromiseType-I aortic rupture with hemorrhage outside the aortic wall with/without cardiac arrest,shock,and hemothoraxType-II threatened aortic rupture typically heralded by refractory pain and/or hypertensionClass BC(Complicated)Branch-vessel malperfusion combined with circulatory compromiseInstitute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalDISSECT:Duration of dissectionIntimal tear(primary)location within the aortaSize of aorta Segmentalextent of aortic involvement from proximal to distal boundaryClinical complications related to dissectionThrombosis of aortic false lumenDake,M.D.,Thompson,M.,Van Sambeek,M.,et al.,DISSECT:A New Mnemonic-based Approach to the Categorization of Aortic Dissection.European Journal of Vascular and Endovascular Surgery,2013.46(2):175-190.Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital主动脉弓主动脉弓TEVAR Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital主动脉弓主动脉弓TEVAR 近左锁骨下破口：近左锁骨下破口：覆盖LSA 取得足够的锚定，但仍有截瘫风险重建LSA LCCA-LSA转流 LSA烟囱支架开窗开槽单分支支架Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalBrian J.Manning,Krassi Ivancev,Peter L.Harris，In situ fenestration in the aortic arch，Journal of Vascular Surgery Volume 52,Issue 2 2010 491-494LSA烟囱支架烟囱支架Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital开窗、开槽支架开窗、开槽支架Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital整体式整体式分体式分体式单分支支架单分支支架Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital微创微创 CastorInstitute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital近左颈总破口：近左颈总破口：杂交技术 RCCA-LCCA/RCCA-LCCA-LSA 烟囱技术 LCCA烟囱 LSA和LCCA双烟囱 分支支架+LCCA-LSA旁路 主动脉弓主动脉弓TEVAR Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital近无名破口：近无名破口：杂交技术 升主动脉-IA-LCCA-LSA旁路 烟囱技术 IA和LCCA双烟囱 三分支支架主动脉弓主动脉弓TEVAR Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital烟囱支架烟囱支架Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital三分支支架三分支支架Inoue K et al.Circulation 1999;100:II-316-Ii-321Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalMoon等通过CTA行对162例患者的升主动脉重建和精确测量，从解剖方面认为32%适合TEVAR，开口没有累及主动脉瓣和冠状动脉，具有合适的直径和长度以及足够的锚定区。升主动脉升主动脉TEVAR Moon,M.C.,Greenberg,R.K.,Morales,J.P.,et al.,Computed tomography-based anatomic characterization of proximal aortic dissection with consideration for endovascular candidacy.J Vasc Surg,2011.53(4):942-9.Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital保留冠脉灌注、主动脉瓣功能和弓上分支的血供是升主动脉夹层TEVAR手术成功的关键。以前认为破口距离冠状动脉开口至少2cm和距IA开口5mm才适合TEVAR，现在则距冠状动脉开口2cm和距IA开口5mm为关键点。升主动脉升主动脉TEVAR Ronchey,S.,Serrao,E.,Alberti,V.,et al.,Endovascular stenting of the ascending aorta for type A aortic dissections in patients at high risk for open surgery.Eur J Vasc Endovasc Surg,2013.45(5):475-80.Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital杂交手术 升主动脉置换+弓上三分支支架 单纯TEVAR覆盖破口 经右颈动脉 经股动脉 穿房间隔，经股动静脉升主动脉升主动脉TEVAR Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalInstitute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalG.Matthew Longo,Iraklis I.Pipinos Endovascular techniques for arch vessel reconstruction，Journal of Vascular Surgery Volume 52,Issue 4,Supplement 2010 77S-81SInstitute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalLu,Q.,Feng,J.,Zhou,J.,et al.,Endovascular repair of ascending aortic dissection:a novel treatment option for patients judged unfit for direct surgical repair.J Am Coll Cardiol,2013.61(18):1917-24.Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital选择的内支架要相对短（10cm）和较大直径（46cm），不推荐近端带有裸架的移植物，因为会损伤主动脉瓣并不能达到合适的锚定。也有报道在紧急情况给下将头端有裸架Talent移植物(Medtronic Inc,Minneapolis,MN)倒装后释放成功 升主动脉升主动脉TEVAR Mccallum,J.C.,Limmer,K.K.,Perricone,A.,et al.,Case report and review of the literature total endovascular repair of acute ascending aortic rupture:a case report and review of the literature.Vasc Endovascular Surg,2013.47(5):374-8.Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital46 100mm Talent or Valor graft Medtronic 40 100mm CTAG graft Gore 46 85 mm Jotec Cook off-the-shelf device for ascendingS.Ronchey,E.et al Endovascular Stenting of the Ascending Aorta for Type A Aortic Dissections in Patients at High Risk for Open Surgery,European Journal of Vascular and Endovascular Surgery Volume 45,Issue 5 2013 475-480Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital最新随访结果Fattori等报告IRAD试验从1995年到2012年收集的1 129例急性TBAD，其中药物组和TEVAR组的1年死亡率基本相同(9.8%vs.8.1%，p=0.604)，而TEVAR组的5年死亡率较低(15.5%vs.29.0%，p=0.018)。Fattori,R.,Montgomery,D.,Lovato,L.,et al.,Survival After Endovascular Therapy in Patients With Type B Aortic Dissection:A Report From the International Registry of Acute Aortic Dissection(IRAD).JACC:Cardiovascular Interventions,2013.6(8):876-882.Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital最新随访结果对于慢性TBAD，INSTEAD-XL实验结果表明TEVAR组比单独药物组具有较低的死亡率，能提高5年生存率和延缓病情进展，并且提到TEVAR可成为复杂性或非复杂性TBAD的一线治疗！Nienaber,C.A.,Kische,S.,Rousseau,H.,et al.,Endovascular Repair of Type B Aortic Dissection:Long-term Results of the Randomized Investigation of Stent Grafts in Aortic Dissection Trial.Circ Cardiovasc Interv,2013.6(4):407-16.Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital并发症及问题Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalDong Z H et al.Circulation 2009;119:735-741逆向撕裂成逆向撕裂成A型型Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital由于弓部的角度及支架的刚性使得两端对动脉壁造成损伤，所以TEVAR过程要考虑弓部形态学及支架的柔顺性，尽量选用近端无刚性裸架结构。支架节段的拐角与弓降部转角契合，防止“杠杆效应”及“鸟嘴”，减少内漏及支架移位。选择合适的放大率，目前我们认为是0-10%。Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital内 漏分5型：型内漏最常见，是型的五倍，与近端锚定区较短以及支架与弓的形态契合差、钙化较重密切相关。处理方法有球囊贴覆、增加Cuff或杂交手术。目前我们认识到假腔血栓化的重要性，一期或二期封堵远端高流量破口，从而保证TEVAR对主动脉重塑和远期治疗效果。Nienaber,C.A.,Kische,S.,Rousseau,H.,et al.,Endovascular Repair of Type B Aortic Dissection:Long-term Results of the Randomized Investigation of Stent Grafts in Aortic Dissection Trial.Circ Cardiovasc Interv,2013.6(4):407-16.Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalLudovic Canaud,et al Lessons learned from midterm follow-up of endovascular repair for traumatic rupture of the aortic isthmus Journal of Vascular Surgery Volume 47,Issue 4 2008 733-738Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalInstitute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan HospitalTEVAR后支架远端组织器官低灌注仍是死亡率较高的并发症目前大部分支架来源于针对动脉瘤设计，而AD特异性的腔内支架有待研发TEVAR常带来入路及器械相关并发症，支架输送系统还有很大进步空间对于合并马凡等结蹄组织病的AD，TEVAR的预后不良Criado,F.J.,Aortic dissection:a 250-year perspective.Tex Heart Inst J,2011.38(6):694-700.Institute of Vascular Surgery Fudan UniversityVascular SurgeryZhongshan Hospital小结小结关于AD的基础理论更新会带来治疗策略的调整目前长期的随访结果表明TEVAR是B型夹层的一线治疗，不论复杂或者非复杂性，TEVAR患者均能获得远期效益在弓部及升主动脉AD 行TEVAR仍有较大挑战，但前景光明支架及器具需进一步革新，减少相关并发症