本文關(guān)鍵詞： 主動脈夾層 主動脈夾層腔內(nèi)隔絕術(shù) 主動脈腔內(nèi)移植物 放大率 錨定區(qū)　出處：《第二軍醫(yī)大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：研究背景:主動脈夾層腔內(nèi)隔絕術(shù)(thoracic endovascular aortic repair,TEVAR)作為微創(chuàng)外科的代表,目前已經(jīng)成為了Stanford B型主動脈夾層(Stanford type B aortic dissection,TBAD)的主要治療方式。在主動脈夾層腔內(nèi)隔絕術(shù)前需要根據(jù)患者的影像學(xué)檢查的圖像上進(jìn)行的主動脈解剖學(xué)參數(shù)的測量結(jié)果,制定包括選擇合適的主動脈腔內(nèi)移植物在內(nèi)的術(shù)前計劃。在主動脈夾層腔內(nèi)隔絕術(shù)中,所選用的主動脈腔內(nèi)移植物需要錨定于近端正常的主動脈之上以避免如再發(fā)夾層等不良事件的發(fā)生,并且主動脈腔內(nèi)移植物的直徑需要與其錨定部位的主動脈的管徑需要形成一個合適的比值才能穩(wěn)固的錨定于主動脈內(nèi)部,這一比值即放大率。已有研究表明放大率與內(nèi)漏、再發(fā)夾層等術(shù)后不良事件相關(guān),但是放大率的選擇是否會影響術(shù)前計劃的實(shí)施以及對于近端沒有正常主動脈作為錨定區(qū)的患者如何選擇主動脈腔內(nèi)移植物的放大率,仍缺少研究證實(shí)。研究方法:首先對于現(xiàn)有關(guān)于主動脈夾層腔內(nèi)修復(fù)術(shù)前動脈管徑測量以及主動脈腔內(nèi)移植物放大率相關(guān)文獻(xiàn)、指南以及主動脈腔內(nèi)移植物使用說明書進(jìn)行回顧和分析。隨后回顧性分析本中心從1998年9月至2014年6月使用主動脈夾層腔內(nèi)隔絕術(shù)治療的Stanford B型主動脈夾層患者的住院資料、手術(shù)資料、隨訪資料和影像學(xué)檢查結(jié)果。通過對比發(fā)生計劃外主動脈腔內(nèi)移植物植入的病例和按計劃實(shí)施的病例,分析主動脈腔內(nèi)移植物錨定區(qū)和放大率等相關(guān)因素對于TEVAR術(shù)前計劃實(shí)施的影響,并探究有哪些原因會導(dǎo)致計劃外主動脈腔內(nèi)移植物植入,以及計劃外移植物所引起后果和對預(yù)后的影響。最后針對近端缺少正常主動脈管壁作為主動脈腔內(nèi)移植物錨定區(qū)的逆向撕裂的A型主動脈夾層患者實(shí)施新的兩階段策略治療,通過兩階段策略,第一階段人為創(chuàng)造和強(qiáng)化近端錨定區(qū),第二階段實(shí)施TEVAR手術(shù),從而避免因主動脈腔內(nèi)移植物及其放大率帶來的相關(guān)不良事件。研究結(jié)果:按照納入和排除標(biāo)準(zhǔn),共納入1998年9月至2014年6月在本中心使用TEVAR治療的322例Stanford B型主動脈夾層患者,其中有83例患者在TEVAR術(shù)中使用了超出術(shù)前計劃的主動脈腔內(nèi)移植物,占25.8%。兩組患者的的5年生存率無明顯統(tǒng)計學(xué)差異,但是使用了超出術(shù)前計劃的主動脈腔內(nèi)移植物的患者的手術(shù)時間、住院天數(shù)以及住院費(fèi)用均高與按計劃實(shí)施的患者。植入計劃外主動脈腔內(nèi)移植物的原因依次為Ⅰa型內(nèi)漏、鳥嘴現(xiàn)象、主動脈腔內(nèi)移植物塑性不良、Ⅰb型內(nèi)漏以及近端裂口未覆蓋。植入計劃外主動脈腔內(nèi)移植物的危險因素包括主動脈腔內(nèi)移植物遠(yuǎn)端放大率過大、近端錨定區(qū)較短、主動脈腔內(nèi)移植物較短等。隨后針對9例近端缺少正常主動脈管壁作為主動脈腔內(nèi)移植物錨定區(qū)的逆向撕裂的A型主動脈夾層患者采取了新的兩階段策略治療,通過第一階段使用彈簧圈聯(lián)合Onyx膠栓塞逆向撕裂的位于升主動脈及主動脈弓的假腔使9例患者的逆向撕裂的假腔完全血栓化,從而使第二階段TEVAR手術(shù)的主動脈腔內(nèi)移植物安全的錨定于其上,避免了因主動脈腔內(nèi)移植物及其放大率錨定于病變主動脈所可能引發(fā)的不良事件。平均12個月(6~18個月)的隨訪中,無再發(fā)夾層等并發(fā)癥出現(xiàn),無患者死亡。研究結(jié)論:主動脈腔內(nèi)移植物遠(yuǎn)端放大率過大、近端錨定區(qū)較短、主動脈腔內(nèi)移植物較短等因素容易引起Ⅰa型內(nèi)漏、鳥嘴現(xiàn)象、主動脈腔內(nèi)移植物塑性不良從而致使主動脈夾層腔內(nèi)隔絕術(shù)中計劃外主動脈腔內(nèi)移植物的使用。在主動脈夾層腔內(nèi)隔絕術(shù)前計劃時應(yīng)對于這些危險因素充分考慮。對于近端缺少正常主動脈作為錨定區(qū)的逆向撕裂的A型主動脈夾層,強(qiáng)化逆向撕裂的假腔作為錨定區(qū)以預(yù)防主動脈腔內(nèi)移植物及放大率相關(guān)不良事件是安全有效的治療方法。
[Abstract]:Background: endovascular graft exclusion (thoracic endovascular aortic repair, TEVAR) as the representative of minimally invasive surgery, has become a Stanford type B aortic dissection (Stanford type B aortic dissection, TBAD). The main treatment in endovascular exclusion of aortic dissection before surgery need according to the measurement results the aortic anatomic parameters of image examination of patients the imaging of the formulation, including the selection of appropriate endovascular aortic graft, preoperative planning. In endovascular aortic dissection, endovascular aortic graft to the proximal end anchored to the normal aorta above to avoid such as hairpin layer and the occurrence of adverse events, and endovascular aortic diameter shift the plant needs and anchoring parts of the aortic diameter need to form a suitable ratio to firmly anchored to the aorta Inside, the ratio of i.e.magnification. Studies have shown that the amplification rate and leakage, and postoperative adverse events such as hairpin layer, but the magnification will choose whether the magnification effect of the preoperative planning and for patients with proximal no normal aorta as the anchoring zone how to choose the main artery endovascular graft. Still, the lack of research confirmed. Research methods: first of all, for the existing of endovascular treatment of aortic dissection and aortic artery diameter measurement before endovascular graft magnification of related literature, guide and shift endovascular aortic were reviewed and analyzed. Then the plant manual retrospective analysis of Stanford type B aortic dissection patients in our center from September 1998 to June 2014 using endovascular aortic dissection exclusion in the treatment of the hospital information, operation information, examination results and follow-up data imaging. By comparing the place outside the main program Endovascular graft implantation in the cases and according to plan the implementation of case analysis of endovascular aortic graft anchoring and amplification effects on TEVAR related factors such as preoperative planning implementation, and explore what causes of unplanned endovascular aortic graft implantation, caused by the consequences and effects of plants on prognosis and shift plan abroad. Finally the lack of normal proximal aortic wall as the aortic lumen moved retrograde tear anchorage plant type A aortic dissection two stage of the implementation of the new treatment strategy, through two stage strategy, the first stage of human creation and strengthen the proximal anchoring area TEVAR surgery in the second stage, so as to avoid the adverse events for endovascular aortic graft and its magnification brings. Results: according to the inclusion and exclusion criteria, from September 1998 to June 2014 in our center were included in the treatment of TEVAR Treatment of 322 cases of Stanford type B aortic dissection patients, including 83 cases of TEVAR patients in the intraoperative use beyond the preoperative planning endovascular aortic graft, accounting for 25.8%. of the two groups of patients 5 year survival rate was no significant difference, but the operation time beyond the lumen of the preoperative planning of grafts patients, hospitalization and hospitalization costs were high and implemented according to the plan. The plan with implantation of endovascular aortic graft were the major causes of type Ia leakage, beak phenomenon, endovascular graft plastic, 1 B internal leakage and proximal gaps not covered. Implantation of unplanned endovascular aortic risk factor for graft including the endovascular distal to the graft amplification ratio is too large, the proximal anchoring area is relatively short, endovascular aortic graft short. Then according to the 9 cases of proximal aortic wall as a normal aortic lumen shift The reverse anchor region of the tear plant type A aortic dissection patients took two stage strategy for new, through the first stage with GDC and Onyx embolization of the retrograde tear in ascending aorta and aortic arch of the false lumen make retrograde tear in 9 patients complete thrombosis of the false lumen, so that the second phase of the aortic lumen the operation of the TEVAR graft anchored to its safety, avoid the adverse events for endovascular aortic graft and magnification anchored aortic may be triggered. An average of 12 months (6~18 months) of follow-up, no complications such as hairpin layer, no patients died. Conclusions: endovascular aortic graft plant distal magnification is too large, the proximal anchoring area is relatively short, aortic endovascular graft short cause type leakage, beak phenomenon, endovascular graft plastic bad so as a result of the initiative The use of endovascular aortic graft surgery in the cavity vein dissection program. In isolated aortic dissection endovascular preoperative planning should be fully considered. For these risk factors for type A aortic dissection proximal aortic retrograde tear normal as the anchoring zone, strengthen the retrograde tear of the false lumen as the anchoring zone to prevent aortic endovascular graft and magnification related adverse events is a safe and effective treatment method.

【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R654.3

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