主动脉腔内移植物锚定区和放大率对TEVAR手术影响的研究

发布时间：2018-02-27 12:03

本文关键词： 主动脉夹层主动脉夹层腔内隔绝术主动脉腔内移植物放大率锚定区　出处：《第二军医大学》2017年硕士论文　论文类型：学位论文

【摘要】：研究背景:主动脉夹层腔内隔绝术(thoracic endovascular aortic repair,TEVAR)作为微创外科的代表,目前已经成为了Stanford B型主动脉夹层(Stanford type B aortic dissection,TBAD)的主要治疗方式。在主动脉夹层腔内隔绝术前需要根据患者的影像学检查的图像上进行的主动脉解剖学参数的测量结果,制定包括选择合适的主动脉腔内移植物在内的术前计划。在主动脉夹层腔内隔绝术中,所选用的主动脉腔内移植物需要锚定于近端正常的主动脉之上以避免如再发夹层等不良事件的发生,并且主动脉腔内移植物的直径需要与其锚定部位的主动脉的管径需要形成一个合适的比值才能稳固的锚定于主动脉内部,这一比值即放大率。已有研究表明放大率与内漏、再发夹层等术后不良事件相关,但是放大率的选择是否会影响术前计划的实施以及对于近端没有正常主动脉作为锚定区的患者如何选择主动脉腔内移植物的放大率,仍缺少研究证实。研究方法:首先对于现有关于主动脉夹层腔内修复术前动脉管径测量以及主动脉腔内移植物放大率相关文献、指南以及主动脉腔内移植物使用说明书进行回顾和分析。随后回顾性分析本中心从1998年9月至2014年6月使用主动脉夹层腔内隔绝术治疗的Stanford B型主动脉夹层患者的住院资料、手术资料、随访资料和影像学检查结果。通过对比发生计划外主动脉腔内移植物植入的病例和按计划实施的病例,分析主动脉腔内移植物锚定区和放大率等相关因素对于TEVAR术前计划实施的影响,并探究有哪些原因会导致计划外主动脉腔内移植物植入,以及计划外移植物所引起后果和对预后的影响。最后针对近端缺少正常主动脉管壁作为主动脉腔内移植物锚定区的逆向撕裂的A型主动脉夹层患者实施新的两阶段策略治疗,通过两阶段策略,第一阶段人为创造和强化近端锚定区,第二阶段实施TEVAR手术,从而避免因主动脉腔内移植物及其放大率带来的相关不良事件。研究结果:按照纳入和排除标准,共纳入1998年9月至2014年6月在本中心使用TEVAR治疗的322例Stanford B型主动脉夹层患者,其中有83例患者在TEVAR术中使用了超出术前计划的主动脉腔内移植物,占25.8%。两组患者的的5年生存率无明显统计学差异,但是使用了超出术前计划的主动脉腔内移植物的患者的手术时间、住院天数以及住院费用均高与按计划实施的患者。植入计划外主动脉腔内移植物的原因依次为Ⅰa型内漏、鸟嘴现象、主动脉腔内移植物塑性不良、Ⅰb型内漏以及近端裂口未覆盖。植入计划外主动脉腔内移植物的危险因素包括主动脉腔内移植物远端放大率过大、近端锚定区较短、主动脉腔内移植物较短等。随后针对9例近端缺少正常主动脉管壁作为主动脉腔内移植物锚定区的逆向撕裂的A型主动脉夹层患者采取了新的两阶段策略治疗,通过第一阶段使用弹簧圈联合Onyx胶栓塞逆向撕裂的位于升主动脉及主动脉弓的假腔使9例患者的逆向撕裂的假腔完全血栓化,从而使第二阶段TEVAR手术的主动脉腔内移植物安全的锚定于其上,避免了因主动脉腔内移植物及其放大率锚定于病变主动脉所可能引发的不良事件。平均12个月(6~18个月)的随访中,无再发夹层等并发症出现,无患者死亡。研究结论:主动脉腔内移植物远端放大率过大、近端锚定区较短、主动脉腔内移植物较短等因素容易引起Ⅰa型内漏、鸟嘴现象、主动脉腔内移植物塑性不良从而致使主动脉夹层腔内隔绝术中计划外主动脉腔内移植物的使用。在主动脉夹层腔内隔绝术前计划时应对于这些危险因素充分考虑。对于近端缺少正常主动脉作为锚定区的逆向撕裂的A型主动脉夹层,强化逆向撕裂的假腔作为锚定区以预防主动脉腔内移植物及放大率相关不良事件是安全有效的治疗方法。
[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.

【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R654.3

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