主动脉疾病治疗现状及思考

doi:10.6040/j.issn.1671-7554.0.2024.0774

摘要/Abstract

摘要： 主动脉瘤和主动脉夹层是血管外科常见疾病。随着腔内技术的发展,主动脉疾病的治疗进入了一个崭新的阶段。由于主动脉不同部位的解剖条件和血流动力学特点不同,治疗中存在的难点、解决方案亦不同。本文对主动脉瘤和主动脉夹层在不同解剖部位的难点和解决方案进行了综述。关于升主动脉的动脉瘤或夹层的腔内治疗,其难点在于在收缩期和舒张期中主动脉管径变化大、锚定困难、锚定区短以及缺少适宜的支架。主动脉弓部疾病的腔内治疗中,目前由一些专科医师参与研发的分支支架或开窗技术在临床腔内治疗中总体取得较满意结果,但还存在技术难度高及与支架的分支数量呈正相关的神经系统并发症发生率的限制。另外,关于支架原位或预开窗技术是否对主动脉疾病腔内治疗的远期效果存在影响还需继续观察。对于累及胸腹主动脉的病变,其难点在于大量内脏分支血管的存在及支架术后并发内漏的问题,相关分支支架已经进入多中心临床实验阶段,其远期结果还需观察;对于解剖条件不满足的患者,如果全身状况允许,开放手术仍然是可靠的治疗方法。因此,未来关于主动脉瘤及主动脉夹层疾病的腔内治疗,一方面,在支架材料上还需要研发柔顺性更好的合适的支架材料;另一方面,要严格把握手术适应证,谨慎选择腔内治疗。

关键词: 主动脉瘤, 主动脉夹层, 腔内技术, 治疗, 支架

Abstract: Aortic aneurysm and aortic dissection are common diseases in vascular surgery. With the development of endovascular technology, the treatment of aortic diseases has entered a brand-new stage. Due to the different anatomical conditions and hemodynamic characteristics of lesions in different parts of aorta, the difficulties and solutions are also different. Therefore, this article reviews the difficulties and solutions for aortic aneurysm and aortic dissection at different anatomical sites. Regarding endovascular treatment of aneurysms or dissection in the ascending aorta, the difficulty lies in the large variation in the diameter of the aortic during systole and diastole, which makes anchoring difficult. On the other hand, there is a lack of suitable stents for patients with a short anchoring zone. In aortic arch disease, branch stenting or fenestration techniques have achieved overall satisfactory results, but there are still limitations in the occurrence of neurological complications due to high technical difficulty and positive correlation with the number of branches of the stent. Additionally, the in situ or pre-opening stenting technique may have potential impacts on the long-term treatment of aortic disease, which needs to been further observed. For lesions involving the thoracic and abdominal aorta, the difficulty lies in the presence of a large number of visceral branch vessels and the complication of endovascular fistulas after stenting. Relevant branch stents have already entered the stage of multicenter clinical trials, and their long-term results need to be observed. For patients whose anatomical conditions do not meet the requirements of endovascular treatment, open surgery remains a reliable method, if systemic conditions allow. Therefore, for future endovascular treatment of aortic aneurysm and aortic dissection, more flexibal stents are needed first; additionauy, vascular surgeons should strictly follow the indications and carefully select the endovascular treatment.

Key words: Aortic aneurysm, Aortic dissection, Endovascular technique, Treatment, Stent

中图分类号:

R543.1

陈忠,王盛. 主动脉疾病治疗现状及思考[J]. 山东大学学报 (医学版), 2024, 62(9): 1-6.

CHEN Zhong, WANG Sheng. Current status and reflections on the treatment of aortic disease[J]. Journal of Shandong University (Health Sciences), 2024, 62(9): 1-6.

参考文献

[1] Czerny M, Schoenhoff F, Etz C, et al. The impact of pre-operative malperfusion on outcome in acute type A aortic dissection: results from the GERAADA registry[J]. J Am Coll Cardiol, 2015, 65(24): 2628-2635.
[2] Evangelista A, Isselbacher EM, Bossone E, et al. Insights from the international registry of acute aortic dissection: a 20-year experience of collaborative clinical research[J]. Circulation, 2018, 137(17): 1846-1860.
[3] Geirsson A, Shioda K, Olsson C, et al. Differential outcomes of open and clamp-on distal anastomosis techniques in acute type A aortic dissection[J]. J Thorac Cardiovasc Surg, 2019, 157(5): 1750-1758.
[4] Uchida K, Karube N, Kasama K, et al. Early reperfusion strategy improves the outcomes of surgery for type A acute aortic dissection with malperfusion[J]. J Thorac Cardiovasc Surg, 2018, 156(2): 483-489.
[5] Conzelmann LO, Weigang E, Mehlhorn U, et al. Mortality in patients with acute aortic dissection type A: analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A(GERAADA)[J]. Eur J Cardiothorac Surg, 2016, 49(2): e44-e52. doi:10.1093/ejcts/ezv356.
[6] Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection(IRAD): new insights into an old disease[J]. JAMA, 2000, 283(7): 897-903.
[7] Dorros G, Dorros AM, Planton S, et al. Transseptal guidewire stabilization facilitates stent-graft deployment for persistent proximal ascending aortic dissection[J]. J Endovasc Ther, 2000, 7(6): 506-512.
[8] Wang CT, von Segesser LK, Maisano F, et al. Catheter-based treatment of the dissected ascending aorta: a systematic review[J]. Eur J Cardiothorac Surg, 2021, 59(1): 80-91.
[9] Tsai TT, Evangelista A, Nienaber CA, et al. Long-term survival in patients presenting with type A acute aortic dissection: insights from the International Registry of Acute Aortic Dissection(IRAD)[J]. Circulation, 2006, 114(1 Suppl): I350-I356.
[10] Sobocinski J, OBrien N, Maurel B, et al. Endovascular approaches to acute aortic type A dissection: a CT-based feasibility study[J]. Eur J Vasc Endovasc Surg, 2011, 42(4): 442-447.
[11] Moon MC, Greenberg RK, Morales JP, et al. Computed tomography-based anatomic characterization of proximal aortic dissection with consideration for endovascular candidacy[J]. J Vasc Surg, 2011, 53(4): 942-949.
[12] Huang C, Zhou M, Liu Z, et al. Computed tomography-based study exploring the feasibility of endovascular treatment of type A aortic dissection in the Chinese population[J]. J Endovasc Ther, 2014, 21(5): 707-713.
[13] Gore WL, Associates. Gore announces successful patient implant of endovascular stent graft for the ascending aorta[ES/OL].( 2018-08-27)[2024-07-23] https://www.gore.com/news-events/press-release/imp.ant-of-endovascular-stent-graft-ascending-aorta.
[14] Wisneski AD, Kumar V, Vartanian SM, et al. Toward endovascular treatment of type A aortic dissection with smaller landing zones and more patient eligibility[J]. J Vasc Surg, 2022, 75(1): 47-55.
[15] Kreibich M, Soekeland T, Beyersdorf F, et al. Anatomic feasibility of an endovascular valve-carrying conduit for the treatment of type A aortic dissection[J]. J Thorac Cardiovasc Surg, 2019, 157(1): 26-34.
[16] Felipe Gaia D, Bernal O, Castilho E, et al. First-in-human endo-bentall procedure for simultaneous treatment of the ascending aorta and aortic valve[J]. JACC Case Rep, 2020, 2(3): 480-485.
[17] Liu F, Zhang H, Rong D, et al. Protocol for Guos aortIc Arch recoNstrucTion: a prospective, multicentre and single-arm study to evaluate the safety and efficacy of the WeFlow-Arch modular inner branch stent-graft system for aortic arch lesions(GIANT study)[J]. BMJ Open, 2022, 12(10): e063245. doi: 10.1136/bmjopen-2022-063245.
[18] 杨鹏. 四川大学华西医院应用主动脉弓部创新一体式三分支支架完成国际首例BentalI术后复杂主动脉弓部夹层全腔内修复术[J]. 首都食品与医药, 2023, 30(22): 10-11.
[19] 左健, 刘金成, 俞世强, 等. 新型全腔内经股动脉三分支覆膜支架系统治疗主动脉弓部病变的FIM研究[J]. 中国普通外科杂志, 2024, 33(6): 894-900. ZUO Jian, LIU Jincheng, YU Shiqiang, et al. First-in-man study of a new femoral endovascular access supra-arch branched stent graft for the treatment of aortic arch disease[J]. China Journal of General Surgery, 2024, 33(6): 894-900.
[20] Spear R, Clough RE, Fabre D, et al. Total endovascular treatment of aortic arch disease using an arch endograft with 3 inner branches[J]. J Endovasc Ther, 2017, 24(4): 534-538.
[21] Tazaki J, Inoue K, Higami H, et al. Thoracic endovascular aortic repair with branched Inoue Stent Graft for arch aortic aneurysms[J]. J Vasc Surg, 2017, 66(5): 1340-1348.
[22] Czerny M, Rylski B, Morlock J, et al. Orthotopic branched endovascular aortic arch repair in patients who cannot undergo classical surgery[J]. Eur J Cardiothorac Surg, 2018, 53(5): 1007-1012.
[23] 秘家学, 戴向晨, 刘宗玮, 等. 体外预开窗TEVAR治疗主动脉弓部疾病的中期结果分析[J]. 血管与腔内血管外科杂志, 2021, 7(7): 773-777. BI Jiaxue, DAI Xiangchen, LIU Zongwei, et al. Midterm outcomes of physician-modified fenestrated tevar in the treatment of aortic arch diseases[J]. Journal of Vascular and Endovascular Surgery, 2021, 7(7): 773-777.
[24] 彭智猷, 金剑, 叶开创, 等. 鞘转流系统辅助下胸主动脉腔内修复术联合原位激光开窗治疗主动脉弓部病变的临床结果[J]. 中华血管外科杂志, 2022, 7(1): 43-47. PENG Zhiyou, JIN Jian, YE Kaichuang, et al. Clinical results of sheath-based bypass system-assisted thoracic endovascular aortic repair with in situ laser fenestration for aortic arch disease[J]. Chinese Journal of Vascular Surgery, 2022, 7(1): 43-47.
[25] Mangialardi N, Serrao E, Kasemi H, et al. Chimney technique for aortic arch pathologies: an 11-year single-center experience[J]. J Endovasc Ther, 2014, 21(2): 312-323.
[26] Yu HYH, Lindström D, Wanhainen A, et al. An updated systematic review and meta-analysis of pre-emptive aortic side branch embolization to prevent type II endoleaks after endovascular aneurysm repair[J]. J Vasc Surg, 2023, 77(6): 1815-1821.
[27] Gao JP, Zhang HP, Jia X, et al. A prospective, multicenter, single-arm clinical trial cohort to evaluate the safety and effectiveness of a novel stent graft system(WeFlow-JAAA)for the treatment of juxtarenal abdominal aortic aneurysm: A study protocol[J]. Front Cardiovasc Med, 2022, 9:1013834. doi: 10.3389/fcvm.2022.1013834.
[28] Guo W, He Y, Zhang H, et al. Total endovascular repair of complex thoracoabdominal/abdominal aortic aneurysms with a Four-Branched Off-the-Shelf G-Branch^TM Stent Graft[J]. Ann Vasc Surg, 2021, 71: 534. doi: 10.1016/j.avsg.2020.08.155.
[29] Dobson G, Flewitt J, Tyberg JV, et al. Endografting of the descending thoracic aorta increases ascending aortic input impedance and attenuates pressure transmission in dogs[J]. Eur J Vasc Endovasc Surg, 2006, 32(2): 129-135.
[30] Zacharoulis AA, Arapi SM, Lazaros GA, et al. Changes in coronary flow reserve following stent implantation in the swine descending thoracic aorta[J]. J Endovasc Ther, 2007, 14(4): 544-550.
[31] Vardoulis O, Coppens E, Martin B, et al. Impact of aortic grafts on arterial pressure: a computational fluid dynamics study[J]. Eur J Vasc Endovasc Surg, 2011, 42(5): 704-710.
[32] van Bakel TMJ, Arthurs CJ, Nauta FJH, et al. Cardiac remodelling following thoracic endovascular aortic repair for descending aortic aneurysms[J]. Eur J Cardiothorac Surg, 2019, 55(6): 1061-1070.

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