Arch-Bypass-in-Hybrid-Operation-for-Aortic-Dissection：对主动脉夹层的杂交手术弓旁路课件

1、夹层动脉瘤杂交手术弓上分支转流方式探讨Aortic Arch Bypass in Hybrid Operation for Aortic Dissection Aneurysm哈尔滨医科大学附属第二医院血管外科姜维良WEILIANG JIANGDept. of Vascular Surgery, 2nd Teaching Hosp.Harbin Medical University, Harbin, Heilongjiang, China 150086夹层动脉瘤杂交手术弓上分支转流Aortic Dissection Hybrid Operation with Arch Bypass 涉及主动脉

2、弓分支的夹层动脉瘤，通过外科手术改变供血位置，可以创造出腔内修复的条件，使得腔内修复手术可以进行。 Aortic Dissection involving arch braches can be repaired with the assistance of the surgical operations alternating the vessel anatomy and creating optimal settings for endovascular repair.病例资料 Cases我科共完成主动脉夹层EVAR 112例弓上分支转流 6例5.3%（6/112）Totally 112

3、cases of TEVAR for aortic dissection were performed in our unit, 6 (5.3%)of which with auxiliary arch bypass 病例资料Cases 转流原因Cause of bypass 同侧转流 Ipsilateral bypass 对侧转流Contralateral bypass弓上分支转位Arch branch translocation2左侧优势椎动脉 Left side predominant vertebral artery2 瘘口位于主动脉弓Arch entry1左颈动脉动脉瘤Aneurys

4、m on left carotid artery1Total 642弓上分支转流方式分类 Type of aortic arch bypass 1.同侧转位 颈动脉-锁骨下动脉 目的：重建左侧优势椎动脉血流2.对侧转位 颈-颈-锁骨下动脉 目的：重建左颈动脉左锁骨下动脉3.升主动脉转流 目的：重建弓上血运1. Ipsilateral：Carotid A.-SCA. aim：to reconstruct the dominant vertebral A.2. Contralateral： Carotid - Carotid SCA. aim：to reconstruct LCA. L. SCA.

5、3. Bypass of arch: aim：to reconstruct the arch branches 1.同侧转位 颈动脉-锁骨下动脉 Ipsilateral bypass: Carotid A.-SCA.1.锁骨下动脉-颈动脉 端侧吻合 （SCA-CA: end-to-side）2.颈动脉-锁骨下动脉 人造血管转流（CA-SCA: artificial graft bypass）2.对侧转位 颈-颈-锁骨下动脉Contralateral Bypass: CA-CA-SCA合理的重建方法尽量缩短颈动脉阻断时间Ideal methods should shorten the carot

6、id blocking time2.对侧转位 颈-颈-锁骨下动脉Contralateral Bypass：CA-CA-SCA可能延长颈动脉阻断时间的重建方式Styles that may prolong blocking time of carotid artery.3.升主动脉转流3. Bypass involving ascending aorta弓上分支转位病例同侧转流Case 1: arch branch translocation (Ipsilateral bypass)BYPASSCase 1BYPASSCase 1BYPASSCase 1BYPASSCase 1BYPASSCas

7、e 1锁骨下动脉-颈动脉转流前后对比Effect of Bypass转流前 Before Bypass转流后After BypassTEVAR手术后After TEVARCase 1锁骨下动脉-颈动脉 对端吻合(SCA-CA: end-to-end)右位主动脉弓夹层动脉瘤Case 2: aortic dissection with right sided aortic arch瘘口位于弓顶，食道受压，进食困难。Entry at the top of the arch, esophagus compressed and dysphasia developedCase 2双侧锁骨下动脉发自降主动脉

8、双侧颈动脉起自升主动脉Bilateral SCA arise from descending aorta, bilateral carotid A. from ascending aorta.Case 2锁骨下动脉-颈动脉同侧转流Ipsilateral Bypass from SCA to CACase 2Angiography of After EVARCase 2术后1个月复查CTA术后CTACTA Follow-up 1m after TEVARCase 2对侧转位 颈-颈-锁骨下动脉转流Contralateral bypass：Carotid - Carotid SCA.颈-颈-锁骨下

9、动脉人造血管转流Carotid - Carotid SCA：Artificial graft bypass瘘口位于主动脉弓病例Case 3： entry on the arch降主动脉多发瘘口 左侧血胸Multiple entry on descending aorta with left side hemothoraxCase 3弓上瘘口位置Entry on the archCase 3瘘口位于颈动脉开口附近Entry near Left Carotid ArteryCase 3Case 3BYPASS颈-颈动脉转流+左颈锁骨下动脉侧侧吻合CA-CA bypass+L. CA-SCA sid

10、e-side anastomosisCase 3TEVARCase 3Closed hemothorax drainage主动脉夹层伴左侧颈动脉受累病例Case 4: aortic dissection with left carotid artery involvement瘘口位置 entry positionCase 4Case 4BYPASS颈颈转流+颈锁骨下对端吻合CA-CA bypass + CA-SCA end-end anastomosisCase 4总结summary1.颈部杂交手术可以对瘘口位于主动脉弓的夹层进行TEVAR手术2.手术并发症发生率相对较低3.转流方式可以根据患

11、者情况个体化选择4.防止并发症发生的要点是尽量缩短颈动脉阻断时间Carotid hybrid operations make TEVAR procedure safe and possible for the aortic dissections with arch entries. With relatively low complication rate, the procedure can be customized for individual patient.Key point for complication prevention is to reduce the carotid artery blocki