1、夾層動脈瘤雜交手術弓上分支轉流方式探討Aortic Arch Bypass in Hybrid Operation for Aortic Dissection Aneurysm哈爾濱醫科大學附屬第二醫院血管外科姜維良WEILIANG JIANGDept. of Vascular Surgery, 2nd Teaching Hosp.Harbin Medical University, Harbin, Heilongjiang, China 150086夾層動脈瘤雜交手術弓上分支轉流Aortic Dissection Hybrid Operation with Arch Bypass 涉及主動脈

2、弓分支的夾層動脈瘤，通過外科手術改變供血位置，可以創造出腔內修復的條件，使得腔內修復手術可以進行。 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.病例資料 Cases我科共完成主動脈夾層EVAR 112例弓上分支轉流 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 病例資料Cases 轉流原因Cause of bypass 同側轉流 Ipsilateral bypass 對側轉流Contralateral bypass弓上分支轉位Arch branch translocation2左側優勢椎動脈 Left side predominant vertebral artery2 瘺口位于主動脈弓Arch entry1左頸動脈動脈瘤Aneurys

4、m on left carotid artery1Total 642弓上分支轉流方式分類 Type of aortic arch bypass 1.同側轉位 頸動脈-鎖骨下動脈 目的：重建左側優勢椎動脈血流2.對側轉位 頸-頸-鎖骨下動脈 目的：重建左頸動脈左鎖骨下動脈3.升主動脈轉流 目的：重建弓上血運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.同側轉位 頸動脈-鎖骨下動脈 Ipsilateral bypass: Carotid A.-SCA.1.鎖骨下動脈-頸動脈 端側吻合 （SCA-CA: end-to-side）2.頸動脈-鎖骨下動脈 人造血管轉流（CA-SCA: artificial graft bypass）2.對側轉位 頸-頸-鎖骨下動脈Contralateral Bypass: CA-CA-SCA合理的重建方法盡量縮短頸動脈阻斷時間Ideal methods should shorten the carot

6、id blocking time2.對側轉位 頸-頸-鎖骨下動脈Contralateral Bypass：CA-CA-SCA可能延長頸動脈阻斷時間的重建方式Styles that may prolong blocking time of carotid artery.3.升主動脈轉流3. Bypass involving ascending aorta弓上分支轉位病例同側轉流Case 1: arch branch translocation (Ipsilateral bypass)BYPASSCase 1BYPASSCase 1BYPASSCase 1BYPASSCase 1BYPASSCas

7、e 1鎖骨下動脈-頸動脈轉流前后對比Effect of Bypass轉流前 Before Bypass轉流后After BypassTEVAR手術后After TEVARCase 1鎖骨下動脈-頸動脈 對端吻合(SCA-CA: end-to-end)右位主動脈弓夾層動脈瘤Case 2: aortic dissection with right sided aortic arch瘺口位于弓頂，食道受壓，進食困難。Entry at the top of the arch, esophagus compressed and dysphasia developedCase 2雙側鎖骨下動脈發自降主動脈

8、雙側頸動脈起自升主動脈Bilateral SCA arise from descending aorta, bilateral carotid A. from ascending aorta.Case 2鎖骨下動脈-頸動脈同側轉流Ipsilateral Bypass from SCA to CACase 2Angiography of After EVARCase 2術后1個月復查CTA術后CTACTA Follow-up 1m after TEVARCase 2對側轉位 頸-頸-鎖骨下動脈轉流Contralateral bypass：Carotid - Carotid SCA.頸-頸-鎖骨下

9、動脈人造血管轉流Carotid - Carotid SCA：Artificial graft bypass瘺口位于主動脈弓病例Case 3： entry on the arch降主動脈多發瘺口 左側血胸Multiple entry on descending aorta with left side hemothoraxCase 3弓上瘺口位置Entry on the archCase 3瘺口位于頸動脈開口附近Entry near Left Carotid ArteryCase 3Case 3BYPASS頸-頸動脈轉流+左頸鎖骨下動脈側側吻合CA-CA bypass+L. CA-SCA sid

10、e-side anastomosisCase 3TEVARCase 3Closed hemothorax drainage主動脈夾層伴左側頸動脈受累病例Case 4: aortic dissection with left carotid artery involvement瘺口位置 entry positionCase 4Case 4BYPASS頸頸轉流+頸鎖骨下對端吻合CA-CA bypass + CA-SCA end-end anastomosisCase 4總結summary1.頸部雜交手術可以對瘺口位于主動脈弓的夾層進行TEVAR手術2.手術并發癥發生率相對較低3.轉流方式可以根據患

11、者情況個體化選擇4.防止并發癥發生的要點是盡量縮短頸動脈阻斷時間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