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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,涉及主动脉弓分
2、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 c
3、ases of TEVAR for aortic dissection were performed in our unit,6(5.3%)of which with auxiliary arch bypass,病例资料Cases,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 vert
4、ebral A.2.Contralateral：Carotid-Carotid SCA.aim：to reconstruct LCA.L.SCA.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 Bypa
5、ss: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 carotid blocking time,2.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(Ipsil
6、ateral bypass),BYPASS,Case 1,BYPASS,Case 1,BYPASS,Case 1,BYPASS,Case 1,BYPASS,Case 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 Bypass,TEVAR手术后After TEVAR,Case 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
7、at the top of the arch,esophagus compressed and dysphasia developed,Case 2,双侧锁骨下动脉发自降主动脉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 CA,Case 2,Angiography of After EVAR,Case 2,术后1个月复查CTA,术后CTA,CTA Fo
8、llow-up 1m after TEVAR,Case 2,对侧转位 颈-颈-锁骨下动脉转流Contralateral bypass：Carotid-Carotid SCA.,颈-颈-锁骨下动脉人造血管转流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 hemothorax,Case 3,弓上瘘口位置Entry on the arch,Case 3,瘘口位于颈动
9、脉开口附近Entry near Left Carotid Artery,Case 3,Case 3,BYPASS,颈-颈动脉转流+左颈锁骨下动脉侧侧吻合CA-CA bypass+L.CA-SCA side-side anastomosis,Case 3,TEVAR,Case 3,Closed 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 position,Case 4,Case 4,BYPASS,颈颈转流+颈锁骨下对端吻合CA
10、-CA bypass+CA-SCA end-end anastomosis,Case 4,总结summary,1.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 blocking time as much as possible.,Thanks for your attention！,谢谢！,Dept.of Vascular Surgery,2nd Teaching Hosp.Harbin Medical University,Harbin,Heilongjiang,China哈尔滨医科大学附属第二医院 血管外科,
