treatment of aortic dissection

treatment of aortic dissection

academic jour Biomedical Engineering and Clinical "-2001 interventional treatment of aortic dissection and clinical application of experimental
Interventional treatment of experimental aortic dissection and clinical application of Experimental and Clinical Study on Interventional Treatment of Aortic DissectionYou can in the "My Services" in the you add a reference to the notification list, and configure access to notices.Interventional treatment of aortic dissection is the treatment of the disease in recent years, a new method, experimental and clinical application of methods of intervention have proven safety, efficacy, feasibility, but the method of intervention are still some problems. Of: Pang Zhanquan PANG Zhan-quan Zhen Hospital, Capital Medical University,; Kailuan Hospital of Tangshan, Title: Biomedical Engineering and Clinical ISTIC English Title: BIOMEDICAL ENGINEERING AND CLINICAL MEDICINE, the volume (of) : 2001 5 (1) Classification: R816.2 Key words: aortic aneurysm stent intervention unit standard DOI: R73 TM1 machine standard Key words: aortic dissection treatment of experimental clinical application of new interventional interventional Method method prove the security of Fund projects: DOI: References (27) Braunwald EHeart disease: A textbook of cardiovascular medicine 5th 1997 Qinwen Han intramural aortic aneurysm in 1985 Sun Yanqing Surgical treatment of aortic dissection [Papers] - Chinese Journal of Surgery 1984 (11) Blanton PS Jr.Muller WH Jr.Warr

en WDExperimental production of d issecti959 Carney WI Jr.Rheinlander HF.Cleveland RJControl of aortic dissec ti975 Trent MS.Parsonnet V. Shoenfeld RA balloon-expandable intr avascular stent for obliterating experimental aortic dissecti990 Moon MR.Dake MD.Pelc LRIntravascular stenting of acute ex perimental type B dissections 1993 Kato M. Ohnishi K. Kaneko MDevelopment of an expandable int ra-aortic prosthesis for experimental aortic dissecti993 Kato M. Takano H. Imagawa HDevelopment of self-expandable i ntra-aortic graft and transcatheter obliteration for experimental aortic dissect i993 Kato M. Matsuda T. Kaneko MExperimental assessment of newl y devised transcatheter stent-graft for aortic dissecti995 Karube N. Noishiki Y. Yamamoto KPercutanous insertion of a jacketed stent to close the entry of dissecting aortic aneurysms of DeBakey typ es I and 1993 Yoshida H. Kakino T. Kajitani MTranscatheter placement of an intraluminal prosthesis for the thoracic aorta. A new approach to aortic diss ections 1991 Yoshida H. Yasuda K. Tanabe TNew approach to aortic dissection: de velopment of an insertable aortic prosthesis 1994 Marty · Ane C.Serres-Cousine O. Laborde JCUse of endovascul ar stents for acute aortic dissection: an experimental study 1994 Charnsangave JC.Wallace S. Wright KCEndovascular stent fo r acute aortic dissection: an in vitro experiment 1985 Balko A. Piasecki GJ.Shah DMTransfemoral placement of int raluminal polyurethane prosthesis for abdominal aortic aneurysm 1986 Parodi JC.Palmaz JC.Barone HDTransfemoral intraluminal graft im plantation for abdominal aortic aneurysm 1991 Dake MD . Miller DC.Semba CPTransluminal placement of endova scular stent-grafts for the treatment of descending thoracic aortic aneurysms 1994 Walker PJ.Dake MD.Mitchell RSThe use of endovascular tec hniques for the treatment of complications of aortic dissecti993 Mitchell RS.Dake MD. Semba CPEndovasclar stent-graft repa ir of thoracic aortic aneurysms 1996 Slonim SM.Nyman UR.Semba CPTrue lumen obliteration in co mplicated aortic dissection: endovascular treatment 1996 Slonim SM.Nyman UR.Semba CPAortic dissection: Percutaneou s management of ischemic complications with endovascular stents and balloon fene strati996 Ishimaru S. Kawaguchi S. Koizumi NPreliminary report on pr ediction of spinal cord ischemia in endovascular stent graft repair of thoracic aortic aneurysm by retrievable stent graft 1998 (1) Ishimaru S. Kawaguchi S. ShimazakiPrognosis of false lumen after endovascular dissecting aneurysm repair 1998 Inoue K. Iwase T. Sato MClinical application of translumin al endovascular graft placement for aortic aneurysms 1997 Picard E.Marty-Ane CH.Vernhet HEndovascular management of traumatic infrarenal abdominal aortic dissecti998 Sun Yanqing hypertension and arterial lesions in 1993
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Our department in June 2003 to November with bilateral femoral artery bypass graft axillary artery bypass surgery, treatment of aortic dissection in 4 cases. 1 case in which DeBakey I, DeBakey I type with myocardial infarction in one case, DeBakeyIII type with myocardial infarction in one case, DeBakey III type with myocardial infarction in one case, DeBakey III type with aortic coarctation in 1. Three cases recovered uneventfully, and 1 cases of surgical treatment of 7 days after the family members to give automatic discharge. In this paper, surgical methods and experiences were summarized and discussed. Case 1, male, 65 years old, atherosclerosis, myocardial infarction ECG before the interval, MR examination showed a dissection starting from the aortic arch tear, tear along the descending thoracic aortic dissection extended length of common iliac artery on both sides of the Ministry for DeBakey III type. Case 2, male 48 years, MR angiography increases aortic isthmus showed narrowing of aortic dissection starting from the narrow section of the top tear, dissection involving the descending aorta length, and the root of the left renal artery, renal perfusion poor the DeBakey III type. Example 3, male, 40 years old, MR shows tear starting from the ascending aorta dissection, (no aortic valve insufficiency) involving the aortic arch and descending aorta length of DeBakey I type. Case 4, male, 45 years old, 6 months before the onset of acute myocardial infarction due to PTCA plus anterior descending coronary artery stent expansion, should not check the line MR and CT revealed dissection tear line starting at the root of the ascending aorta (aortic valve without insufficiency) aortic dissection involving the extended length of common iliac artery on both sides of the Ministry of tearing dissection involving the left subclavian artery is also the root of the root of celiac artery, superior mesenteric artery root and the root of right renal artery. Abdominal CT showed the liver, pancreas, spleen, large flake has avascular necrosis. Case 1 Case 2 Case 3 are the sudden onset of tearing chest and back pain, sweating, chest and back pain subsequently became. 4 cases of sudden onset, and the persistent abdominal pain and melena. The 4 patients had history of hypertension, admission blood pressure check in the upper limb between 170/90 ~ 210/110 after admission underwent ECG, are used Nitroprusside, Plendil, Division of Accor, Captopril Metoprolol and other drugs in combination for treatment of blood pressure and expand the tube, combined with diuretic therapy protect renal function and support. Example 1, Examples 2 and 3, were to be in stable condition after drug treatment, through the acute phase in three weeks after the onset of surgery. Example 4 ischemic necrosis of the internal organs, serious condition, after anti-pancreatitis patients blood pressure diffuser, complete fasting 75 days, continuous decompression of 75 days, the disease fluctuations, did not improve, and there continues to deteriorate, forced by illness, had an extremely critical in the case of illness onset 76 days after the surgery. Surgery with tracheal intubation for general anesthesia, supine position, from the side of the internal jugular vein central venous pressure tube inserted, at the same time on both sides of the radial artery puncture, and the side of the dorsal artery piezometers inserted three arteries, while monitoring upper and lower limb blood pressure and monitor alternately left and right upper limb blood pressure. 2cm along the side of bilateral axillary subclavian to about 5 ~ 7cm lateral incision of skin and subcutaneous fascia pectoralis major, pectoralis major muscle fibers isolated, cut off the head of pectoralis minor muscle tendon to expose the initial segment of the axillary artery, free axillary artery exposure of about 5cm or so, in the axillary artery, the downstream use of fine cotton rope cuffs. In the groin, parallel to the femoral artery, oblique skin incision and subcutaneous tissue, cut off the inguinal ligament, fascia incision along the inguinal canal, separate muscle fibers, revealing initial segment of the femoral artery about 5cm or so, the stock with a fine cotton cord artery upstream and downstream sets of belts. Then along the middle axillary line trend in the axillary line in their to do 3 2 ~ 3cm of the transverse incision, skin incision and subcutaneous tissue, with a long curved forceps and fingers with the separation, along the axillary line to create a 2 ~ 3cm wide, self-diameter axilla in the subcutaneous tunnel to the thigh, the 10mm diameter, 60 ~ 70cm long grafts (Dacron or PTFE tube) two from the bilateral axillary line through the subcutaneous tunnel, is in place, avoid twisting and folding into a corner. After the operation is complete, the two ends of artificial blood vessels and the axillary artery and femoral artery segments to carry out the end to side anastomosis. Artificial blood vessel anastomosis with the axillary artery into a 90 degree angle, artificial blood vessels and anastomotic femoral artery is a 45 degree angle, was about two anastomotic 1.5cm, consistent with 4-0 Prolene sutures or 5-0 Prolene continuous suture. Artificial blood vessels and the axillary artery in the anastomosis 3 minutes before the start, the use of 1mg/kg dose intravenous heparin to prevent blood clots during the match until the femoral artery anastomosis at the end, the artificial blood vessel exhaust and emission, discharge of residual gas inside the artificial blood vessels and small blood clots that may exist, after completion of all anastomoses, the use of protamine and heparin. Later in the axilla and the thigh incision placed approximately 0.5cm wide and disposal of the 1 / 2 circumference of the hose and pump it, the axillary midline skin incision is set three rubber sheet drainage. To reduce the full time operation, surgery can be divided into the axillary artery anastomosis group and the femoral artery anastomosis group, surgery in both groups. 3 patients recovered uneventfully, surgical extubation the next morning, next afternoon to eat, get up activity after 7 days. Upper and lower limbs activities such as normal, without any signs of dysfunction and upper extremity ischemia, both sides of the dorsalis pedis artery was significantly increased compared with that before, upper and lower limbs manometry showed the existence of the upper primary hypertension, hypotension, signs of lower extremity been corrected, the lower limb blood pressure returned to the same level. 3 cases 3 weeks after the line in the vascular ultrasound examination, have shown that artificial blood vessels into the diversion channel pulsatile blood flow, blood flow, shunt satisfaction row 3 weeks after MR examination revealed 3 cases of dissection downstream true lumen tube expanded compared with the preoperative diameter, slightly reduced false lumen dissection, dissection of visceral blood vessels and lower blood perfusion of renal patients were significantly improved compared with preoperative renal artery and splanchnic vascular imaging slow and weak, after the rapid development, developing strong and clear, thick blood vessel diameter compared with that before. The other one case of DeBakey I type, with myocardial infarction and ischemic necrosis of multiple organs in patients with bilateral axillary artery femoral artery bypass operation completed successfully, after respiration and circulation stability, lower body perfusion was significantly improved compared with before surgery, reduced the original The dorsalis pedis artery pulse was significantly strengthened compared with the preoperative, upper and lower limbs between blood pressure and the gap from 40-50mmHg into upper and lower limbs returned to the same level of blood pressure, upper and lower blood pressure 120-130/80-90mmHg so. However, the absence of any abdominal symptoms improved after surgery, and postoperative day 3 Laboratory examination revealed BUN, liver and muscle were significantly higher than the preoperative blood ammonia, respectively, 23mmol / L, 267umol / L and 68.2umol / L, patient irritability and anxiety, the condition deteriorated, the family members lost confidence in the rescue, the first 7 days after surgery to give up treatment automatically discharged. Aortic dissection into the aortic wall tear both true and false lumen, proliferation of blood flow in the false lumen, the pressure continues to grow, expanding false lumen compression true lumen, the true lumen diameter becomes smaller, and even true lumen blocked. With the further development of laminated tear, tear can affect the folder show the various important branches of the aorta, such as the brachiocephalic and visceral vessels and renal artery blood root, aortic dissection and removal of artificial blood vessel replacement, surgical difficulty large cerebral complications and the high incidence of paraplegia, the mortality rate is very high. Some patients, especially arterial disease in addition to dissection, but also the existence of other serious complications, such as atherosclerosis, myocardial infarction, and poor respiratory function, the patient can not accept open heart surgery, these patients or because the ascending aorta their disease (such as the DeBakey I type) or because of poor general condition, not only can not accept the aneurysm surgery, and even the ascending aorta and abdominal aorta bypass bypass surgery is impossible, in this extremely difficult situation , using non-thoracotomy, laparotomy is not that the femoral artery with bilateral axillary artery bypass grafts subcutaneous tunnel through the two-channel shunt has its specific advantages. On one hand, pairs of upstream channel able to sandwich a lot of blood around the false lumen, diverted to the lower mezzanine true lumen, thus greatly ease the pressure upstream of sandwich sandwich lesions on the impact of blood flow and pressure, to prevent and reduce the interlayer the further development of disease, preventing the breakdown of sandwich disease; the other hand, a large number of flow diversion around the mezzanine lesions in the lower body, while the effective perfusion, some retrograde perfusion through the femoral artery blood flow to the abdominal aortic true lumen, the true lumen resume shipping, and gradually expand the true lumen, retrograde perfusion has a corresponding branch of the descending aorta, visceral and renal blood vessels to improve perfusion. The group 3 patients showed postoperative MR angiography increases, the celiac artery, superior mesenteric artery and renal artery imaging compared with that before a strong, thick and fast development, part of the internal organs before surgery failed to show a clear development of vascular surgery also , indicating that visceral blood vessels after surgery was good reperfusion, Carpentier, and Liotta and other scholars will artery bypass surgery has been called the "isolated operation", that is, blood flow bypass bypass, blood flow to sandwich reduce, slow blood flow, mezzanine "isolation" of blood flow in most of the other, prompting the gradual collapse of every sandwich, and gradually place of thrombosis and thrombotic mechanisms, leaving the Sandwich gradually closed. s [3] Since 1993, eight cases of consecutive ascending aorta and abdominal aorta bypass graft and one case of the ascending aorta and iliac artery bypass bypass surgery by more than 5 years of follow, MR shows false lumen in all cases varying degrees of thrombosis and thrombotic mechanisms. believes that: Bilateral axillary artery and femoral artery bypass surgery and abdominal aortic bypass line aortic bypass surgery, as both belong to shunt surgery, belong to the same treatment principles, the false lumen will gradually interlayer thrombosis and thrombotic mechanisms to achieve the closure of. of the bilateral femoral artery bypass graft axillary artery bypass surgery than the abdominal aorta bypass aortic bypass, compared with iliac artery bypass aortic bypass, traumatic smaller, wider indications, more safety, and its application prospects will be much wider. On the bilateral femoral artery bypass graft axillary artery bypass surgery related to technical measures of the following important issues that deserve attention and discussion. 1, before surgery the need for left, right and left upper limb, right lower limb manometry respectively, to assess the situation in the limbs of vascular involvement, in order to know exactly how both sides of the subclavian artery and femoral artery atherosclerosis in the presence or dissection or aortic inflammation, preoperative need for axillary artery using vascular ultrasound to detect and femoral artery in order to determine whether the line of axillary artery femoral artery bypass is feasible. 2, the intraoperative use of the side of the internal jugular vein central venous pressure measurements for patients in the timely adjustment of blood volume. The need for surgery in the left and right radial artery puncture, and the side of the dorsal artery to the same time monitoring on blood perfusion and lower body during the side of the axillary anastomosis movement and artificial blood vessels, through the contralateral radial artery pressure measurement observe the upper body of the blood perfusion and pressure, systemic blood pressure in favor of the control of anesthesiologists and related drugs. 3, the axillary artery and the artificial blood vessel end to side anastomosis, the use of wall blocking the clamp together with the posterior wall of the axillary artery and clamp about 5cm, which can block the axillary artery anastomosis in all branches of segment, without the need of various branches of ligation or sets of lines, or clamp, just anterior to the axillary artery-1.5cm longitudinal incision made to complete the match, time-saving surgery, the surgical field clear and clean. 4, artificial blood vessels should not be below the inguinal ligament inguinal ligament across the top of the adoption or adoption, and the need to inguinal ligament, in order to avoid artificial blood vessel in the area through the inguinal ligament or tendon when lifting pressure to form folding distortion. 5, artificial blood vessels need to walk through the subcutaneous tunnel in the middle axillary line, not partial or biased, after the former, because the former will be biased when he bends over to make artificial blood pressure, and after partial artificial blood vessel is due to be stretched when bending, bear tension. Subcutaneous tunnel should be large enough, to avoid compression of artificial blood vessels. Artificial blood vessels to avoid distortion and folding, artificial blood vessels to be long enough, usually about 60cm, can not pull with violence after the operation to prevent the artificial vascular grafts under pressure, patients should use more supine or semi-recumbent position, to prevent the pants artificial blood vessels with repression, can be made through the area in the artificial blood vessel equipped with bow bow of plastic or metal clip to do a special belt or belt strap instead of belt. 6, artificial blood vessels to prevent thromboembolism after surgery for 6 months to 1 year need to use warfarin and aspirin for anticoagulation and antithrombotic therapy, warfarin dosage of 2.5mg / day, aspirin 50mg / days to maintain PT at 16 to 18 seconds. 7, most patients with aortic dissection complicated with hypertension, patients still need to use Plendil, yaws up, metoprolol, captopril and other drugs continues to drop medicine and diffuser, control of hypertension in an attempt to use of drug therapy combined with vascular bypass surgery, for dissection of the closure and natural healing. 8, for the branches associated with aortic dissection Erzhi multiple visceral organs in patients with avascular necrosis, two-channel diversion, although retrograde blood flow can improve visceral perfusion, but the visceral ischemic necrosis is reversible and requires further study, and visceral blood flow reperfusion will induce visceral injury, deserves further study. 1, Carpentier A, Deloche A, Fabiani JN et al. New surgical approach to aortic dissection: flow reversal and thromboexclusion J Thorac Cardiovasc Surg 1981; 81: 695-698 2, Liotta D, Bracco D, Navia JA et al Technigues combines: remplacement valvulaire aortiqne associe a un pontage aorte ascendante-aorte abdominal. La chirurgie cardiaqne d''aujourd''hui. Paris; Maloine SA Editeur. 1984; 205-212 3, Yang Chen Zong-Yuan Hongjun identical blue, 15 cases of aortic dissection in the surgical treatment, Journal of Thoracic and Cardiovascular Surgery 2000 16 (1), 22-24. (Article Tongji Medical College, Huazhong University of cardiovascular disease The Cardiac Surgery)

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