“杂交”手术治疗活动期炎性Ⅳ型胸腹主动脉瘤

DEPARTMENTofVASCULARSURGERYCHANGHAIHOSPITAL“杂交”手术治疗活动期炎性Ⅳ型胸腹主动脉瘤冯翔上海长海医院血管外科DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL病史•男性37岁•发现TAAA1年，腹痛2月•SLE10年•左肾动脉闭塞，左肾萎缩•11年6月6日入院时：ESR46mm/hWBC1.8×109/LScr120mmol/L口服强的松25mg1/日DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL治疗计划•分期杂交手术：一期手术：手术室腹腔脏器血管去分支间隔一周二期手术：导管室EVARDEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL一期去分支：2011-6-10第一吻合口：8mmPTFE血管与左髂总端侧吻合第二吻合口：6mmPTFE与8mmPTFE端侧吻合DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL一期去分支：第三吻合口：8mmPTFE血管与SMA端侧吻合第四吻合口：6mmPTFE血管与右肾动脉端端吻合DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL一期去分支：结扎SMA近端，后腹膜覆盖旁路血管重建完成（腹腔干、左肾动脉未重建）DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL二期腔内：2011-6-16造影示桥血管通畅DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL二期腔内：Microport定制支架移植物22-16-150DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL二期腔内：Microport髂动脉延长支16-16-80DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL术后随访：2011-7-42011-7-6出院口服强的松25mg/日，ESR16mm/hDEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITALTAAA杂交手术的发展历程1999Quinones-Baldrich(Thefirstcase)RepairoftypeⅣthoracoabdominalaorticaneurysmwithacombinedendovascularandsurgicalapproach1999;30:555-5602006BlackSA(StMary’sHospital,London)29casesComplexthoracoabdominalaorticaneurysm:endovascularexclusionwithvisceralrevascularization2006;43:1081-1089Thesameteampublished81casesin20092009ChiesaR(Milan)34casesIshybridprocedurethebesttreatmentoptionforthoracoabdominalaorticaneurysm?EurJVasc2009;38:26-34DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL炎性TAAA手术时机炎性TAAA手术方式炎症活动期手术的围术期抗免疫治疗腹腔干动脉是否需要重建流入道的选择旁路血管路径、材料、重建方法支架移植物的选择与本例相关的问题？DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL1、炎性TAAA手术时机共识：稳定期本例：？腹痛瘤体迅速增大瘤体包裹破裂失去左肾DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL2、炎性TAAA手术方式传统开放手术分支移植物Chimney/Sandwich“杂交”目前无共识，基于个人技术选择最可靠方法DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL腹腹腔干是否重建共识：非必须重建本例：肝动脉起源于SMA腹腔干开口狭窄胰腺周围炎性粘连DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL流入道、旁路血管选择及重建方式流入道：远离炎性病变重建方式：大弧度避免移植物与SMA成锐角或扭曲，右肾动脉需横断左肾静脉后向右牵下腔静脉，在其后方显露、吻合DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL支架移植物选择尽量长的锚定区不超过10%的oversize因此定制的锥形移植物最为合适本例：Microport22-16-150DEPARTMENTOFVASCULARSURGERYCHANGHAIHOSPITAL谢谢！炎性TAAA：稳定期—理想手术时机活动期--濒临破裂时的被迫选择手术方式：开放手术：远期吻合口破裂及假性动脉瘤形成腔内手术：支架近远端假性动脉瘤形成杂交手术：远离部位吻合重建长锚定区、小放大率的定制支架移植物