胸主動脈延長近端錨定區(qū)新技術的再思考課件

1、胸主動脈延長近端錨定區(qū)新技術的再思考主動脈弓部病變特點 TAA的發(fā)病率約為6/21萬/年 根部及升主動脈的占到45; 主動脈弓部占10; 胸降主動脈占35； 高齡、并發(fā)疾病多； TAD的發(fā)病率約為100/10萬/年 累及升主動脈及主動脈弓的占2/3； 國內常為中年患者； Bortone AS, Circulation. 2004;110(11 Suppl 1):262-7. Olsson C, Circulation. 2006;114(24):2611-8. 主動脈弓部病變腔內治療現(xiàn)狀 完全腔內技術 雜交技術主動脈置換雜交去分支化雜交Mitchell RS. J Endovasc Ther.

2、 2002;9(Suppl 2):II98-105. 頸-胸雜交術式（Cervical-thoracic）去分支化（Debranching ）雜交 胸-胸雜交術式（Thoracic-thoracic）去分支化（Debranching ）雜交LSA-LCA 旁路術后出血并發(fā)癥Favor CCA-LSA Bypass, whenever possibleSeparate Debranching from Stenting完全腔內技術直接覆蓋煙囪技術（Chimney technique）豁口技術（Scallop technique）開窗技術（Fenestrated technique） 預開窗技術（

3、Pre-fenestration technique） 原位開窗技術（In situ fenestration technique）分支支架技術（Branched stent-graft technique） 一體化分支支架（Unibody branched stent-graft） 模塊化分支支架（Modular branched stent-graft）Ch-TEVAR Limitations: #1 StrokeCh-TEVAR Limitations: #2 Parallel Graft PatencyChimneyBare stentFracture Ch-TEVAR Limitat

4、ions: #2 Parallel Graft Patency提高煙囪支架的通暢性REINFORCE THE PARALLEL GRAFT! ESPECIALLY IF LONG WHEN IS THE ONLY FEEDING VESSELCh-TEVAR Limitations: #3 Gutter endoleaksCHEVAR GUTTER-RELATED ENDOLEAKSINSIGHTS FROM PERICLES REGISTRYDonas KP, Criado FJ, Torsello G, Minion D, JEVT 20176% of PERICLES chEVAR pa

5、tients had a type Ia endoleak at completion angiography, but the rate of persistent endoleaks was only 2.9% at a mean 17.1 months.30% Oversizing Overeem SP, Boersen JT, Schuurmann RCL. J Vasc Surg. 2017 Aug;66(2):594-599. M，78y，2013年因TAD行TEVAR手術，術中可見近端內漏雙煙囪+LCCA-LSA旁路術治療近端內漏，遠端延長支架防止內漏：延長煙囪支架長度；LCCA

6、-LSA旁路術；LSA起始部栓塞 Avoids Brachial Access Long Overlap Zone to Minimize Gutter Leak Secure Seal at Leading Edge Preserves Access to Reno-Visceral VesselsRetro-Sandwich Graft迷走右鎖骨下動脈（chimney + snorkel）Ch-TEVAR unquestioned values:- Urgency/Emergency, Custom SG Limitations, RescueCh-TEVAR major limits:-

7、 Stroke, Gutters, Parallel Graft PatencyStandardizations (new C-TAG) keystone to reduce complications 開窗技術原位開窗技術habh: Immediately Angiography a/b:CTA follow up after 6 month 分支支架的通暢性（6年后）ValiantHerculesTX2TAGAnkuraISF was performed with the Talent (54%), followed by the Zenith (37%) and the (9%) Sea

8、n A. Crawford. JVS. 2016 Choices of Stent-graft ZenithEndurantTalentConventional ePTFEPrototype ePTFEL pic. Zenith fabric had the greatest strength with respect to tearing strength and bursting strength, both before and after RF puncture and balloon expansion. Eadie LA. Eur J Vasc Endovasc Surg. 201

9、4;47:501-8.R pic. The Zenith stent graft has been consistently shown to be the most resistant to dilation with a residual stenosis of 15% despite extensive dilation. Saari P. J Vasc Interv Radiol 2011;22:89-94. Choices of Stent-graft Vertical angle is the best Riga CV, Bicknell CD, et al. In vitro f

10、enestration of aortic stent-grafts: implications of puncture methods for in situ fenestration durability. J Endovasc Ther. 2013;20(4):536-43. Choices of branch stent Balloon-expandable bare stents Express LD (Boston Scientific)Balloon-expandable covered stents iCAST (Atrium Medical) Jostent (ABBOTT Vascular)Self-expandable covered stents Viabahn (W.L. Gore Associates) Fluency (Bard) ISF reconstruct all branches of archChronic TAD, Aberrant RSA, M, 57 years