哈尔滨医科大学附属第二医院 血管外科 姜维良 涉及主动脉弓的夹层动脉瘤 杂交手术转流方式探讨 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 JIANG Dept. of Vascular Surgery, 2nd Teaching Hosp. Harbin Medical University, Harbin, Heilongjiang, China 150086

主动脉夹层动脉瘤腔内修复术 Aortic Dissection Endovascular Anuerysm Repair（EVAR）

主动脉夹层动脉瘤腔内修复术 Aortic Dissection Endovascular Anuerysm Repair（EVAR）

主动脉夹层动脉瘤腔内修复术 Aortic Dissection Endovascular Anuerysm Repair（EVAR） 弓上分支血管重建方法 1.外科血管重建（旁路技术） 2.介入开通（烟囱技术）

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 转流原因 Cause of bypass 同侧转流 Ipsilateral bypass 对侧转流 Contralateral bypass 弓上分支转位 Arch branch translocation 2 － 左侧优势椎动脉 Left side predominant vertebral artery 瘘口位于主动脉弓 Arch entry 1 左颈动脉动脉瘤 Aneurysm on left carotid artery Total 6 4

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 vertebral 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 Bypass: 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 (Ipsilateral 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

Case 2 瘘口位于弓顶，食道受压，进食困难。 Entry at the top of the arch, esophagus compressed and dysphasia developed

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

Ipsilateral Bypass from SCA to CA Case 2 锁骨下动脉-颈动脉同侧转流 Ipsilateral Bypass from SCA to CA

Angiography of After EVAR Case 2 Angiography of After EVAR

Case 2 术后CTA 术后1个月复查CTA CTA Follow-up @ 1m after TEVAR

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

瘘口位于颈动脉开口附近 Entry near Left Carotid Artery Case 3

BYPASS Case 3

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

TEVAR Case 3

Closed hemothorax drainage Case 3

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

BYPASS Case 4

颈颈转流+颈锁骨下对端吻合 CA-CA bypass + CA-SCA end-end anastomosis Case 4 颈颈转流+颈锁骨下对端吻合 CA-CA bypass + CA-SCA end-end anastomosis

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 ①Carotid hybrid operations make TEVAR procedure safe and possible for the aortic dissections with arch entries. ②With relatively low complication rate, ③the procedure can be customized for individual patient. ④Key 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