胸主动脉真性、假性和夹层动脉瘤行主动脉腔内修复术的临床和影像学研究

摘要:目的总结胸主动脉真性、假性和夹层动脉瘤的术前诊断和腔内修复的要点，对术前、术后的主动脉CT血管造影（CTA）影像进行评估和比较，以探讨用统一的影像学指标在术前、术中、术后和随访中对病变演变和疗效进行系统评价和动态观察。方法48例胸主动脉瘤和夹层动脉瘤患者在术前CTA图象指导下行主动脉腔内修复术（EVR），植入覆膜支架，植入前、后做数字减影血管造影（DSA），术后定期多次做CTA随访评价疗效。所有CTA和DSA图象输入e-FilmTM软件中建立影像数据库，筛选关键层面，测量分析对比。结果48例共行EVR49次，准确植入长、短支架54枚，夹层内膜破口封闭42例，胸主动脉真性动脉瘤完全隔绝2例，假性动脉瘤颈口封闭4例。术后发生不同程度的内漏9例，经相应的处理消除；因导入动脉出血抢救成功，但发生弥漫性血管内凝血、多器官功能衰竭死亡1例。随访47例，随访时间6~51个月。所有患者恢复良好，临床效果满意。结论EVR治疗胸降主动脉真、假性和夹层动脉瘤效果良好；夹层动脉瘤的早期诊断要点为胸痛和CTA扫描；CTA特定层面和左前斜位图象是术前评估和术后疗效评定的重要参考。关键词：主动脉瘤；夹层；腔内修复术，支架；影像学中图分类号：R543.1+6文献标识码：A文章编号：1007-4848（2008）06-0423-05AClinicalandImageologicalStudyonEndovascularRepairofThoracicAorticAneurysm,ThoracicPseudoaneurysmandAorticDissectionYANGJian1,ZHANGEryong1,CHENXia1,CAOGe1,FANJingxiu1,GUANYongsong2,HEQing（1.DepartmentofThoracicandCardiovascularSurgery,WestChinaHospital,SichuanUniversity,Chengdu610041,P.R.China,Email:ak8328@hotmail.com;2.CenterofIntervention,WestChinaHospital,SichuanUniversity,Chengdu610041,P.R.China）Abstract:ObjectiveTosummarizethecriticalpointofdiagnosisandendovascularrepairment（EVR）tothoracicaorticaneurysm（TAA）,thoracicpseudoaneurysm（TPA）andaorticdissection（AD）,bycomparisonthecomputerizedtomographyangiography（CTA）imagesbeforeandafterEVRtoobserveeffects,soastoexploreauniqueindexofimageologytoassessthepathologicaldevelopmentandevaluatetherapeuticallyeffectindynamicandsystemicreviewsinpre,intra,postEVRandfollowupperiod.MethodsFortyeightpatientsinvolvinganeurysmordissectionofthoracicaortaweretreatedwithEVRbasedonthepreoperativeCTAimaging.Beforeandaftertheintroducingofstentgraft,digitalsubstationangiography（DSA）wastakenplaceandsequentialenhancedCTAwasfollowedtoevaluatetheeffectsofthetreatment.AllimagingsofCTAandDSAwerecollectedandinducedintoeFilmTMdatabasetoselectkeysectionsforanalysesandmeasurement.ResultsFortynineEVRwerepreformedand54stentgraftswereimplantedin48cases,withendothelialtearssealedin42casesofdissection,aneurismalcavitiesexcludedin2casesofaorticaneurysm,andrupturesiteclosedin4casesofpseudoaneurysm.Endoleakagehappenedin9cases,whichweretreatedsuccessfullybyappropriatemeasures.Onecasesufferedhemorrhagefromintroducingartery（iliac）whichwascontroledbysurgery,buthediedofdisseminatedintravascularcoagulationandthenmultipleorgansfailure.Fortysevencaseswerefollowedupin6-51monthswithasatisfiedclinicaleffect.ConclusionEVRisfavorableintheeffectofrepairmenttotrue,falseanddissectionofthoracicdescendingaorta.ChestpainandCTAscanisthekeyofearlydiagnosisofaorticdissection.Certainsectionsandleftanteriorobliqueviewingarethecrucialprofileforassessmentandevaluationbeforeandafteroperation.Keywords:Aorticaneurysm;Aorticdissection;Endovascularrepair,Stentgraft;Imageology