1、胸主动脉延长近端锚定区新技术的再思考胸主动脉延长近端锚定区新技术的再思考主动脉弓部病变特点主动脉弓部病变特点p TAA的发病率约为6/21万/年 根部及升主动脉的占到45;主动脉弓部占10;胸降主动脉占35；高龄、并发疾病多；p TAD的发病率约为100/10万/年 累及升主动脉及主动脉弓的占2/3；国内常为中年患者；Bortone AS,Circulation.2004;110(11 Suppl 1):262-7.Olsson C,Circulation.2006;114(24):2611-8.主动脉弓部病变腔内治疗现状主动脉弓部病变腔内治疗现状p 完全腔内技术p 杂交技术主动脉置换杂交去分
2、支化杂交Mitchell RS.J Endovasc Ther.2002;9(Suppl 2):II98-105.颈-胸杂交术式（Cervical-thoracic）去分支化（去分支化（Debranching）杂交）杂交 胸-胸杂交术式（Thoracic-thoracic）去分支化（去分支化（Debranching）杂交）杂交LSA-LCA 旁路术后出血并发症旁路术后出血并发症Favor CCA-LSA Bypass,whenever possibleSeparate Debranching from Stenting完全腔内技术完全腔内技术p直接覆盖p烟囱技术（Chimney techniq
3、ue）p豁口技术（Scallop technique）p开窗技术（Fenestrated technique）预开窗技术（Pre-fenestration technique）原位开窗技术（In situ fenestration technique）p分支支架技术（Branched stent-graft technique）一体化分支支架（Unibody branched stent-graft）模块化分支支架（Modular branched stent-graft）Ch-TEVAR Limitations:#1 StrokeCh-TEVAR Limitations:#2 Paralle
4、l Graft PatencyChimneyBare stentFracture Ch-TEVAR Limitations:#2 Parallel Graft Patency提高烟囱支架的通畅性提高烟囱支架的通畅性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,Cri
5、ado FJ,Torsello G,Minion D,JEVT 20176%of PERICLES chEVAR patients 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年因年因TAD行行TEVAR手术，
6、术中可见近端内漏手术，术中可见近端内漏双烟囱双烟囱+LCCA-LSA旁路术治疗近端内漏，远端延长支架旁路术治疗近端内漏，远端延长支架防止内漏：延长烟囱支架长度；防止内漏：延长烟囱支架长度；LCCA-LSA旁路术；旁路术；LSA起始部栓塞起始部栓塞 Avoids Brachial Access Long Overlap Zone to Minimize Gutter Leak Secure Seal at Leading Edge Preserves Access to Reno-Visceral VesselsRetro-Sandwich Graft迷走右锁骨下动脉迷走右锁骨下动脉（chimn
7、ey+snorkel）Ch-TEVAR unquestioned values:-Urgency/Emergency,Custom SG Limitations,Rescue Ch-TEVAR major limits:-Stroke,Gutters,Parallel Graft Patency Standardizations(new C-TAG)keystone to reduce complications 开窗技术开窗技术原位开窗技术habh:Immediately Angiography a/b:CTA follow up after 6 month 分支支架的通畅分支支架的通畅性（
8、性（6 6年后）年后）ValiantHerculesTX2TAGAnkuraSean A.Crawford.JVS.2016 Choices of Stent-graft Choices of Stent-graft L 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.
9、2014;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 Choices of Stent-graft Vertical angle is the best Vertical angle is
10、the best Riga CV,Bicknell CD,et al.In vitro fenestration 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 Choices of branch stent Balloon-expandable bare stents Express LD (Boston Scientific)Balloon-
11、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 yearsCastor分支支架术后随访（分支支架术后随访（1月）月）分支支架技术分支支架技术模块化分支支架 Lioupis C.Eur J Vasc Endovasc Surg.2012;43(5):525-32.内嵌式分支支架内嵌式分支支架小小 结结 主动脉弓部病变，开放手术依然是首选 去分支化技术证据较多，但创伤仍较大 烟囱及开窗技术发展快，远期结果待定 模块化分支支架是未来的主要发展方向
