主动脉弓复杂病变主动脉弓复杂病变 Hybrid, Chimney or else?贾鑫、郭伟贾鑫、郭伟Vascular and Endovascular Surgery DepartmentChinese PLA General Hospitalu Endovascular Chimney Fenestration Branched Stent-graftCriado et al, J Endovasc Ther 2002累及主动脉弓病变可采用技术u Hybrid approach Cervical-thoracic Debranching Hybrid Procedures ResearchNo.Landing ZoneZ0/Z1/Z2SuccessMortalityStrokeParaplegiaEndoleakHughes 20138748/19/0955.74.639Lotfi 20125148/19/0-1012616Vallejo 20123827/11/097.423.713.12.710.5Melissano 201214332/35/7690.94.92.8-8.4Ye 20124510/4/10/2197.86.76.7022.2Geisbusch 20114715/23/9-196.3614.9Guo 2010255/12/89842011Weruman 20092626/0/01001540-Chaevel 2008165/8/3810190-杂交技术文献分析LandingzoneNo.ofpatientsPrimarytechnicalsuccessReinterventionsIn-hospitalmortalityInitialclinicalsuccessLatemortalityZone0130120（95.2%）12(12%)11（8.5%）111（88.1%）0Zone113170（83.3%）16(25.8%)6（4.6%）71（84.5%）2Total261190（90.5%）28（17.3%）17（6.5%）182（86.7%）2Pvalue0.00690.03210.220.530.16Oddsratio42.551.931.35N/AKotelis D,et al. Total vs hemi-aortic arch transposition for hybrid aortic arch repair. J Vasc Surg.2011 ;54 (4) : 1182-1186.Meta-analysisLandingzoneNo.ofpatientsStrokeSpinalcordinjuryTypeIendoleakTypeIIendoleakZone01304(3.2%)1(0.8%)5(4%)10(10%)Zone11315(4.2%)3(2.3%)13(15.5%)8(12.9%)Total2619(3.7%)4(1.5%)18(8.6%)18(11.1%)Pvalue0.740.620.0050.61Oddsratio0.750.334.430.75Kotelis D,et al. Total vs hemi-aortic arch transposition for hybrid aortic arch repair. J Vasc Surg.2011 ;54 (4) : 1182-1186.Meta-analysisIn-hospitalmortalityisrelativelylow(6.5%),neurologicalcomplicationsnear5%.Endoleakrateisalsolow(8.6%fortypeI/III).Limitednumber,needlargevolumeandlong-termfollow-up主动脉弓杂交手术临床证据Chimney Technique 烟囱技术临床证据烟囱技术临床证据sourcesTechnical success Perioperative mortality(all-cause)Perioperative morbidityEndoleakStrokeLarzon et al, 20051/2(50%)0/2(0%)0/2(0%)2/2(100%)0/2(0%)Criado et al, 20078/8(100%)0/8(0%)0/8(0%)0/8(0%)0/8(0%)Baldwin et al, 20086/7(85.7%)0/7(0%)1/7(14.1%)2/7(28.5%)1/7(14.2%)Ohrlander, et al, 20083/4(75%)0/4(0%)1/4(25%)2/4(50%)1/4(25%)Sugiura, et al, 20099/11(81.8%)2/11(18.1%)a3/11(27.2%)2/11(18.2%)1/11(9.1)Cires et al, 20119/9(100%)1/9(11/1%)2/9(22.2%)1/9(11.1%)1/9(11.1%)Yoshida et al,20112/2(100%)0/2(0%)0/2(0%)0/2(0%)0/2(0%)Sue et al, 20118/8(100%)0/8(0%)0/8(0%)2/8(25%)0/8(0%)No.ofpatients(vessels)Landingzone(Z0/Z1/Z2) Technical successStrokeIEndoleakChimneygraftspatentcy94(101)20/48/3398%5.3%18%100%Hogendoornw,etalThoracicendovascularaorticrepairwiththechimneygrafttechnique.JVascSurg.2013:May19,S0741-745.Meta-analysisofclinicaloutcomeswithchimney烟囱技术临床证据Overallperioperativemortality(3.2%)Morbidityrate(strokerate5.3%)Graftpatency(100%)Allcomparabletohybridseries.Hogendoornw,etalThoracicendovascularaorticrepairwiththechimneygrafttechnique.JVascSurg.2013:May19,S0741-745.Allthechimneystentswereofflabeluse,thesamplenumbersmall,mostlessthan10cases.Relativenew,withamedianfollow-upof11months与杂交手术证据相比，烟囱技术问题1Hogendoornw,etalThoracicendovascularaorticrepairwiththechimneygrafttechnique.JVascSurg.2013:May19,S0741-745.Inchimneyseris,nearly1/3inZone2,thetypeIendoleakratewas18%1.ThehigherrateofendoleakswhentheBCAorLCCAarestentedcomparedwiththeLSAonly(30%and27%vs9.1%).与杂交手术证据相比，烟囱技术问题Hogendoornw,etalThoracicendovascularaorticrepairwiththechimneygrafttechnique.JVascSurg.2013:May19,S0741-745.JVasSurg.2013,June:57(6):1664-67LioupisC,etal.EuroJVasEndovasSurg.2012,May,525-32TAA Involving LSA and LCCA Fenestration in situWith home-made endo-shuntsCuttingBalloonFenestration in situ of LCCA and LSAConclusionslHybrid procedure well proved and could be used in most cases at present time.lChimney grafts should only be used in specific cases ( eg. high surgical risk, Zone 2). lFenestration and branched grafts need further investigation.Thanks Thanks for your attentionfor your attention