腹主動(dòng)脈瘤EVAR術(shù)中陷阱及規(guī)避技巧課件

腹主動(dòng)脈瘤EVAR術(shù)中陷阱及規(guī)避技巧復(fù)旦大學(xué)附屬中山醫(yī)院血管外科復(fù)旦大學(xué)血管外科研究所符偉國(guó)唐驍王玉琦InstituteofVascularSurgeryVascularSurgeryFudanUniversityZhongshanHospital腹主動(dòng)脈瘤EVAR術(shù)中1這是一個(gè)純技術(shù)的話題InstituteofVascularSurgeryVascularSurgeryFudanUniversityZhongshanHospital這是一個(gè)純技術(shù)的話題2背景EⅤAR的特點(diǎn)是微創(chuàng)EⅤAR的重點(diǎn)是評(píng)估EVAR的挑戰(zhàn)是規(guī)避陷阱術(shù)前確切評(píng)估手術(shù)風(fēng)險(xiǎn),充分考慮術(shù)中技術(shù)難點(diǎn),制定合理規(guī)避方案,對(duì)提高EVAR療效有重要價(jià)值InstituteofVascularSurgeryVascularSurgeryFudanUniversityZhongshanHospital背景3貍想的腹主動(dòng)脈瘤InstituteofVascularSurgeryVascularSurgeryFudanUniversityZhongshanHospital貍想的腹主動(dòng)脈瘤4概述患者自身的血管解剖是EVAR獲得滿意療效的主要限制因素,體現(xiàn)在:1、充足的近端瘤頸這是是保證EVAR療效的絕對(duì)要素之一,近端錨定區(qū)不理想則難以很好實(shí)施傳統(tǒng)EⅤAR(約50%)2、充足的遠(yuǎn)端錨定區(qū)3、良好的入路途徑不良的入路途徑及遠(yuǎn)端錨定區(qū)不足也可影響EVAR療效,但多種措施和技巧可減輕其不利影響Lancet2019;364:843-8.InstituteofVascularSurgeryVascularSurgeryFudanUniversityZhongshanHospital概述5EVAR更高要求破裂腹動(dòng)脈瘤的治療各種EⅤAR的并發(fā)癥的處理InstituteofVascularSurgeryVascularSurgeryFudanUniversityZhongshanHospitalEVAR更高要求6EVAR術(shù)中的陷阱InstituteofVascularSurgeryVascularSurgeryFudanUniversityZhongshanHospitalEVAR術(shù)中的陷阱7血管徑路的陷阱>股動(dòng)脈穿刺S股動(dòng)脈切開(kāi),究竟如何選擇?謹(jǐn)慎選擇患者并在術(shù)前仔細(xì)評(píng)估入路條件,包括股總動(dòng)脈直徑、股動(dòng)脈分叉與腹股溝韌帶的相對(duì)位置、排除閉塞性病變(尤其是前壁鈣化)InstituteofVascularSurgeryVascularSurgeryFudanUniversityZhongshanHospital血管徑路的陷阱8血管徑路選擇>經(jīng)皮穿刺股動(dòng)脈行EVAR的禁忌證重度肥胖腹股溝區(qū)嚴(yán)重疤痕術(shù)中需頻繁交換血管鞘股動(dòng)脈分叉位置較高嚴(yán)重的髂動(dòng)脈閉塞性病變髂股動(dòng)脈內(nèi)徑較細(xì)股動(dòng)脈前壁鈣化InstituteofVascularSurgeryVascularSurgeryFudanUniversityZhongshanHospital血管徑路選擇9導(dǎo)絲使用中的陷阱上送硬導(dǎo)絲必需導(dǎo)管配合,在透視下進(jìn)行,以避免誤入弓上分支、導(dǎo)致斑塊脫落或腦卒中的風(fēng)險(xiǎn)導(dǎo)絲到位后標(biāo)記其末端在手術(shù)臺(tái)的相對(duì)位置,術(shù)中避免向近心端深入,誤傷頭向動(dòng)脈、冠狀動(dòng)脈主動(dòng)脈瓣和心臟InstituteofVascularSurgeryVascularSurgeryFudanUniversityZhongshanHospital導(dǎo)絲使用中的陷阱10腹主動(dòng)脈瘤EVAR術(shù)中陷阱及規(guī)避技巧課件11腹主動(dòng)脈瘤EVAR術(shù)中陷阱及規(guī)避技巧課件12腹主動(dòng)脈瘤EVAR術(shù)中陷阱及規(guī)避技巧課件13腹主動(dòng)脈瘤EVAR術(shù)中陷阱及規(guī)避技巧課件14腹主動(dòng)脈瘤EVAR術(shù)中陷阱及規(guī)避技巧課件15腹主動(dòng)脈瘤EVAR術(shù)中陷阱及規(guī)避技巧課件16腹主動(dòng)脈瘤EVAR術(shù)中陷阱及規(guī)避技巧課件17腹主動(dòng)脈瘤EVAR術(shù)中陷阱及規(guī)避技巧課件18腹主動(dòng)脈瘤EVAR術(shù)中陷阱及規(guī)避技巧課件19腹主動(dòng)脈瘤EVAR術(shù)中陷阱及規(guī)避技巧課件20