The impatient mezzanine aneurysm is the acute disease which is taken bad an extremely dangerous cardiovascular disease, such as can not accurately diagnose with treatment, afterward the fruit be disaster.Recently cultural heritage report way, the outbreak rate of impatient mezzanine aneurysm can be up to(10~29) annually/one 000000 people ［’s one ］s.This part of patients if do not accept a treatment, will have 36%~72% die in after the outbreak a 48 hs, 62%~91% die in an outbreak after a week.
The physiology characteristics of the main disease of one mezzanine aneurysm
Aorta mezzanine aneurysm, have already been called the film removal disease or wall in the aorta aneurysm as well, is because the different reason results in film inside the aorta break, at inside film and Chinese and Foreign layer have a blood the dated pressure to cause greatly the blood vessel lengthways removes, formation double chamber aorta(double-barrel), or the aorta lump kind extend.A handful of patient possibility didn’t inside film break but is an intermediate issue of blood formation mezzanine.
The reason of the aorta mezzanine formation is a lot of, the artery harden, high blood pressure, artery the intermediate bag be bad to die, horse any surname comprehensive the disease, aorta Suo be narrow, aorta burning, external injury and syphilis etc..Excepted harm outside, it all of pathologic foundations be the changes of the aortas intermediate peaceably slippery muscle.
In the clinical case, the western nation regards high blood pressure as principle, since go toward think local case green prime of life much is congenital intermediate growth bad such as horse who surname synthesize disease etc., but be taken bad in recent years artery harden, the comparison of high blood pressure increases gradually Gao.
Film inside the artery tear to pieces and the artery tube wall removal and blood be swollen to in the center spread to extend to the whole layer the pathologic process which is a mezzanine aneurysm outbreak in the artery wall.Film inside the artery’s tear to pieces is see in to rise the aorta near heart to carry and declines an aorta start department and the namely left lock bone descends the artery openings far side.The major axis of tear to pieces is often mutually perpendicular with aorta major axis.Inside film once tear to pieces, because of blood of agreeable to pound at with contrary, remove scope will enlarge gradually, to the high blood pressure sufferer be more dangerous and take care of a wall removal blood then swollen spread have another in inside the film with intermediately 1/3 with outside 1/3 it development, make to tear to pieces to deeply reach inside the film intermediate, and often in intermediate of 1/3, the mezzanine blood is swollen to fluently go or the treacherous acts spread, can break cause to die abruptly into the chest, heart pack or the heart pack stop up to cause death, or break into aorta inside appear the second openings, the false chamber which becomes inside aorta flows a way.
Aorta mezzanine aneurysm according to be taken bad of nasty slowly can is divided into impatient and chronic mezzanine aneurysm.Outbreak at 2 with in the week be called impatient mezzanine aneurysm, have no the history of impatient disease or be taken bad to belong to chronic mezzanine aneurysm over more than 2 week.
The aorta arises from aorta wreath, follow after spinal column be partial to, ascension department calls to rise aorta, go to right and unknown artery branch to walk sideways to the lock bone to descend artery, call aorta bow, henceforth follow the left side of the spinal column next call to decline aorta, cut through a Ge muscle into belly to call stomach aorta, go directly to or so Ka artery branch.The head, carotid artery of the department important branch of the aorta bow supplies the blood of two armses and Lu brains, with the unknown artery and the left lock bone descend artery for marking again is divided into right bow and left bow.Decline the aorta contains several branches and supply the blood of spinal cord.Stomach aorta is belly cavity many dirty machine bloods provide of branch lord stem, fasten a film a top artery such as the or so kidney artery, liver, Pi and the bowel etc..The choice which understands aorta dissection for understanding and comprehension mezzanine aneurysm cures very importance.
Mezzanine aneurysm according to inside the film tear to pieces the dissimilarity of part to contain two kinds of in common use classification methods and the DeBakey is divided into its 3 in 1955.Film inside the I type tears to pieces to be located on to rise aorta or bow department, removing scope to extend to the bow department can reach Ka artery with declining aorta and include to break into abuse to be located on left bow among them but inside the film treacherous acts remove to rise an aorta.Film inside the II type tears to pieces to be limited by with I type but the removal blood swollen to rise aorta and bow department.The III type is located on an aorta Xia department, left lock bone to descend the artery far side, again according to whether mezzanine involves in a Ge abdomen aorta to is divided into an III type IIIa and IIIb or not.Miller etc. needs to is divided into mezzanine aneurysm Stanford AN according to the surgical operation in the clinical fulfillment, the B be 2, the A type includes DeBekay I, II type and breaks into abuse to be located on left bow but treacherous acts to remove to rise an aorta;B type the film one who tear to pieces to be located on the aorta bow Xia department but spread as follows toward the chest aorta inside.
2 The mezzanine aneurysm of the chest aorta diagnose
Early years’ understanding toward mezzanine aneurysm shortage, correspond of the check means be few, as a result diagnose a rate not high, the often easy and impatient heart Geng mutually confuses.Along with know to the cardiovascular disease of deepen, the understanding level of the medical worker to the impatient mezzanine aneurysm continuously raise, didn’t create a sex check technique to continuously develop and it diagnoses a rate exaltation and made greatly parts of patients get to diagnose in early days.
2.1 Mezzanine aneurysm impatient expect clinical performance abrupt and violent ache for outbreak hour the most familiar symptom, invite occurrence at 90% sufferers.The ache presents to tear to pieces or the knife mow kind and and is hard to bear with.The patient express for fidgety uneasy, worry anxiously, fear and be close to a dead felling, and is sex continuously, the analgesic thing is hard to alleviate.The impatient period has around 1/3 patients appear complexion pale, the big sweat pours Li, arms and legs skin damp and cold, the pulse is quickly weak and be short of breath etc. shock phenomenon.When the mezzanine removal involves in the aorta big branch or lump body oppression around organize can cause each performance that the organ correspond.
When DeBekay I, II type the mezzanine removal involve in an aorta petal, comfortable Zhang Qi2 or constringency which appear an aorta petal area expect a miscellaneous sound, the aorta petal close not whole hour easiest take place impatient and left heart to crock up, appear a heart rate quickly, dyspnea etc.
.The mezzanine removal can cause an impatient myocardial to lack blood or myocardial Geng dead when the mezzanine removal involves in a coronary artery, the mezzanine removal breaks to wrap into the heart can quickly take place a heart pack to stop up, cause an abrupt death.When be taken bad few hour behind can appear surroundings artery to jam phenomenon, can appear carotid artery or body artery to pulsate strong or weak not etc., the serious can take place a body to lack the blood bad dead.The mezzanine involves in the aorta bow department head arm artery, can cause a brain to provide blood shortage, even at the obfuscation, be partial to Tan etc..The mezzanine which declines aorta involves in a rib artery and can influence spinal cord to be provided for blood to cause to cut Tan.Involve in the belly cavity dirty machine branch can then cause liver to provide blood shortage, liver achievement damaged, the type nasty stomach disease express or the digest way bleed, the kidney achievement injure and kidney high blood pressure etc..
The body of the mezzanine aneurysm of the chest aorta advertises for to check with laboratory, excepted appear the above-mentioned merger disease to generally have no especially different.There has been variety having never created sex check to apply currently in clinical, can accurately diagnose mezzanine aneurysm.
2.2 The laboratory checks most sufferer’s bloods, urine normal regulations normal.Parts of sufferers are taken bad acute to expect and can appear white cell to go up, neutral grain cell increment, wet the normal regulations check urine egg white masculine gender, appear tube type and in great quantities red cell.
2.3 The image learns a check
2.3.1 Super voice’s moving diagram and should check is clinical to up open an exhibition currently more of do not create sex check, can display the part, size, scope of lump body, pulsate and complications.Such as merger mezzanine aneurysm, the super voice moves diagram and can show separation of inside film, true chamber, false chamber and attach wall blood to bolt.Such as is a false sex aneurysm, then can show break into abuse of false sex aneurysm, lump chamber and attach wall blood to bolt.Now some conditioned units gradually expand an application Be moved the diagram(TEE) diagnosis aneurysm ［ of the aorta mezzanine 2 ］s by the esophagus super voice.For rise aorta mezzanine the diagnosis of the aneurysm, the TEE sensitivity can be up to 78.3%~98%, the particularity is 63%~96%.But to the distant place decline the sensitivity of aorta lump then is big in order to lower, is 3 ］s just for the 40% or so ［ .The TEE can observe the position, false blood inside the chamber that film inside the mezzanine tear to pieces to bolt and the blood, heart wrap inside whether the existence accumulates liquid etc., and it is thus clear that true or false chamber motion of inside film slice.Because the TEE is subjected to the Examiner empirical restriction, lack good contrast to the reexamination case, it to chest aorta the lump and near segment’s stomach aorta lump observation be effective, to stomach aorta and its branch observation ineffective.
2.3.2 Ex- and side show chest aneurysm shadow behind the X line chest X line even slice.Parts of sufferers walk to go district at the chest aorta lump it is thus clear that calcify spot or slice form calcify shadow, and show under the clairvoyance that extending sex pulsate.
2.3.3 The check of CT CT can show part, size and scope of lump body.The recent years apply extremely high soon CT and spiral CT used for diagnosing chest aorta lump, carry on the two-dimensional and 3D reconstruction can show that lump body and surroundings organize of adjacent, clear identify an arm dry afferent circumstance, especially for decline the mezzanine treacherous acts of the aorta lump to tear to pieces to involve in a left side lock a bone to descend the sufferer of artery.The check generally can be the advantage of CT check in completion inside the 10 mins.Its diagnosis in declining aorta mezzanine sensitivity is 83%~94%, the particularity is 87%~100%.And for rise the sensitivity of aorta lump less than 80%, its main weakness is disadvantage in tear to pieces oscular position and the afferent circumstance of the artery branch of judgment, to aorta whether the existence returns to flow to can’t make to judge ［ 4 ］s, either.
2.3.4 Nuclear magnetic resonance’s should check is the important check means which quickly diagnoses mezzanine aneurysm currently.The traditional nuclear magnetic resonance(MRI) adoption heart electricity door controls to return to a T1 to add power to be like from the Xuan, many flat surface have another mutually become be like.But because the sufferer breathes the influence of activity, the picture quality is worse.In recent years quickly hold back breath a MRI technique under the condition, overcame above weakness, be advantageous to aorta paroxysm a dynamic state to show, especially film inside the aorta tear to pieces and it the observation of false chamber.The researcher adopts a true steady state fast steps degree to return to wave to scan a technique, half Fu to sign a leaf to collect a single time to stir up quickly to return to wave(HASTE) and 3D small angle to stir up a fast steps degree to return to a sequence(the 3 D CE MRAD) etc. method to carry out fast diagnosis ［ 5 ］s to the aorta disease from the Xuan.The Rrata wait report the application doesn’t strengthen an image technique and depend on 3D fast from Xuan echo technique check aorta mezzanine, result manifestation aorta disease the type can get clear present ［ 6 ］s.As a result currently should check is the gold standard which diagnoses aorta mezzanine.
Can adopt to create a check when it’s necessary, build a shadow such as the artery.Building a shadow through an artery can discover the aneurysm of aggrandizement.If is a mezzanine aneurysm, the blood existence in the true or false chamber difference, as a result can pass to develop a difference of density to carry on differentiation.If the electrocardiogram hint the pathological changes may involve in hat vein to result in the myocardial provide blood shortage, can consider carrying out hat vein to build a shadow in the meantime.In order to too many of develop an existence kidney toxicity, so the recent years should check on clinically of the utilization rate have to descend, but stop up to the existence aorta branch of sufferer, that check can provide a worthy information.
3 choose of project of the aneurysm treatment of the aorta mezzanines
For impatient orta mezzanine aneurysm, as soon as diagnose, should be immediately carry on serving as guardian a treatment, adopt under the tight monitor valid intervention measure, make the life advertise for stability, include blood pressure, heart rate and heart Lyu, center vein to press and wet row to measure, and according to need to measure the lung hair thin afferent Xie to press with the heart eject quantity.Main treatment the measure include a town a pain and decline to press, control inside film removal, the blood pressure generally controls in the constringency to press 100~120 mmHg level and equally press at 60~70 mmHgs.Need a condition steady after, should carry on finally diagnosing, reexamine a super voice, CT, MRI etc., with decision whether the demand surgical operation cure.If appear the complications of threat life, such as aorta break of omen or removal(the heart wrap, the heart chamber accumulate a liquid), invade and the omen(lack blood symptom and electrocardiogram change) of coronary artery, the impatient aorta petal close not whole, heart pack the blood circulation which press to fill or injured life organ etc., should immediately consider a surgical operation treatment.
For the I, II type mezzanine aneurysm, especially merge aorta close not wholes be the adaption of the surgical operation.The surgical operation principle is parts of aortas which cut off to tear to pieces inside the film, repair a film inside the removal of both ends, connect aorta piping with the artificial afferent transplantation, the merger aorta petal close not whole, use the displacement aorta of the artificial valve petal.For pathological changes extensive I type mezzanine aneurysm, Borst etc.1983 beginning of years report “trunk” technique first, while professional is rising aorta and bow department displacement apply another an artificial blood vessel to is near it to carry to decline a department with bow to fit together, the distant place suspend in decline inside aorta.When II expected the surgical operation line to decline aorta replacement, needed under the normal temperature to be afferent an artificial direct expect with I the surgical operation place go into of the artificial blood vessel(namely”trunk”) goes to carry to fit together, then avoided declining a directly swim of the department to leave to the aorta bow, also need not at deep the low temperature stop circulation to transplant fit together of blood vessel and aorta bow under the completion and lowered a surgical operation risk.In addition, “trunk” can make is oppress of decline the aorta true chamber to open, oppress a false chamber, make a part of sufferers formation blood inside the false chambers bolt but need not an II period surgical operation.The local etc. of Sun Li4 Zhong has already included the report ［ of clinical application 7 ］s.In addition, the Bentall, Wheat, Cabrol, Robicsek etc. Shu types all have already apply mezzanine aneurysm at the treatment I type, local Sun Yan3 celebrate, the etc. author of Sun Li4 Zhong all has report ［ 8, 9 ］s.
For the treatment of III type mezzanine aneurysm, can adopt to decline the afferent transplantation of the aorta artificial, for correspond organ to implicate, should consider a blood luck reconstruction, such as rib artery, kidney artery or bowel fasten a film a top artery a reconstruction Shu.For the one who break into abuse to limit, Sun Yan3 celebrate etc. the assertion adoption break into abuse a repair to decline aorta to take shape Shu ［ 10 ］s.Because the recent years didn’t create a sex diagnosis technical exaltation, to III type film inside the removal of the mezzanine aneurysm can accurate fixed position, support inside the blood vessel has already extensively used for the treatment which declines aorta mezzanine aneurysm.Generally think as long as the lump body is apart from a left lock bone to descend artery over the 2 cms, aneurysm without excessiveness circuit, get involved thoroughfare lucid, the false chamber is smaller, can consider that the adoption Fu film support gets involved a treatment.This kind of method can ease circulation etc. outside the surgical operation, anaesthesia, body to the sufferer’s wound and should arouse.Foreign Fattori ［ 11 ］s, Bergeron ［ 12 mountain hospital, the subsidiary hospital, Fu outside hospital, Anne Zhen hospital…etc. of the University of Zhejiang first in local long total hospital, Shanghai of the sea hospital, University of Peking people’s hospital, Liberation Arm in Shanghai ］’s etc.s all report the clinical application result of support inside the blood vessel, , all carried on to try to this technique, the effect was good in the near future.
4 The body outside circulates technique and related research in the mezzanine aneurysm surgical operation
I, II type the surgical operation treatment of the mezzanine aneurysm need outside body circularly under carry on, with normal regulations heart surgery of circulation comparison outside the body, the body of mezzanine aneurysm is outside circularly have a little bit higher request, don’t exert a homology because of each patient’s circumstance, pathological changes scope and implicate district can have very great degree difference.The body outside circulates a method to need to follow a following principle, on wanting to go into road and method to choose according to the surgical operation, two want to always notice function of protect the important and dirty machine.
Regardless rise aorta or artery to put a tube while rising aorta to put a tube, all and probably mistake go into mezzanine, as a result want a tight monitor in infuse note, make a judgment in time, adopt measure, in order to prevent cause the loss that can’t save.
While involve in the aorta bow department surgical operation, protection and surgical operation of central nervous system system prepare after closely related.As early as 1957 Cooley once adopt through the head arm artery put tube selectivity a brain infuse note, in 1975 the Grieep is in the department aneurysm of the aorta bow the surgical operation first the application deep low temperature stopped a circulating technique carry on a brain protection, but because of the complications of the central nervous system system and related death rate still higher, as a result protect the quest of method to the central nervous system system hasn’t been stop.In 1992 Ueda etc. report after ascend chamber vein treacherous acts infusing to note a brain protection, local Sun Yan3 celebrate, the etc. of Dong3 Pei2 Qing apply this technique to protect at the brain of the bow department greatly afferent surgical operation, up to now case already more than 60 ［s be 13 ］s, the local Guangdong heart grind, river City in the town the first people’s hospital’s etc. include application.Out of the Fu hospital’s Sun Li4 Zhong’s etc. report after lock bone descending artery to put a tube to carry on heart lung to turn to flow, being lock bone to descend artery a distant place to decline aorta to stop directly through right lock the bone descend artery selectivity a brain to infuse to note and obtained better clinical effect ［ is 14 ］s.In recent years these brain protection measure at clinical gradually get expansion, but related foundation research report way very few lack to the evaluation of brain protection method objective with generally accepted standard.Local Liberation Arm total hospital river dynasty light etc. imitates a research outside body medium, adopt polypropylene a hollow fiber film emulation hair for the very first time thin blood vessel constitute tiny circulation, pass the adjustment model parameter, body circularly with tiny circulation organic combine together, the emulation imitates really afferent discharge and pressure wave form, discover a body outside negative infuse model to have good imitate true, function and maneuverability, is study an organ protection of good experiment model the ［ be 15 ］s.Anne’s Zhen hospital Dong3 Pei2 Qing, tube jade dragon etc. the report adopts eye bottom blood vessel to build shadow in the experiment the animal, the super voice wave probe into, the brain infused to note effect to get the image learn of the confirmation ［ be 16 ］s.Take care of jade dragon’s etc. adopts laser to totally focuse a microscope to directly examine to live a body brain a slice fluorescence strengths with 2+ Ca for the very first time, confirm to stop circulation with simplicity to compare, the treacherous acts infuses to note a brain protection and can obviously ease Ca 2+ to overload and have protection function ［ to the nerve cell 17 ］s.Together the Hong Wei waits to protect measure to carry on to the different brain in the experiment the animal comprehensive comparison, the confirmation adoption treacherous acts infuse to note the degree ［ that can ease a nerve dollar cell Diao Wu and die 18 ］s.Related pathology with super and tiny learn an examination confirmation treacherous acts to infuse to note can ease to stop circulation behind nerve cell of lack the blood anoxia degree ［ 19 ］s.
The domestic above-mentioned related foundation research provided a basis for the evaluation that the central nervous system system brain protect, raised to the brain protective understanding, extended surgical operation adaption, norm the technique method of the aorta bow department surgical operation, expanded surgery inside the nerve and cerebral disease brain protective principle.
III type mezzanine aneurysm surgical operation, can adopt according to experience of the pathological changes part and the surgical operation don’t turn to flow and turn to flow a method.Turn to flow a technique to include whole heatedly lung to turn to flow deep low temperature to stop circulation or top and bottom personal status and don’t infuse to note, action vein the part turn to flow and the left heart turn to flow etc..Anne Zhen hospital in Peking report the adoption improves left heart to turn to flow a method in 157 III type mezzanine aneurysms and obtained better effect.So can lower whole heatedly the lung turn to flow and negative influence of low temperature to machine body, can make the important and dirty machine functions, such as heart, brain, lung, kidney and spinal cord…etc. protect.For parts of demands long segment chest aorta cut off of case, carry on a rib artery to transplant probably prevent°from Shu being 13 ］s after the occurrence ［ of the spinal cord complications.For the research of spinal cord blood luck observation, the abroad has scholar in the Shu according to the measurement which induct electric potential of the motor nerve dollar with whether decision carries on a rib artery transplantation or not, that method of clinical the expansion be worth to still need the further experiment to confirm ［ 20 ］s.
5 The aneurysm treatment of the aorta mezzanine make progress
In order to being this disease cognitive exaltation to the mezzanine aneurysm, correspond of have never created a sex check technique to progress unremittingly, surgery technique improvement, get involved sex treatment to gradually open an exhibition, related of the anaesthesia and body be outside circulation, especially important and dirty machine protection research of thorough, make aorta mezzanine the treatment of the aneurysm has already exceeded a new step.Hagan etc. the summary 12 medical treatment center in the United States accept to cure for 1996~1998 years 464 impatient rise aorta mezzanine the result of the aneurysm, surgical operation death rate is 26%, Medicine treatment of death rate is 58%.Impatient decline the treatment death rate of the aneurysm Medicine of the aorta mezzanine as 10.7%, the surgical operation death rate is 21 ］s for 31.4% ［s.Tally up Anne a Zhen hospital is 564 treatment result of the chest aorta lump surgical operations for 1982~2002 years, 300 among those examples show that rising aorta lump is total as a result for the mezzanine aneurysm the death rate be 6.8%(25/365) and decline aorta lump total the death rate be 13.8%.(27/195)Hospital professor Sun Li4 Zhong tallies up out of the local Fu 1994~1999 years 231 aorta roots substitute the surgical operation effect of Shu, result surgical operation death rate is 3.03%, the emergency call surgical operation death rate then rises to 6.81%, Shu after with visit to show left room comfortable Zhang Mo4 Jing4 from before the Shu of(68.1 ±s 9.4) the mm lower to(54.8 ±s 8.2) mm ［ 22 ］s.These result with former cultural heritage report the chest aorta lump of the way over 20% the death rate has already shown Zhao already of lower.
The choice in surgical operation project, the technical expansion application of”trunk” is a huge progress, expect the surgical operation to provide convenience for the II and parts of sufferers even didn’t need two surgical operations.In the surgical operation in the meantime transplant a support also in the quest.
The III type aneurysm gets involved the success rate cultural heritage report way of treatment different, but generally and all in above 90%.Support inside the blood vessel reduced the wound of traditional surgical operation and the effect was affirmative in some clinical applications of small samples.Germany of Brunkwall to the cultural heritage report of 642 nasty and chronic mezzanine aneurysm adoption as a result carry on of the support inside the blood vessel analytical manifestation, death rate is 6.2%, for the sufferer of impatient mezzanine surgical operation high Wei particularly in keeping with applied ［ 23 ］s.Certainly decline get involved of aorta lump, the treatment is still placed in development stage, many centers in the world report to take small sample as many, after get involved treatment possible occurrence support inside the blood vessel seep into, the support move a , a side body to paralyze etc. the complications ［ be 24 ］s and even result in mezzanine to bow department and rise aorta contrary removal ［ 25 ］s.
6 Conclusion
In fine, pass the doctor of the surgery, anaesthetist, body to outside circulate teacher, the image section effort of doctor 20 years, the make a diagnosis and give treatment of aneurysm of the aorta mezzanine level has already come to an a new level.But can’t deny in the meantime, with often the heart surgical operation compare, the chest aorta lump is still a present stage the risk bigger disease, surgical operation operation more complicated need the researcher of related realm to make great effort further, exaltation surgical operation success rate and improvement sufferer Shu empress of existence quality
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