摘要
主动脉根部-升主动脉段，由于其复杂的解剖结构及血流动力学湍流特点，使得在设计腔内移植物时，需考虑“主动脉瓣膜、双侧冠脉开口、主动脉窦部膨大、头臂干开口”等几个因素。因而被视为腔内修复最后的“禁区”，至今仍然无理想的腔内移植物能够用于此段病变的治疗，成为全球各大血管外科中心聚焦的前沿问题。现有研究方案包括Endo-Bentall法、Endo-Wheat法以及“景氏瓣窗型”移植物腔内修复动物实验等，但是主要存在个体化局限性、冠脉支架的远期通畅率不明确和移植物感染等悬而未解问题。目前尚无完善的腔内移植物或腔内手术方案可解决主动脉根部-升主动脉段病变。鉴于目前此技术的局限性和有限的临床经验，这项技术应保留给高危患者，特别是那些拒绝开放干预的患者。笔者对目前现有的腔内修复累及主动脉根部及升主动脉病变方案做一综述。
累及主动脉根部及升主动脉的病变包括急性A型主动脉夹层、壁内血肿、穿透性动脉粥样硬化性溃疡和慢性动脉瘤样扩张等，开胸在体外循环下行Bentall或Wheat等传统开放手术（主动脉瓣和升主动脉置换，伴或不伴冠状动脉再植），仍然是对累及主动脉根部-升主动脉病变的治疗的“金标准
主动脉根部包括左室流出道、主动脉瓣、主动脉瓣环、主动脉窦（冠脉开口）、窦管交界。窦管交界至主动脉弓发出头臂干间的这段升主动脉非常短，长度变化区间为（62.6±11.4）~（68.6±13）mm。升主动脉直接承受来自左室的高速脉冲血流，在心动周期中并非规则的层流，而是在主动脉窦中形成湍流，导致升主动脉直径在同一心动周期内变化可达2.70 m
对于一部分Debakey Ⅱ型夹层，或升主动脉局限性溃疡、动脉瘤的患者，已有很多中心使用市场上现有的短覆膜支架，成功进行单纯累及升主动脉病变的全腔内修
自Cribier
2020年1月，巴西圣保罗医院报告了世界首例“Endo-Bentall”手
图1 Endo-Bentall解决方案示意图 A：Endo-Bentall方案概念图解；B：Endo-Bentall方案关键部位设计示意图；C：Endo-Bentall方案俯视图
Figure 1 Endo-Bentall solution schematic diagram A: Conceptual diagram of the Endo-Bentall solution; B: Schematic diagram illustrating the key component design of the Endo-Bentall solution; C: Top view diagram of the Endo-Bentall solution
2014年Rylski团
图2 Endo-Wheat解决方案示意图（根据术中造影分别选择合适的介入瓣和覆膜支架，在手术台上将二者缝合连接；双侧冠状动脉开口处为裸支架，保证冠脉血流灌注；设置3个锚定区；可经心尖入路一期修复）
Figure 2 Endo-Wheat solution schematic diagram (Based on intraoperative angiography, suitable intervention valves and covered stents are selected, and they are sutured and connected on the operating table. The openings of the bilateral coronary arteries are left uncovered to ensure coronary blood flow perfusion. Three landing zones are established. The repair can be performed through a transapical approach in a one-stage procedure)
图3 主动脉瓣组件与半覆膜支架移植物拼接示意图（锚定点1：主动脉瓣环，通过瓣膜装置稳定支架移植物；锚定点2：窦管连接处，形成近端密封区；锚定点3：头臂干近端，形成远端密封区）
Figure 3 Schematic diagram of aortic valve component and semi-covered stent graft integration (Landing zone 1: Aortic valve annulus, stabilizing the stent graft through valve device; Landing zone 2: Sinotubular junction, forming a proximal sealing zone; Landing zone 3: Proximal end of the brachiocephalic trunk, forming a distal sealing area)
长海医院在2020年发表了研
图4 一体化带瓣开窗分支型腔内移植物示意图
Figure 4 Schematic diagram of integrated valved-fenestrated-bifurcated endograft
目前尚无完美的腔内移植物或腔内手术方案可解决主动脉根部-升主动脉段病
作者贡献声明
毛逸伦负责书写原稿；郭媛媛负责审核和修改；邬光敏、单智远、张子正负责查阅文献并核修。
利益冲突
所有作者均声明不存在利益冲突。
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