主动脉夹层-讲课幻灯.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,一、,动 脉 粥 样 硬 化,（,Atherosclerosis,）,常见，严重，,发达国家：主要死因,我国：,尸检,40-49,岁 冠状,A 58%,主,A 88%,北方高于南方，老人多，但有年轻化趋势，,40-49,岁发展最快,概念：是一种与血脂异常及血管壁成分改变有关的动脉疾病,累及大中动脉,动脉内膜脂质沉积，内膜灶性纤维化，深部组织坏死、崩解形成粥样斑块纤维管壁变硬、管腔狭窄,What,s,atherosclerosis,?,一、,危险因素,1.,高脂血症,2.,高血压,重要相关因素,3.,吸烟,与剂量相关,4.,致继发性高脂血症的疾病,高血糖 高胰岛素 肾病综合征,5.,遗传因素：,家族性高脂血症,6.,其它：,年龄、性别和肥胖,复合病变,(,Complicated lesion),斑块内出血,斑块破溃 血栓形成；钙化；动脉瘤形成,夹层动脉瘤形成,(,Aorta Dissecting Aneurisms),(3),脑动脉粥样硬化,Cerebral Vessels AS,基底动脉,大脑中动脉,Willis,环,脑萎缩 痴呆,脑梗死,Brain Infarct(Stroke),脑出血,:,动脉瘤形成破裂偏瘫死亡,与大动脉炎鉴别,由于动脉夹层导致血管真腔变窄,故听诊可闻及血管杂音,加之患者年轻,有低热,极易与多发性大动脉炎混淆。,11/16/2025,流 行 病 学,主动脉夹层（,aortic dissection,，,AD,）,临床上最复杂、最危险的心血管疾病之一，通常认为,AD,的形成是血流进入动脉管壁破裂口致动脉撕裂的结果。,因主动脉中层囊性坏死常出现局灶性出血,随着出血灶的扩大,血肿逐渐将中层撕开,加之主动脉内压力高,撕开的夹层向远端及主动脉各大分支扩展,，,形成广泛的动脉夹层。,11/16/2025,病 理,组织病理学：,1.,弹性纤维的断裂、缺失，蛋白聚糖的,沉积增加的中层变性为特点,2.,中层平滑肌细胞部分缺失,3.,动脉粥样硬化的表现,4.,炎性细胞浸润的表现（最近文献报道）,11/16/2025,危 险 因 素（一）,主动脉壁压力增加,未受控制的高血压,嗜络细胞瘤,服用可卡因或其他兴奋剂,举重或做,Valsalva,动作,外伤,减速或扭转损伤（如：汽车相撞时）,主动脉缩窄,11/16/2025,危 险 因 素（二）,主动脉中层异常,遗传：,Marfan,综合征、,Ehlers-Danlos,综合征、二叶式主动脉瓣、,Turner,综合征、,Loeys-Dietz,综合征、遗传性胸主动脉瘤或夹层综合征,炎性血管炎：大动脉炎、巨细胞性动脉炎、,Behet,病,其他：妊娠、多囊性肾病、长期使用激素或免疫抑制剂、感染,11/16/2025,分期（三）,分期,急性主动脉夹层定义为发病在,2,周以内；发病在,26,周间为亚急性；大于,6,周为慢性,11/16/2025,辅助检查（一）,目前公认的影像诊断方法有主,动脉造影、,CT,增强扫描、,MRI,和经食管超声心动图,(TEE),检查,胸部,X,线,：,主要作为评估潜在的急性胸主动脉疾病手段的一部分，可用来鉴别其他疾病，很少用来排除胸主动脉疾病，除非极低危患者。,CT,：,多层螺旋,CT,的敏感性可达,100%,，特异性,98%99%,能够清晰的显示主动脉腔内，主动脉壁及动脉周围组织的情况，胸主动脉及其分支血管的解剖学异常，判断各种急性主动脉疾病如主动脉壁内血肿、穿透性溃疡、急性主动脉夹层等,11/16/2025,辅助检查（二）,超声心动图,经胸超声诊断主动脉夹层的敏感性约,77%80%,，特异性约,93%96%,经食管超声的敏感性与特异性分别为,88%98%,与,90%95%,主动脉扩张的诊断主要依靠测量胸主动脉内径，同时考虑到患者的年龄、性别、身高、体表面积等因素的影响。,11/16/2025,辅助检查（三）,动脉造影术,优点,：精确的显示夹层部位，受累分支以及真假腔的情况，同时可以对冠状动脉疾病做诊断与治疗。,缺点,：有创检查，需要经验丰富的医生；操作时间比较长，患者受到的辐射及造影剂使用量较大；当假腔内血栓形成时可能出现假阴性结果。,11/16/2025,多发性大动脉炎,TAKAYASU ARTERITIS,多发性大动脉炎,定义：是一种原因不明，发生在主动脉和,/,或其主要分支的慢性非特异性炎症性动脉疾病。,国外一般命名为高安动脉炎（,Takayasu Arteritis,TA,）,多发性大动脉炎,多发性大动脉炎,一般发病情况,青少年多见，发病年龄多在,5-40,岁,女性：男性,7-8:1,以头部及臂部动脉受累最多见,其次可累计降主动脉、腹主动脉、肾动脉,冠状动脉、肺动脉受累较少见,多发性大动脉炎,可能的病因,1.,自身免疫性：,及,球蛋白，,IgG,、,IgM,，抗主动脉壁抗体（,+,），急性期可有,Coombs,抗体（,+,）等,2.,遗传因素：与,HLA,系统有一定关系,3.,内分泌功能：与高雌激素水平有关,病理生理改变,1.,病变远侧缺血,2.,病变近侧高血压,多发性大动脉炎,临床表现,1.,全身症状：活动期可有发热、全身不适、纳差、体重下降等。可能伴有关节炎、结节红斑、雷诺综合症及脾肿大等。,2.,局部症状：可分为,5,型,头臂动脉型 胸腹主动脉型,肾动脉型 肺动脉型 混合型,实验室检查,无特异性检查,ESR,、,CRP,可有明显升高。,抗“,O”,阳性，白细胞及血小板可升高。,影像学检查,金标准：动脉造影检查。,动脉造影显示,髂总动脉狭窄,影像学检查,血管多普勒检查,可发现增厚的颈动脉壁中亚毫米的改变，空间分辨率高于,CTA,与动脉粥样硬化鉴别：,管壁增厚,狭窄,狭窄段长度,TA,弥漫性环形增厚,向心性,长,atherosclerosis,不均匀不对称增厚,偏心性,短,影像学检查,磁共振检查（,MRI/MRA,）的优点,避免动脉穿刺,避免碘造影剂负荷,避免大量放射线暴露,可提供清晰的动脉壁解剖图像,可提供完整的全身大动脉信息,T2,加权未见明显异常,EWI,见管壁狭窄、水肿,钆,增强扫描可,见活动性病变,MRA,显示颈总动脉、锁骨下动脉及肾动脉多发狭窄,病变初期,起病,12,个月之后,影像学检查,PET-CT,检查,可在病变早期，尚未发生动脉狭窄时发现细胞代谢异常,缺点：特异性不高,第二节 动脉病变,一、动脉硬化,【,典型病例,】,1.,患者，男，,68,岁，因心悸、心慌、胸痛、胸闷、四肢凉麻、头晕来诊，临床诊断为冠心病。,2.,患者，男，,45,岁，患糖尿病,10,年，发现两侧下肢发凉,2,月，行,CTA,检查。,【CT,诊断要点,】,多层螺旋,CT,对血管显像具有极大优势，可直接显示血管走行、形态，血管壁钙化情况、软硬斑块情况、血管狭窄程度及与周围组织关系，检查快捷，诊断符合率高。,二、主动脉夹层动脉瘤,【,典型病例,】,患者，女，,37,岁，因撕裂样胸痛、大汗淋漓,1,小时就诊。,【CT,诊断要点,】,1.,平扫，主动脉局限性或广泛性增宽、增粗，钙化的内膜瓣内移，此征象具有诊断价值。,2.,增强扫描可显示充满造影剂的高密度双腔间的低密度内膜片，有确诊价值。,3.,真假两腔形成，尤以增强扫描表现突出。,4.,真腔受压变形。,5.,血栓形成，多见于假腔内。,三、主动脉瘤,【,典型病例,】,1.,患者，男，,58,岁，腹部钝痛月余，腹腔可触及包块，听诊可闻及血管杂音。,2.,患者，女，,71,岁，近期出现腹部和背部疼痛血压高并心动过速。,3.,患者，男，,65,岁，高血压病史,30,年，突然腹部剧痛就诊，临床考虑为夹层动脉瘤。,4.,患者，男，,60,岁，因恶心、呕吐入院。无明显发热，白细胞计数不高，无腹肌紧张。,【CT,诊断要点,】,1.,主动脉扩张直径,3cm,或超过瘤体近端主动脉管径的,1/3,以上作为诊断标准。,2.,瘤体可是囊状或梭形，瘤壁钙化及血栓形成，平扫可见弧形、线状或小斑块状钙化。,3.,增强血栓表现为瘤体内环形或新月形低密度影。,4.,主动脉瘤破裂表现为主动脉旁高密度影，并沿筋膜扩展至肾周间隙，液,-,液平面常见。,四、大动脉炎,【,典型病例,】,患者，女，,33,岁，因头疼、头晕、低血压个月，近日加重就诊。,【CT,诊断要点,】,1.,以腹主动脉、胸降主动脉、锁骨下动脉和肾动脉为其好发部位。主动脉分支病变多累及开口部或近心段，局限性狭窄、阻塞多见。侵犯主动脉的狭窄，病变多较广泛。,2.,管腔粗细不均、边缘比较光滑的向心性动脉狭窄和阻塞。,3.,动脉扩张和动脉瘤形成。,4.,病变部位钙化，见于青少年者意义大。,5.,可闻及局部血管杂音。,6.,心脏可有不同程度的增大，多为以左室为主的轻至中度增大。,The Affiliated Hospital of Inner Mongolia Medical College,M 40yrs AVM,突发头痛呕吐,2,周。头颅,CT,脑室出血。,MRI,提示胼胝体占位性病变。,DSA:,左顶枕区,AVM,，供血动脉来自双侧大脑前动脉、左侧大脑后动脉，左侧横窦充盈差，闭塞。,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,VR,The Affiliated Hospital of Inner Mongolia Medical College,MIP,The Affiliated Hospital of Inner Mongolia Medical College,M 57yrs,Clinical Data:,头晕、恶心、呕吐，伴肢体无力，右侧面瘫，病理征阳性，有高血压史。MRI:大脑前动脉瘤，双侧大脑中动脉狭窄。BUS：双侧颈内动脉斑块，左侧颈总动脉斑块。,CT:,脑内多发腔梗,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,M 62yrs L-ICA-S,、,R-ECA-S,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,M 63yrs PE+DVT,Clinical Data:,左下肢肿胀半月，胸疼、咳嗽,10,天。彩超：左股总至股浅静脉上段见中等回声物填充，其内见少量血流信号。曾,2006,年,12,月,9,日住院，最终手术切除左腹股沟淋巴结（转移性低分化粘液表皮样癌）。,The Affiliated Hospital of Inner Mongolia Medical College,M 63yrs PE+DVT,优维显（,300mgI/ml,）,80ml,（速率,4ml/s,）自动触发,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,M 64yrs AA+T,Clinical Data:,中腹部搏动性包块,2,月。无明显诱因中腹部偏右侧可触及包块，有搏动。无高血压、糖尿病史。人工血管置换术。,The Affiliated Hospital of Inner Mongolia Medical College,M 64yrs AA+T,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,VR,The Affiliated Hospital of Inner Mongolia Medical College,MIP,The Affiliated Hospital of Inner Mongolia Medical College,F 69yrs AD-Type I,Clinical Data:,间断性头晕,20,年，发作性胸痛,2,年，加重,3,小时。血压：,160/100mmHg,。,The Affiliated Hospital of Inner Mongolia Medical College,F 69yrs AD-Type I,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,VR,The Affiliated Hospital of Inner Mongolia Medical College,CTVE,The Affiliated Hospital of Inner Mongolia Medical College,CTVE,The Affiliated Hospital of Inner Mongolia Medical College,CTVE,The Affiliated Hospital of Inner Mongolia Medical College,Clinical Data:,反复头痛,3,年。血压,210/120mmHg,，上腹部闻及,3/8,级收缩期杂音。双下肢水肿。,M 37yrs RAS,The Affiliated Hospital of Inner Mongolia Medical College,M 37yrs RAS,The Affiliated Hospital of Inner Mongolia Medical College,RAS,The Affiliated Hospital of Inner Mongolia Medical College,F 70yrs LE-A,The Affiliated Hospital of Inner Mongolia Medical College,M 79yrs LEA-O,Clinical Data:2,月前无明显诱因出现左下肢行走乏力，发困，休息时略好转。近,2,月患者上述症状频发，并渐加重，半月前患者左下肢远端麻木，肢体发凉。彩超：动脉粥样硬化闭塞。查体：双侧足背动脉无搏动，左足发凉，皮温低。,The Affiliated Hospital of Inner Mongolia Medical College,M 79yrs LEA-O,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,M 60yrs Takayasu,s arteritis:history 2-year,、,Clinical Data:4,年前无明显诱因出现左侧肢体活动不灵。双下肢肿胀疼痛,1,周。双下肢麻木。,1,周前因长时间行走出现右足红肿胀痛，渐加重，伴行走困难（感染）。足背动脉搏动消失。血压,180/110mmHg,。,BUS:,左上肢及双下肢深动脉血流充盈减少，双下肢动脉与腹主动脉壁增厚。腹主动脉,MRI,示未见异常。,DSA,（,2948,）：右髂总动脉狭窄，球囊扩张后支架植入，左股动脉人工血管搭桥术。,The Affiliated Hospital of Inner Mongolia Medical College,M 60yrs Takayasu,s arteritis:history 2-year,、,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,The Affiliated Hospital of Inner Mongolia Medical College,祝本次大会圆满成功！,THANKS,