肾下型腹主动脉瘤腔内修复术后内漏的原因分析及应对策略

Causes and strategies of endoleaks after endovascular repair of infrarenal abdominal aortic aneurysm

目的探讨腹主动脉瘤腔内修复术(EVAR)后内漏发生的原因及防治策略。方法 2007年1月~2012年12月,共43例肾下型腹主动脉瘤患者接受腔内治疗。根据CT血管造影(CTA)检查及数字减影血管造影(DSA)结果选择覆膜支架植入。植入分叉型支架34例(79.1%),直管型支架6例(14.0%),主-髂单臂型支架3例(7.0%)。术后通过定期随访,了解动脉瘤大小变化及内漏发生的情况。结果术后即时造影发现内漏11例,其中Ⅰ型内漏8例(Ⅰa型5例,Ⅰb型3例),Ⅱ型1例,Ⅲ型2例。分叉型支架植入致内漏9例;直管型支架植入致Ⅰa、Ⅰb型内漏各1例。Ⅰ、Ⅲ型内漏经过一期球囊扩张、植入支架型血管或裸支架等处理,8例内漏消失。39例患者获得随访,随访时间4~50(平均18.3)个月,3例残留内漏在3个月时消失。在术后6、12个月随访时分别发现迟发性Ⅰb型、Ⅱ型内漏各2例,继续随访1~2年,未见瘤体明显增大。结论内漏的发生与动脉瘤的解剖学条件、移植物缺陷和操作技术有关;防治内漏需要把握好手术适应证、合理选择支架,并有成熟的操作经验。

Objective To investigate the causes and strategies of endoleaks after endovascular aneurysm repair (EVAR). Methods From January 2007 to December 2012, 43 patients with infrarenal abdominal aortic aneurysm were treated with endovascular repair. Stent-graft implantations were chosen by computed tomographic angiography (CTA) and digital subtraction angiography (DSA). During procedure, bifurcated stents were implanted in 34 cases (79.1%), straight tubular stents in 6 cases (14.0%) and aorto-uni-iliac stents (AUI) in 3 cases (7.0%). After operation, size of aneurysm and occurrence of endoleaks were assessed by regular follow-up. Results Endoleaks were found in 11 cases by postoperative immediate angiography, including typeⅠin 8 cases (typeⅠa in 5 cases, typeⅠb in 3 cases), typeⅡin 1 case and typeⅢin 2 cases. Among them, 9 endoleaks occurred in bifurcated stents, 1 typeⅠa and 1 typeⅠb endoleaks occurred in straight tubular stents. Eight typeⅠand typeⅢendoleaks disappeard after balloon dilatation,stent-graft or bare stent implantation. Thirty-nine cases were followed up for 4 to 50 months (average, 18.3 months). Three residual endoleaks disappeared at 3 months. Moreover, 2 late typeⅠb and 2 late typeⅡendoleaks were found at 6 months and 12 months after EVAR. The size of aneurysm did not significantly increase during the following 1 to 2 years. Conclusion The occurance of endoleaks is related to anatomic condition of aneurysm, stent defects and surgical skill. Controlling surgical indications, proper stents and skilled operation are important to prevent endoleaks.