动脉旁路辅助下胸主动脉腔内修复的探讨

Arterial-bypass-supported endovascular thoracic aortic repair

目的探讨动脉旁路辅助下胸主动脉腔内修复(endovascularrepair,EVR)的可行性和有效性。方法回顾分析自2003年6月至2005年1月动脉旁路辅助下腔内修复DebakeyⅢ型主动脉夹层动脉瘤5例(aorticdissectionaneurysm,ADA),主动脉弓动脉瘤、主动脉弓外伤性假性动脉瘤和胸降主动脉瘤(descendingthoracicaorticaneurysm,DTAA)各1例的治疗经过、结果和并发症。所有患者近端锚定区均<15mm。1例ADA行右左腋腋动脉旁路,其余都行右左颈总动脉、左颈总左锁骨下动脉旁路,1周后行EVR。结果8例都取得技术成功。DTAA患者动脉旁路术后无并发症,EVR术后并发脑梗死而死亡。腋腋旁路患者EVR术后即时造影显示左锁骨下动脉返流导致Ⅱ型内漏,未作特殊处理。其余患者围手术期无卒中、截瘫或肢体缺血性并发症。存活的7例都获随访,随访期3～22个月(平均14个月),未发生神经系统或肢体缺血性并发症,术后3个月CT证实7例均胸主动脉段假腔或者(假性)动脉瘤瘤腔完全血栓形成,腋腋旁路患者内漏消失。结论辅助性动脉旁路可以为胸主动脉腔内修复创造额外的近端锚定区,扩大腔内修复的适应证范围。

Objective To study the feasibility and efficacy of endovascular thoracic aortic repair supported by preliminary arterial bypass. Methods From June 2003 to Jan. 2005, eight patients underwent endovascular repair （EVR） combined with supportive arterial reconstruction in the thoracic aorta. Five patients had Debakey type Ⅲ aortic dissection aneurysm （ADA）, and the remaining 3 had descending thoracic aortic aneurysm （DTAA）, aortic arch aneurysm and aortic arch pseudoaneurysm respectively. The proximal landing zone was measured less than 15 mm in all instances by contrast-enhanced CT scan and digital subtraction angiography. The preliminary right-left axillary bypass was performed in an ADA case in whom the distance from the primary entry site to the origin of the left common carotid artery was longer than 15mm, and the right-left carotid and left carotid-subclavian bypass in the remaining 7 cases. EVR was conducted 1 week after the bypass. Results All procedures were performed successfully. However, the DTAA patient died of the hemispheric cerebral infarction and subsequent multiple system organ failure, albeit the uneventful recovery from the prior cervical reconstruction. Type n endoleak occurred at the completion of EVR in the patient receiving the axillary bypass, but disappeared on 3-month CT. No neurological deficits or limb ischemia developed perioperatively or during the follow-up raging from 3 to 22 months, and complete thrombosis of the thoracic aortic false lumen or of the aneurysm/pseudoaneurysm was revealed on CT at 3 months in the 7 patients. Conclusion The adjunctive surgical bypass appeared to be feasible and effective in creating extra proximal landing zone for endovascular thoracic aortic repair, and thus broaden its aunlication.