腔内隔绝术治疗主动脉夹层及胸主动脉瘤

Endovascular stent-grafts exclusion for the treatment of DeBakeyⅢ type aortic dissections and thoracic aneurysm

目的 探讨腔内隔绝术治疗DeBakeyⅢ型主动脉夹层及胸主动脉瘤的手术时机及操作技巧。方法 10例DeBakeyⅢ型主动脉夹层及胸主动脉瘤（DeBakeyⅢ型主动脉夹层9例、胸主动脉瘤1例）患者行腔内隔绝术，术前行CTA或MRA及主动脉造影检查，判断主动脉夹层裂口位置与数量及胸主动脉瘤范围、左锁骨下动脉开口左侧胸主动脉直径、近端裂口至左锁骨下动脉开口的距离、真腔直径以及腹主动脉主要分支血管的血供来源，选支架规格及输送路径，然后在全麻下行右股动脉切开，透视引导下置入支架释放系统，定位准确后释放覆膜支架，完成腔内隔绝术。1例因破裂口位于左颈总动脉与左锁骨下动脉之间而先行右颈总动脉．左颈总动脉．左锁骨下动脉转流术。结果10例患者腔内隔绝术均获得成功。近端裂口距左锁骨下动脉开口距离平均3．5cm。出现Ⅱ型内漏1例。随访1-24个月，术后无截瘫发生，胸背部疼痛症状消失。1例胸主动脉瘤破裂伴食道瘘患者术后1个月死于感染。结论腔内隔绝术治疗DeBakeyⅢ型主动脉夹层和胸主动脉瘤是一种创伤小、疗效确切的方法。但远期效果仍有待进一步观察。

Objective To assess the operative timing and technique of endovascular graft exclusion （EVGE） for DeBakey III type thoracic aortic dissection and aneurysm. Methods Ten patients （9 patients with thoracic aortic dissection and 1 with aneurysm） underwent EVGE. Preoperative computed tomography angiography（CTA） or magnetic resonance angiography （MRA）and digital subtraction angiography （DSA） were performed to confirm the location and number of the dissecting tears and range of the aneurysm and measure the diameter of true lumen of the aorta both in the left side of left subclavian artery and descending part and the distance from proximal edge of the tear to the left subclavian artery. The blood flow in the main bronch from the abdominal aorta was estimated （ if the blood flow was from the false lumen, then catheterization to the main bronch and angiography were performed to confirm the patency）. The suitable graft was selected and deleavry route was decided. After the general anaesthesia,the right femoral artery（FA） was cut open. The dilivery system was inserted to the aorta though the opening of FA and graft was released after accurate posisioning under the guidance of fluoroscopy. Bypass from right carotid artery to left carotid and subclavian artery was performed in 1 case because the tear located between the left carotid and subclavian artery. Resuits The grafts were installed successfully. All procedure in 10 patients were successful. The distance from proximal edge of the tear to the left subclavian artery was 3.5 cm averagely. Type II endoleak was found in 1 case. One to twenty four months follow-up showed that no paraplegia occurred. The back pain was released in all 10 patients. The case with ruptured thoracic aneurysm and esophagus fistular died from infection. Conclusions EVGE may be a mini-invasive alternative for the treatment of DeBakey m type thoracic aortic dissection and aneurysm. Further follow-up is necessary for the evaluation of its longterm effectiveness.