高危胸降主动脉瘤腔内修复治疗

Clinical outcomes of endovascular repair of descending thoracic aortic aneurysm in high-risk patients

目的总结高危患者行胸降主动脉瘤（descending thoracic aortic aneurysm，DTAA）腔内修复治疗（endovascular aneurysm repair，EVAR）的经验。方法回顾分析2001年1月至2007年7月我科24例高危DTAA患者行EVAR诊治经过、结果和并发症。所有患者因动脉瘤部位、破裂、高龄或严重合并症而不适合行开放手术。EVAR术后1个月、3个月、6个月、12个月和每年行螺旋CT血管造影、三维重建随访。结果所有患者均获技术成功（100%）。围手术期死亡2例（8.3%），分别死于多系统器官功能衰竭和急性心肌梗死。2例（8.3%）术后发生严重并发症（1例缺血性脑卒中和1例急性肾功能不全）。11例（46%）术后即时造影显示近端Ⅰ型内漏，其中3例内漏量大，行球囊扩张后内漏消失；另8例随访观察。19例患者获随访，随访时间为1-60个月（平均18.6±4.2个月）。1例患者术后4年发生支架型人工血管移位并发Ⅰ型内漏，1例术后2年出现迟发性Ⅲ型内漏，均成功行EVAR。1例死于结肠癌。其余患者术后3个月CT证实瘤腔内完全血栓形成，无支架移位和内漏。随访期间动脉瘤最大直径缩小0-18 mm（平均6.3±3.1 mm），4例辅助性动脉旁路在随访期间人工血管均通畅。结论EVAR治疗高危DTAA早期死亡率和并发症发生率尚可接受，对某些病例可能是首选治疗方法。

Objective To evaluate the mid-term outcomes of endovascular repair of descending thoracic aortic aneurysm （DTAA） in high-risk patients. Methods Twenty four patients with DTAA received stent-grafts implantation between January 2001 and July 2007 and their clinical data were retrospectively analyzed. All patients were considered high-risk for open surgical repair due to the location or rupture of the aneurysm, high age and severe comorbidities. Spiral computed tomography angiography and 3- dimentional reconstructions were performed at 1, 3, 6 and 12 months postoperatively and thereafter every year. Results The primary operational success rate was 100%. There were 2 deaths （8.3%） during perioperative period due to multiorgan failure and acute myocardial infarction respectively. Two （8. 3% ） patients had severe post-operational complications （ 1 stroke and 1 acute renal insufficiency）. Eleven cases of type Ⅰ （46%） endoleak were detected immediately after the operation and among them, the endoleak disappeared after balloon dilatation in 3 cases while the other 8 patients were treated conservatively. Follow- up of 1 to 60 months （mean 18.6 ±4.2 months） was completed in 19 patients （79.2%）. Stent displacement with type Ⅰ endoleake was found in 1 patient at 4 years after the operation and delayed type Ⅲ endoleak occured in another patient at 2 years post-operation. Both patients received endovacular repair again and the endoleaks were closed successfully. One patient died of colon cancer during the follow up. Complete thrombosis of the thoracic aneurysm sac and no stent migration or endoleak was found on the follow-up CT at 3 months after the operation in all the patients. The decrease in maximal aneurysm diameter was 0 - 18 mm （ mean 6. 3 ± 3.1 mm）. The prosthetic vascular grafts implanted in 4 patients with preliminary carotid subclavian bypass surgery were patent during the follow-up period. Conclusion Treatment of descending thoracic aortic aneurysm in high-risk patients with endovascular approach showed acceptable early mortality and morbidity and may be considered as a treatment alternative for carefully selected patients.