主动脉夹层腔内隔绝术中支架移位的处理

Stent-graft migration during endovascular repair of aortic dissection

目的探讨主动脉腔内治疗术中支架移位的原因及处理方法。方法回顾性分析2001年5月至2007年12月完成的主动脉Ⅲ型夹层腔内隔绝术中发生支架移位的17例患者的临床资料，其中男13例，女4例，急性夹层15例，慢性夹层2例。发生支架后移11例，包括球囊扩张过程中支架后移2例，支架释放后撤鞘过程中将支架刮带后移1例，支架半释放时发生移位2例；支架前移6例，包括支架前移阻塞左锁骨下动脉3例，阻塞左颈总动脉3例，其中1例为后移支架被cuff输送器推向前方阻塞左颈总动脉，1例为cuff释放过程中前跳堵塞左颈总动脉。结果支架后移的11例通过将支架向前顶推或放置cuff缓解，本组围手术期无死亡病例。支架前移6例，其中3例锁骨下动脉受阻，未做处理，其中1例术后因小脑梗塞死亡；另外3例覆盖左颈总动脉，2例使用球囊扩张拖拽，1例采用抓捕器牵拉左锁骨下动脉的导管，将支架向远侧牵拉，使左锁骨下动脉重新开放。结论主动脉腔内隔绝术中支架移位除与技术因素有关外，还和解剖因素和支架设计有关。支架前移相对少见，但对患者危害更大。除用球囊扩张拖拽外，用抓捕器牵拉左锁骨下动脉导管是一种较好的补救办法。

Objective To evaluate the cause and management of intraoperative stent-graft migration during endovascular repaire of aortic dissection （AD）. Method During the period between May 2001 and Dec 2007 intraoperative stent-graft migration occurred in 17 cases （ 14 males and 3 females） including 15 acute AD cases and 2 chronic AD cases. Backward migration was noticed in 11 cases including the 2 cases found during balloon extention, in 1 case the migration found during the removal of the releasing sheath which scratched the stent-graft, in 2 cases the migration occurred when the grafts were half released. Forward migration occurred in 6 cases resulting in left subclavian artery （LSA） occlusion in 3 cases and left common carotid artery （LCCA） occlusion in the other 3 cases. For the 3 cases of LCCA occlusion, the backward migrated stent-graft was pushed forward by the cuff releasing system and consequently occluded the LCCA in 1 case, and the cuff jumped forward during release and occluded the LCCA in 1 case. Result Backward migration of stent-grafts can be treated by pushing forward the graft with the sheath or additional placement of a cuff. Intraoperative complication may be less life threatening and no pefioperative death occurred in this group. Occlusion of LSA in 3 cases by forward migration of stent-grafts were left untreated and 1 case died of leter cerebellar infarction. For the LCCA occlusion in 3 cases, 2 were treated by drawing back the graft with a balloon, and in the remaining 1 case the migrated graft was pushed back with the catheter in the LSA captured by a snare. Conclusion Stent-graft migration during endovascular repair may be related with poor experience of the operator, specific anatomical condition of the patient and the design drawback of the stent-graft. Forward migration of stent-graft is less common but may be more harmful for the patient. Beside back drawing with a balloon, the captured catheter with a snare may be helpful in the management of forward migration of the released stent graft.