108例支架近端锚定区不足患者胸主动脉覆膜支架置入术治疗分析

Analysis of thoracic aortic stent-graft placement in 108 cases with insufficent proximal ancher area

目的探讨胸主动脉覆膜支架置入术在支架近端锚定区不足时左锁骨下动脉的处理方法及支架直接覆盖左锁骨下动脉开口的安全性。方法回顾分析支架近端锚定区不足的108例胸主动脉病变(B型夹层94例,假性动脉瘤14例)左锁骨下动脉的处理方法、结果及并发症。2例行人工血管旁路联合覆膜支架置入术(杂交手术),其余患者直接行覆膜支架置入术,其中,完全覆盖左锁骨下动脉开口72例(A组),部分覆盖左锁骨下动脉开口34例(B组)。对比两组术后内漏、LSA显影、双上肢收缩期压差等结果。结果支架均顺利置入,术后除1例出现脑供血不足,死于呼吸循环衰竭,余患者均未出现神经系统并发症及左上肢严重缺血症状。A组左上肢收缩期血压低于右侧(84.8±44.0)mmHg和(130.8±21.4)mmHg,差异具有统计学意义;B组双上肢收缩期血压差异无统计学意义。随访(31.3±23.7)个月,仅A组中33例出现轻微左上肢乏力、麻木及头晕症状,无需手术处理。结论胸主动脉覆膜支架置入术中近端锚定区不足时,直接覆盖左锁骨下动脉开口以延长锚定区是可行的,特别是部分覆盖LSA开口更为安全;但必需严格把握适应证、仔细评估双侧椎动脉及颈动脉血供情况,对合并脑梗塞、呼吸睡眠暂停综合征等影响脑供血疾病的患者即使右侧椎动脉及双侧颈动脉血供良好,也不宜直接完全覆盖LSA开口。

Objective To discuss the strategies for management of insufficient proximal anchoring during transluminal stent-graft placement （TSGP）,and to evaluate the safety of intentional coverage of the left subclavian artery （LSA）.Methods We retrospectively investigated the outcomes and complications after the TSGP in 108 cases of thoracic aortic cases with short proximal anchoring area （94 aortic dissections,14 aortic pseudoaneurysms） between 2002 and 2009.The ostium of LSA was intentionally covered by stent graft completely without any supportive bypass in 72 patients,and partially covered in 34 patients.Primary prophylactic revascularization of LSA was performed only in 2 patients.Results Technical success wa achieved in all cases.One patient developed acute stroke and died of respiratory and circulatory failure.Thirty three patients with complete LSA coverage had mild clinical symptoms during a mean follow-up of 31.3±23.7 months but no other neurological deficits or severe limb ischaemia developed.The upper limb systolic pressure of the left side was significantly lower than the right side （84.8±44.0 mmHg vs.130.8±21.4 mmHg,P=0.000） in patients with complete LSA coverage.Conclusion Intentional LSA coverage can expand the applicability of TSGP with high tolerability,expecially with partial LSA coverage.Pre-assessment of posterior cerebral circulation and indications for TSGP should be done before the procedure.