覆膜血管内支架治疗StanfordB型胸主动脉夹层临床分析

Endovascular stent graft treatment of Stanford type B aortic dissection-clinical analysis of 76 cases

目的探讨覆膜血管内支架治疗StanfordB型胸主动脉夹层的近期疗效，总结主要并发症的发生及防治。方法回顾性分析2005年1月至2009年8月间我科收治的76例急慢性StanfordB型胸主动脉夹层患者接受覆膜血管内支架治疗的效果。患者于术后即刻行数字减影血管造影（DSA），并于术后1个月、半年及以后每年1次行胸腹主动脉增强CT扫描，随访患者的生存状态、内漏类型及夹层真假腔最大直径。结果63例患者获得随访，平均随访时间（14．3±10．9）个月。术中DSA造影发现I型内漏5例，术后1个月胸主动脉增强CT扫描发现I型内漏1例，术后8d闪大量内漏致胸主动脉破裂死亡1例，术后半年随访时自行封闭2例，3例少量内漏持续存在，但假腔直径未进一步扩大。术中封闭左锁骨下动脉开口16例，无脑干缺血发生，亦未见窃血综合征及左上肢缺血发生，1例封闭迷走右锁骨下动脉开口致急性右上肢缺血，术后6h急诊取栓并行腋-腋转流术治愈。术后支架段假腔内血栓完全形成7例，降主动脉夹层最大直径与术前比较[（56．3±11．7）mmVS（65．7±17．8）mm，P〈0．05]有明娃缩小。结论覆膜血管内支架治疗StanfordB型胸主动脉夹层安全、有效，近期随c方结果满意。内漏足该术式主要并发症，许可导致患者死亡，远期疗效有待进一步观察。

Objective To evaluate results of endovascular stent graft treatment of acute or chronic Stanford type B aortic dissection and to summarize the occurrence, prevention and treatment of complications. Methods A retrospective analysis was performed in 76 cases of type B aortic dissections who were treated with endovascular stent graft in Anzhen Hospital from January 2005 to August 2008. All patients were performed digital subtraction angiogra- phy （DSA） immediately after operation and were checked by enhancement CT of thoracic aorta and abdominal aorta at 1 month, 6 months and every year during follow-ups. Survival state of patients, type and fluence of endoleak, maximum diameter of true lumen and false lumen, the extent of thrmnbosis, blood flow change of branched artery of abdmninal aorta debouched at false lumen were recorded. Results Totally 63 cases had follow-ups （ mean follow-up time 14.3 ± 10.9 months ）. We observed 5 patients with type I endoleak middle-operation. 2 type I endoleaks sealed spontaneously after 6 months; 3 small type / endoleaks were persistent but the false lumen diameter had no enlargement. 1 month after operation, type I endoleak formation was observed in lease by enhancement CT. I case was dead due to large endoleak caused rupture of thoracic aorta. Left subclavian artery of 16 cases were occluded. No occurrence of brainstem ischemia, steal syndrome and left upper limb ischemia were obeserved. Acute right up- per limb ischemia was observed in 1 case because aberrant right subclavian artery was occluded and was cured by dislodged thrombus emergently and simultaneously treated axillo-axillary artery bypass grafting. Blood flow of branched artery of abdominal aorta were improved or did no change after operation, no occurrence of ischemia aggra- vated. We observed complete thrombosis of false lumen within stent in 7 patients, maximum diameter of false lumen significantly reduced compared with preoperation（56.3 ± 11.7 mm vs 65.7 ± 17.8 ram, P 〈 0. 05 ）. Conclusions Endovascular stent-graft treatment of Stanford B dissections is safety and effective and has satisfactory outcome in short-term follow-up. Endoleak is the major complication of the operation and can cause death. Further clinical in- vestigations are warranted to evaluate long-term efficacy of this theaary.