Ⅲ型夹层动脉瘤介入治疗误堵颈动脉的处理

Management of wrong coverage of carotid artery during endovascular repair of type Ⅲ aortic dissection by stented graft

目的 总结Ⅲ型夹层动脉瘤介入治疗误堵左颈总动脉的处理和经验教训.方法 4例Ⅲ型夹层动脉瘤患者行支架型人工血管封堵降主动脉内膜破口时不慎误堵塞左颈总动脉.4例患者均为男性,年龄37～45岁,平均年龄41岁.1例因存在内漏加Cuff时将第一个支架推向近侧导致左颈总动脉和左锁骨下动脉堵塞,经球囊拖向下方后解决;1例放置支架时支架前跳堵塞左颈总动脉和左锁骨下动脉.立即从股动脉进抓捕器抓住从左上肢肱动脉进入升主动脉的刻度猪尾导管将支架拖向远侧后恢复左颈总动脉和左锁骨下动脉血流;1例因定位误差导致支架堵塞2/3左颈总动脉和左锁骨下动脉,立即显露左颈总动脉分叉经颈外动脉置入左颈总动脉支架（chimney技术）后左颈总动脉血运完全恢复;1例是在心外科误将前端无裸支架的支架型人工血管当成有裸支架而将一半的无名动脉、左颈总动脉和左锁骨下动脉封堵,经正中开胸行升主动脉双颈动脉及左腋动脉人工血管搭桥后缓解.结果 4例患者均成功封堵Ⅲ型主动脉夹层的近侧内膜破口,无明显内漏,无脑梗死和左上肢缺血表现.结论 介入治疗Ⅲ型主动脉夹层误堵颈动脉后需立即通过手术或介入手段解决以避免发生脑缺血并发症.

Objective To evaluate the management of wrong coverage of the left common carotid artery （ CCA ） during interventional treatment of type Ⅲ aortic dissection by stented graft. Methods Coverage of the left CCA occurred in four cases during endovascular repair of type Ⅲ aortic dissection using stented graft. All four cases were male. The ages ranged from 37 to 45 years old with the average of 41. The first case was due to moving proximally of the first stented graft during delivery of one more cuff because of endoleak. Recanalization of the left CCA and subclavian artery （ SA） was acquired through sliding distally of the stented graft with the help of an aortic balloon. Coverage of the left CCA and SA in the second case was due to jumping-forward of stented graft during deploying, we dragged the stented graft distally through the pigtail catheter introduced from the left brachial artery with the help of a trap device. Then, the covered left CCA and SA were recanalized. The 2/3 left CCA was covered because of mislocation of the left CCA for the 3rd case. We recanalized the covered left CCA using chimney technique with the exposure of the left CCA. For the 4th case, half the innominate artery, the left CCA and SA were covered because the performer mistake the stented graft without naked stent as one with proximal naked stent. A bypass of assending aorta to bi-carotid arteries and the left axillary artery was performed using vascular graft one month after the endovascular repair. Result The proximal intimal entry was sealed successfully in all four cases. No endoleak, cerebral infarction and ischemia of the left upper limb occurred. Conclusion In cases of wrong coverage of carotid artery during endovascular repair of type Ⅲ aortic dissection, the CCA must be recanalized as soon as possible through surgical or interventional treatment in order to avoiding cerebral ischemia.