腔内修复术治疗Stanford B型胸主动脉夹层临床分析

Clinical analysis of endovascular repair of Stanford type B thoracic aortic dissection

目的探讨腔内修复术治疗胸主动脉夹层的方法和疗效。方法回顾性分析78例StanfordB型胸主动脉夹层的临床资料。术前均采用CT血管造影(CTA)或磁共振血管造影(MRA)对患者进行评估;在数字减影血管造影(DSA)的监控下经股动脉将带膜支架型人工血管置入胸主动脉内膜破口处,封闭夹层近端第一破口;术后即行DSA。于术后1,3,6个月及1年以后每隔1年行CTA随访,随访患者生存状况、内漏类型及残余夹层真假腔内径。结果腔内修复后,术中造影发现I型内漏6例,其中2例内漏在cuff植入后消失;2例近端内漏行球囊扩张后内漏消失;2例漏血少,假腔显影浅淡,未予处理;术后3个月发现1例内漏仍持续存在,但假腔直径未见增大。II型内漏2例,因漏血少,未予处理。术后6个月发现其中自行封闭1例;另1例内漏仍存在,但假腔直径未见增大。78例患者中,术中封闭左锁骨下动脉者15例。其中2例出现左上肢窃血综合征,并伴有乏力症状;2例2年后出现脑梗死;1例6个月后出现Stanford A型夹层而行升主动脉置换术。其余患者无心、肺、肾功能衰竭及截瘫等严重并发症。结论近期随访结果表明,腔内修复术治疗Stanford B型胸主动脉夹层安全、有效;内漏是该手术的主要并发症。

Objective To investigate the techniques and effectiveness of endovascular repair for treating Stanford type B thoracic aortic dissection.Methods The clinical data of 78 patients with Stanford type B thoracic aortic dissection were retrospectively analyzed.All patients were evaluated before surgery by CT angiography（CTA） or magnetic resonance angiography（MRA）.A vascular prosthesis（membrane-covered stent） was introduced via the femoral artery into the dissected thoracic aorta under digital subtraction angiography（DSA） guidance to exclude the proximal primary entry tear.DSA examination was carried out immediately after the stent placement procedure to confirm the exclusion of the dissection.Follow-up CTA was performed at 1,3 and 6 months after surgery,and then every one year thereafter.The survival status,endoleak types,true and false lumen diameter of the residual dissection of the patients were recorded.Results Intraoperative angiography revealed 6 cases of type I endoleak following endovascular repair.Of these patients,the endoleak in 2 cases disappeared after cuff insertion,the proximal endoleak in 2 cases disappeared after the balloon expansion,and another 2 cases with small leak as evidenced by less contrast material in the false lumen received no treatment.A persistent endoleak was only found in 1 case,but no enlargement of the false lumen diameter 3 months later.Type II endoleak occurred in 2 cases who received no treatment due to small amount of blood leakage.Of the 2 cases,endoleak spontaneously closed in 1 case,and persisted without enlargement of the false lumen diameter 6 months later in the another one.Of the 78 patients,15 cases underwent intentional occlusion of the left subclavian artery during surgery,of whom,2 cases presented the steal syndrome of left upper limb accompanied by debilitating fatigue,2 cases suffered cerebral infarction after 2 years,and 1 case,after 6 months,developed Stanford type A aortic dissection,that underwent ascending aorta replacement.No severe complications（such as,heart,lung and renal function failure or paraplegia） occurred in the rest of the patients.Conclusions Our brief follow-up study suggests that endovascular repair for Stanford type B thoracic aortic dissection is safe and effective treatment.Endoleak is the major complication after endovascular treatment.