近端锚定区不足的胸主动脉覆膜支架置入术治疗分析

Analysis of thoracic endovascular aortic repair in 29 cases with insufficient proximal landing zone

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的处理方法。方法回顾性分析支架近端锚定区不足的29例胸主动脉病变（B型主动脉夹层16例，假性动脉瘤1例，动脉瘤8例，穿透性溃疡4例）患者的处理方法、结果及并发症。结果主动脉覆膜支架均顺利置入，8例直接封闭左锁骨下动脉，15例采用烟囱技术，6例进行杂交手术。2例患者Ⅰ型内漏，2例患者出现轻度左上肢缺血症状，4例头晕，1例发生吻合口瘘，1例失血过多。结论胸主动脉覆膜支架置人术中近端锚定区不足时，对右侧椎动脉优势的患者可以直接覆盖左锁骨下动脉开口；左侧椎动脉优势时，采用“烟囱术”或进行杂交手术以延长锚定区。上述方法可以保持颅内供血的通畅，是安全可靠的。

Objective To discuss the strategies for management of insufficient proximal landing zone during thoracic endovascular aortic repair（TEVAR）. Methods We retrospectively investigated the outcomes and complications after the TEVAR in 29 patients of thoracic aortic cases with short proximal anchoring area（16 aortic dissections, 1 aortic pseudoaneurysms, 8 aortic aneurysms,4 penetrating ulcer） between 2009 and 2011. The endoleak, left subclavian artery（LSA） developing, left upper limb symptom and other results were evaluated after operation. Results Technical success were achieved in all eases（8 intentional coverage of the LSA, 15 ＂chimney operation＂, 6 hybrid operation）. Two patients happened type 1 endoleak. Two patients with complete LSA coverage had mild clinical symptoms . 4 patients had dizziness . One patient had excessive blood loss, and one patient had anastomotic fistula. Conclusion Intentional LSA coverage can expand the applicability of TEVAR with high tolerability. However, intentional LSA coverage with ＂Chimney operation＂ or hybrid operation was needed when the patient had advantage of the left vertebral artery. They can be especially used for patients with left vertebral artery blood supply dominance or with cerebral infarction and other brain blood supply diseases.