胸主动脉覆膜支架并左锁骨下动脉烟囱术疗效分析

Thoracic aortic stent-graft placement combined with left subclavian artery "chimney operation":therapeutic analysis of 15 cases with insufficient proximal anchor area

目的探讨胸主动脉覆膜支架植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并左锁骨下动脉"烟囱"术的可行性。方法回顾分析2009年12月-2011年4月收治的支架近端锚定区不足的15例胸主动脉病变患者(B型夹层6例,假性动脉瘤1例,动脉瘤4例,穿透性溃疡4例),其中13例病变距左锁骨下动脉锚定区小于15 mm,2例大于15 mm。采用胸主动脉覆膜支架并左锁骨下动脉烟囱术治疗,观察脑及上肢缺血并发症发生情况。术后评价内漏、左锁骨下动脉显影等结果。结果 15例患者均成功地在主动脉内植入覆膜支架1枚,并在左锁骨下动脉植入"烟囱"支架1枚,术后患者均未出现神经系统并发症及左上肢严重缺血症状。术后5 d～3个月复查,主动脉覆膜支架形态良好,未发现I型内漏,"烟囱"支架内血流通畅。结论胸主动脉覆膜支架植入术中近端锚定区不足时,直接覆盖左锁骨下动脉开口并左锁骨下动脉"烟囱术"以延长锚定区并保持左锁骨下动脉通畅,更为安全。

Objective To discuss the strategies for the management of insufficient proximal anchoring area during the performance of transluminal stent-graft placement（TSGP）,and to evaluate the feasibility of intentional coverage of the left subclavian artery（LSA） together with left subclavian artery stent-graft placement by using ＂chimney operation＂ technique.Methods A total of 15 patients with thoracic aortic diseases complicated by insufficient proximal anchoring area,who were encountered in authors＇ hospital during the period from Dec.2009 to April 2011,were enrolled in this study.The clinical data were retrospectively analyzed.The thoracic aortic diseases included aortic dissection（n = 6）,aortic pseudoaneurysm（n = 1）,aortic aneurysm（n = 4） and penetrating ulcer（n = 4）.Of the 15 patients,the distance between the lesion and LSA anchoring site 15 mm was seen in 13 and the distance 15 mm in 2.TSGP was carried out.The ostium of LSA was intentionally and completely covered by thoracic aortic stent-graft and left subclavian artery stent-graft placement was subsequently performed.The patients were kept under observation for symptoms of cerebral and upper limb ischemia.The postoperative complications such as endoleak and the patency of LSA were assessed with angiography.Results Thoracic aortic stent-graft placement was successfully carried out in all 15 patients.In addition,one ＂chimney＂ stent was properly implanted in LSA in each patient.After the procedure,no complications of nervous system or severe ischemia of upper extremity occurred.Follow-up examinations performed between 5 days to 3 months after the treatment revealed that the aortic stent-graft remained in stable condition and no type I endoleak occurred,meanwhile the blood flow in ＂chimney＂ stent was unobstructed.Conclusion Intentional LSA coverage with ＂chimney operation＂ can expand the applicability of TSGP with high tolerability.It is especially useful for patients with left vertebral artery blood supply dominance or with cerebral infarction,sleep apnea syndrome and other brain insufficient blood supply diseases.Some parameters should be assessed before the procedure,which include the diameter and location of the chimney stent.Avoidance of type I endoleak of aortic stent should be stressed.（J Intervent Radiol,2012,21： 18-22）