DebakeyⅢ型夹层动脉瘤远侧破口的腔内封堵

Endovascular repair for distal intima tears in Debakey type Ⅲ dissecting aneurysm

目的初步总结使用腔内技术处理夹层动脉瘤远侧破口的经验。方法总结15例DebakeyⅢ型夹层动脉瘤近端破口腔内修复术后腹主动脉以远破口的二期介入处理经验。所有病例远侧破口持续存在，出现腰腹部症状或局部腹主动脉外径增加。本组病例中内脏动脉处破口7个（1个腹腔动脉内破口，6个肾动脉处破口），肾下腹主动脉破口4个，髂动脉破口7个；其中3例为内脏动脉破口合并髂动脉破口。肾下腹主动脉破口均采用一体式覆膜支架封堵；1例近右肾动脉破口使用先心封堵伞；其余内脏动脉和髂动脉破口均采用小覆膜支架封堵。结果所有病例均顺利完成操作，腹主动脉和髂动脉破口封堵良好，无内漏。使用封堵伞的病例，夹层破口封堵良好，但由假腔供血的右肾动脉同时闭塞；肾动脉破口使用覆膜支架封堵病例中，1例显著内漏，2例微量内漏，其余病例封堵良好，无内漏。病例随访2～10个月，平均（5．0±2．0）个月，内漏病例CTA示假腔内部分血栓形成，但破口附近假腔仍有血流，其余病例夹层内均血栓形成。结论针对适当患者，个体化方案封堵夹层动脉瘤的远侧破口是可行和安全的。

Objectives To evaluate the method and short-term result of endovascular repairing for distal tears of Debakey type m dissecting aneurysm. Methods In this study the continously existing distal intima tears were repaired using different method in 15 Debakey type III dissections after previous successful repair of the proximal entry. All patients have symptoms caused by unclosed distal tears or increased false lumen in abdominal aorta. 7 visceral artery tears （ 1 celiac and 6 renal）, 4 abdominal aorta and 7 iliac artery tears were repaired （3 cases have both viscera and iliac tears）. All abdominal aorta entries were repaired by bifurcation stent grafts. Blocking umbrella was used in 1 renal tear, and all other viscera and iliac tears were repaired by small covered stents. Results All endovascular procedures were successfully completed. No any endo-leak occurred in abdominal and iliac entry repairs. One near renal tear was totally blocked by an umbrella which also blocked blood flow from false lumen to right renal artery. One major endo-leak and 2 minor endo-leak occurred in visceral artery tearing repair, all other visceral tears were completely repaired. All patients were followed up from 2 to 10 months （average 5.0 ± 2. 0 months）. Follow-up CTA revealed false lumen thrombosis in non-endo-leak cases. Three endo-leak cases still have blood flow in false lumen with partly thrombosis. Conclusions In selected patients, salvage endovascular repair for left over distal tears in Debakey IU dissecting aneurysm after initial repair is feasible and safe.