腔内隔绝术治疗Stanford B型主动脉夹层动脉瘤临床分析

Clinical analysis on endovascular graft exclusion in the treatment of Stanford type B dissecting aortic aneurysm

目的总结腔内隔绝术（EVGE）治疗StanfordB型夹层动脉瘤的临床经验并评估其疗效。方法回顾性分析2007年1月至2012年3月我院收治的40例StanfordB型主动脉夹层动脉瘤患者的临床资料。所有患者术前均采用CT血管造影（CTA）对主动脉夹层动脉瘤进行评估。在数字减影血管造影（DSA）监视下，穿刺左侧桡动脉或者肱动脉行胸主动脉造影，判断主动脉夹层动脉瘤内膜破口位置、形态和累及范围，测量左锁骨下动脉开口与夹层内膜破口之间距离、破口近端正常主动脉最大直径。选择一侧腹股沟作纵行切口，暴露股动脉，穿刺后沿导丝置入支架输送器，在透视下经主动脉真腔植入覆膜血管内支架。术后随访6～48个月。结果所有患者手术操作均成功。随访6—48个月，所有患者均存活。其中3例患者术后即刻发现I型内漏，经球囊扩张后内漏减少；31例患者术后3个月随访CTA显示无移植物移位；1例左肾动脉开口于假腔患者放置肾动脉支架后，DSA显示。肾动脉支架通畅，肾实质显影良好；9例封闭左锁骨下动脉开口患者（其中6例行人工或自体血管搭桥术）仅出现左侧桡动脉波动减弱，无脑供血不足症状。结论EVGE治疗StanfordB型夹层动脉瘤创伤小，安全、有效。

Objective To summarize the experiences of endovaseular graft exclusion （EVGE） on Stanford type B dissecting aortic aneurysm and evaluate the efficacy in clinical implication. Methods Retrospective analysis was made among the 40 hospitalized patients with Stanford type B dissecting aortic aneurysm from January 2007 to March 2012. Preoperative evaluation was made on all patients with dissecting aortic aneurysm by CT angiography. Under the guidance of digital subtraction angiography, thoracic angiography was performed from the left radial or braehial artery access. Pertinent information was carefully evaluated in regard with the characteristics of aneurysm （location of the crevasse, morphological feature and the involvement of the aorta） , the distance from the opening of left subclavian artery to the crevasse and the maximum diameter of the normal aortic lumen proximal to the crevasse. One of the femoral arteries was punctured for vascular access after exposure through a longitudinal incision of the skin in inguinal region. The covered stent graft was then inserted under fluoroscopic guidance. Results The procedure was successfully performed for all patients and all of the patients remained survival during follow-up of 6-48 months. Type I internal leakage was found in 3 cases and the leakage was reduced after balloon dilation. No migration of stents was found in 31 cases during follow-up of 3 months. For one patient with affected left renal artery, angiography demonstrated patency of the renal artery after implantation of a renal stent. Nine cases in whom the opening of left subclavian artery was covered by the stent （ artificial or autologous vessel bypasses were performed in 6 cases ）, showed only decreased pulsation of left radial artery without any symptoms of insufficient encephalic blood supply. Conclusion EVGE may be a safe and effective treatment for the Stanford B aortic dissection with minimal trauma and fast recovery.