限制性裸支架预防腔内隔绝术后支架移植物远端再发夹层的研究

Restrictive bare stent prevents stent graft induced distal re-dissection after TEVAR for type B aortic dissection

目的总结限制性裸支架预防腔内隔绝术后支架移植物远端再发夹层的经验。方法回顾性分析第二军医大学附属长海医院血管外科中心1997年4月至2010年3月，采用腔内隔绝术治疗StanfordB型主动脉夹层674例患者的临床资料。按照纳入标准，共465例病例纳入本研究。结果311例行经典腔内隔绝术，154例行腔内隔绝术＋限制性裸支架植入术。共9例发生远端再发夹层。远端再发夹层组术前不匹配率和随访期不匹配率（腔内移植物远端口径／术前腔内移植物远端水平主动脉夹层真腔长径）明显大于正常组。与传统腔内隔绝术相比，限制性裸支架能有效预防远端再发夹层的发生（O％比2．9％，P=0．033），明显减少再次腔内介入治疗的发生率（3．9％比9．3％，P=0．040）。在腔内隔绝术后的主动脉重构方面，限制性裸支架能明显扩张降主动脉最窄段和腔内移植物远端附近的真腔口径。结论腔内移植物远端口径和主动脉夹层真腔受压后的口径不匹配是腔内移植物远端再发夹层的主要危险因素。作为传统腔内隔绝术的辅助技术，合理使用限制性裸支架能降低腔内移植物远端再发夹层的发生率。

Objectives To prevent stent graft induced distal re-dissection （SIDR） after endovascular repair for complicated Stanford type B aortic dissection. Methods From April 1997 to March 2010, 674 type B aortic dissections patients were treated by TEVAR at our center. The inclusion criteria for this study had two parts： patients were primarily treated by TEVAR; the estimated mismatch rate （ratio of the distal diameter of the stent graft to the long diameter of the true lumen） was greater than 120%. A total of 465 patients were included in this two-arm study. Results A total of 311 patients were treated with standard TEVAR and 154 patients with TEVAR ＋ restrictive bare stent （RBS）. The preoperative mismatch rate （ counted by the preoperative long diameter of true lumen at the level of intended distal end of the stentgraft） of the SIDR was significantly higher than that of the non-SIDR [ （ 193 ± 55 ） % vs （ 132 ± 10） %, P 〈 0. 05 ]. The follow-up mismatch rate of SIDR was significantly higher than non-SIDR （ 145 ± 35 vs 120 ± 16, P 〈 0. 05 ）. Compared with the standard TEVAR, TEVAR ＋ RBS was with lower incidence of SIDR （0% vs 2. 9% , P =0. 033） and less secondary intervention （3.9% vs 9.3%, P =0. 040）. The placement of RBS significantly expanded the true lumen at the level of descending aorta with narrowest true lumen and at the level of distal end of stent-graft. Conclusions The mismatch between the distal diameter of stent-graft and the diameter of the compressed true lumen seems to contribute to the occurrence of SIDR. Restrictive bare stent, as an adjunctive technique to TEVAR, reduces the incidence of SIDR.