晚期妊娠和产褥期主动脉夹层的腔内修复治疗

Endovascular repair for aortic dissection during late pregnancy and early postpartum

目的:探讨腔内修复术治疗晚期妊娠和产褥期主动脉夹层的临床效果。方法:回顾性分析4例妊娠相关性B型主动脉夹层行腔内带膜支架修复术患者临床资料。在4例患者中,2例夹层发生于37孕周,1例发生于产后2 h,1例发生于产褥期;3例患马凡综合征(MFS),1例病因不明。患者均接受胸主动脉带膜支架腔内植入术,辅助技术包括主动脉狭窄段球囊扩张,左颈总动脉烟囱支架植入术。产妇及新生儿均进行临床观察随访,术后1,3,6个月分别对产妇进行CT血管造影监测。结果:围产期及随访时间无产妇及胎儿死亡,1例胎儿经阴道娩出,3例胎儿剖宫产娩出。4例患者主动脉支架均成功植入,初始破口完整覆盖,3例患者覆盖左锁骨下动脉,无I型内漏及支架移位。1例患者初始破口位于左锁骨下动脉开口处,锚定区向主动脉弓部拓展,同期植入左颈总动脉烟囱支架,术后出现II型内漏,随访11个月内漏自行消失。平均随访时间17.5个月,产后新生儿均存活良好,1例出现新生儿黄疸,产后12 d消失。结论:腔内带膜支架治疗晚期妊娠及产褥期B型主动脉夹层早-中期疗效肯定,手术时机与适应证需要根据孕产期临床状况综合判断。

Objective： To evaluate the clinical efficacy of endovascular repair for aortic dissection during third trimester of pregnancy and early postpartum. Methods： The clinical records of 4 patients with pregnancy-related type B aortic dissection who underwentendovascular stent-graft repair were retrospectively analyzed. Of the 4 patients, aortic dissection in 2 cases occurred at 37 weeks of pregnancy, in one case occurred at 2 hours after delivery, and in one case occurred during the early postpartum period; 3 cases were diagnosed with Marfan syndrome （MFS）, and the cause in one case was unknown. All patients underwent thoracic endovascular aortic stent-graft repair, and the assistantprocedures included balloon dilation of aortic coarctation and insertion of chimney stent-graft into the left common carotid artery, The patients were followed by regular CT angiography monitoring at 1 month, 3 and 6 months after operation.Results： No maternal or child death occurred during the perinatal and follow-up period. One fetus was delivered via vaginal delivery and the other 3 fetuses were delivered by caesarean section. The aortic stent- grafts were successfully implanted in all of the 4 patients, with complete coverage of the primary tear in all cases and intentional coverage of the left subclavian artery in 3 cases, and there were no cases of type Ⅰ endoleak or stent migration. In one patient with the primary tear located at the opening of the left subclavian artery, the landing zone was extended to the aortic arch and a chimney stent-graft was synchronously inserted into the left common carotid artery, and type Ⅱ endoleak devolped after operation, which disappeared within the 11-month period of follow-up. The average follow-up time was 17.5 months, during which time, all the newborns survived, and one of them had neonatal jaundice that disappeared 12 d after delivery. Conclusion： Endovascular stent-graft repair has demonstrable short- and mid-term efficacy in treatment of type B aortic dissection during late trimester of pregnancy and early postpartum period. However, the timing and indications for repair should be determined with integrated consideration of the period of pregnancy and the clinical status of the patients.