B型主动脉夹层腔内修复术后远端裂口处理临床研究

Management of distal reentry in type B dissection and evaluation:A report of 43 cases

目的探讨主动脉夹层腔内修复术(TEVAR)后远端裂口的处理策略,评价在亚急性期隔绝胸主动脉段裂口、栓塞假腔内逆向血流通道、选择性封堵远端裂口对主动脉重塑的影响。方法从2015年6月至2018年8月新疆维吾尔自治区人民医院共对43例TEVAR后仍存在远端裂口的B型主动脉夹层(Type B aortic dissection,TBAD)病人进行了处理,所有病人均进行胸主动脉段假腔完全处理,针对内脏动脉区以上裂口采用胸主动脉主体支架或短段支架血管(cuff)腔内隔绝,经远端裂口的逆向血流通道采用弹簧圈或先心封堵器进行封堵,有11例行肾动脉覆膜支架置入。8例病人胸主动脉段假腔完全血栓化后出现腹主动脉段假腔直径明显增大或症状明显,再次行腔内修复术(EVAR)。回顾性对比分析处理前后主动脉形态变化。结果随访1年,43例病人远端裂口处理后的主动脉最大径显著低于处理前[(27.36±4.92)mm vs.(32.03±6.35)mm,t=5.899,P<0.001];主动脉假腔未血栓化范围,处理后明显小于处理前,且有6例主动脉假腔完全血栓化。结论在亚急性期隔绝胸主动脉段裂口、栓塞假腔内逆向血流通道、选择性封堵远端裂口对于TEVAR后远端裂口的处理安全有效。

Objective To discuss the management of distal reentry in type B dissection,evaluate the influence of isolating the distal reentry in thoracic aorta and embolization of the reverse flow channel in the false lumen and selective closure of distal reentry.Methods From June 2015 to August 2018,43 patients with TBAD (type B aortic dissection) with distal reentry after TEVAR admitted in People's Hospital'of Xinjiang Uygur Autonomous Region were collected.All patients underwent complete treatment of the thoracic aorta segment of the false lumen,TEVAR or short cuff were applied to managing the reentry above the visceral artery.The reverse flow channel from the distal reentry was blocked by coil or closure device.Renal artery stent graft placement was performed in 11 cases,8 cases of thoracic aortic false lumen thrombosis after TEVAR,but the diameter of the abdominal aorta increased significantly,they were performed EVAR. The morphological changes of aorta were compared.Results The time of follow-up was 1 year.The maximal diameter of aorta after distal reentry treatment in 43 patients was significantly lower than preoperative diameter [(27.36±4.92)mm vs.(32.03±6.35)mm,t=5.899,P <0.001].The range of unthrombosed false lumen significantly shrank after operation. There were 6 cases of complete aortic thrombosis.Conclusion Occlusion of distal reentry in thoracic aorta during subacute phase,blocking the reverse blood flow channel and selective closure of distal reentry are safe and effective.