“象鼻”支架术治疗Stanford B型主动脉夹层胸主动脉腔内修复术后Ⅰ型内漏

Treatment with stented elephant trunk surgery for typeⅠ endoleak after TEVAR for stanford B aortic dissection

目的：回顾应用支架＂象鼻＂术治疗Stanford B型主动脉夹层胸主动脉腔内修复术（TEVAR）术后Ⅰ型内漏的临床效果。方法：2009年3月至2013年1月,首都医科大学附属北京安贞医院,收治的Stanford B型主动脉夹层TEVAR术后Ⅰ型内漏12例患者进行回顾性分析。12例患者均为男性,平均年龄（50.2±6.2）岁,平均身高（171.92±4.98）cm,平均体质量（77.50±8.43）kg,所有患者均无相关家族遗传病史,均有高血压病史,与第一次TEVAR术间隔时间平均34.4个月。支架＂象鼻＂术均在全麻体外循环下进行。如漏口暴露清楚,可缝闭漏口;如置入支架裸区妨碍象鼻支架缝合,可剪除部分裸露部分金属支架或将置入支架取出;如漏口累及左锁骨下动脉开口,可将左锁骨下动脉近端缝闭,截断左锁骨下动脉,其远端与左颈总动脉行端侧吻合,建立左颈总动脉至左锁骨下动脉转流或8mm人工血管行升主动脉至左腋动脉或左锁骨下动脉转流。于之前置入的支架内置入26~30mm Microport术中支架血管,覆盖内漏破口。术后随访6~48个月,平均6.53个月。结果：12例支架＂象鼻＂术均为择期手术,其中7例患者漏口位置累及左锁骨下动脉,4例剪除置入支架金属裸区;1例将置入支架取出;3例术中支架血管近端吻合于左锁骨下动脉以远,8例吻合于左颈总动脉与左锁骨下动脉之间;4例同期行左颈总动脉至左锁骨下动脉转流术;2例行升主动脉-左锁骨下动脉转流术;2例行升主动脉-左腋动脉转流术;1例患者因合并二尖瓣关闭不全同期行二尖瓣置换术;1例合并迷走右锁骨下动脉的患者同期行升主动脉-右腋动脉转流术。12例患者手术时间为平均（5.92±1.14）小时,平均住院时间为（21.92±9.14）天,2例患者术后出现围术期并发症,其中1例胸骨哆开,行再次胸骨固定痊愈;1例术前肾功能不全,术后出现急性肾衰竭,经透析治疗后肾功能恢复。本组患者均顺利出院。所有患者术后内漏均消失,术后随访6~48个月,平均6.53个月,均无复发。在术后随访期间,3例患者支架远端病变需再次处理,1例患者术后7个月出现支架感染、咯血、死亡。结论：应用支架＂象鼻＂术治疗Stanford B型主动脉夹层TEVAR术后Ⅰ型内漏,有较好的临床疗效,但远期效果仍需进一步观察。

Objective：To evaluate the patients with stented elephant trunk surgery for type Ⅰ endoleak after TEVAR for Stanford B aortic dissection. Methods： From Mar. 2009 to Jan. 2013, 12patients were treated by stented elephant trunk surgery for type 1 endoleak after TEVAR for Stanford B aortic dissection in Beijing Anzhen Hospital. They are all males and have history of hypertension. The average age was （48.5 ± 3.2） years. The mean interval after first TEVAR surgery was 34. 42 months. Stented elephant trunk surgeries were carried out under general anesthesia and cardiopulmonary bypass. Seven patients drain port position involving the left subclavian artery. Proximal stent angioplasties of 3 patients were anastomosis to the distal aorta of left subclavian artery, of 8 patients were anastomosis between the left common carotid artery and the left subclavian artery, of 4 patients concomitantly received the bypass between the left subclavian artery and the left common carotid artery, of 2 patients receive the bypass between the ascending aorta and the left subclavian artery＇, of 2 patients receive the bypass between the ascending aorta and left anterior artery; 1 patient concomitantly received mitral valve replacement for mitral valve regurgitation; 1 patient with vagus right subclavian artery received the bypass between the ascending aorta and the right axillary artery. Results： The mean surgical time of all 12 patients with was （5.92 ± 1.14） hours. Perioperative complications occurred in 2 patients, including one with sternal dehiscence, who received sternal refixed and recovered. 1 patient with preoperative renal insufficiency had acute renal failure after the surgery, his renal function recovered after dialysis. All patients were successfully discharged. Endoleak disappeared in all patients after surgery, there was no recurrence of the proximal leak after 6-48 months follow-up. One patient had infection outside the stent, hemoptysis and death 7 months after operation. Conclusion： Stented elephant trunk surgery was easy and effective to correct type I endoleak after TEVAR for Stanford B aortic dissection. The early and mid-term outcome was satisfactory, and long-term result required further investigation.