杂交手术治疗胸腹主动脉瘤

Hybird approach to thoracoabdominal aortic aneurysms

目的:回顾近8年我院使用杂交技术(腹腔内脏动脉去分支加主动脉瘤腔内修复)治疗胸腹主动脉瘤的病例,总结随访结果并分析并发症发生原因。方法:对2007年8月至2015年3月我院以杂交手术治疗的13例胸腹主动脉瘤病人的临床资料进行回顾性研究。手术方法为一期先行腹腔内脏动脉去分支手术,二期行腔内修复术。结果:13例胸腹主动脉瘤病人Ⅱ型3例,Ⅲ型3例,Ⅳ型5例,马凡综合征A型夹层全弓置换术后2例。一期行内脏动脉去分支手术,其中以升主动脉为流入道行腹腔内脏动脉顺行去分支5例,以髂动脉或腹主动脉下段为流入道行腹腔内脏动脉逆行去分支8例。二期行胸腹主动脉瘤覆膜支架腔内修复术。病例无截瘫发生。围手术期1例死于弥漫性血管内凝血;因肾动脉人工血管闭塞,术后肾功能不全需长期血透1例。结论:杂交技术治疗胸腹主动脉瘤创造了良好的支架移植物锚定区,并完整保留了内脏动脉的血供,是一种有效的治疗方法。但去分支手术创伤较大,仍有术后发生凝血功能障碍、慢性肾功能不全的风险。尤其在瘤体巨大时肾动脉的显露及重建困难。

Objective To summarize the results of hybrid procedure with visceral arteries debranching and endovascular aortic aneurysm repair for the patients with thoracoabdominal aortic aneurysm in eight years. The operational compli-cations and the causes were analyzed. Methods Data of 13 patients with thoracoabdominal aortic aneurysms treated with hybrid procedure between August 2007 to March 2015 were studied retrospectively. Visceral arteries were bypassed from ascending aorta or iliac arteries in first stage operation followed by endovascular stent-graft repair in second stage operation. Results According to Crawford classification, there were 3 cases with type Ⅱ and 3 cases with type Ⅲ, 5 casess with type Ⅳ, and 2 cases with dissected thoracoabdominal aortic aneurysm after arch replacement for type A dissection with Marfan syndrome. Five cases bypassed visceral arteries with inflow from ascending aorta and 8 cases from bilateral iliac arteries or distal abdominal aorta. The thoracoabdominal aortic aneurysms were repaired with endovascular stent-graft in second stage operation. None paraplegia occurred. One patient died of disseminated intravascular coagulation（DIC） during the perioperative period. One patient got chronic renal dysfunction and needed hemodialysis because of renal artery graft occlusion. Conclusions Hybrid procedure creates reliable landing zone for stent-graft and reserves the visceral arteries which might be an effective method for thoracoabdominal aneurysm. However, visceral artery debranching is still a com-plicated procedure with postoperative complications including DIC and chronic renal dysfunction, especially for giant a-neurysm which makes difficult renal artery exposure and reconstruction.