Stanford B型主动脉穿透性粥样硬化性溃疡腔内治疗临床分析

Clinical analysis of transluminal therapy for Stanford type B penetrating atherosclerotic aortic ulcer

目的总结Stanford B型主动脉穿透性粥样硬化性溃疡腔内治疗的手术时机及手术治疗效果。方法回顾分析内蒙古医科大学附属医院2009年10月至2014年10月共32例Stanford B型主动脉穿透性粥样硬化性溃疡行覆膜支架腔内植入患者资料,所有患者均在局部麻醉加强化下行右侧股动脉切开,在介入治疗下行覆膜支架腔内植入术,术后1、3、6及12个月及之后每年均行计算机断层扫描血管造影(computed tomography angiography,CTA)复查,比较患者术后血肿吸收率、溃疡修复率,围术期有无脊髓缺血及支架远端有无并发症。结果所有患者均成功置入覆膜支架,技术成功率100%。共植入36枚支架,4例患者溃疡位置较低且为多发溃疡,术中植入2枚支架,其中第二枚支架为渐细支架。4例患者溃疡位于左锁骨下动脉起始部,2例直接封闭左侧锁骨下动脉,2例先行腋-腋转流后再行支架植入术。围术期无死亡,1例(3%)患者术后2周出现进食咽下困难(食道造影未见受压)3个月后全身消耗死亡。1(3%)例患者支架远端出现假性动脉瘤二次行支架植入术。伴发主动脉壁内血肿患者血肿在1年左右完全吸收。13例(40.6%)患者术后发热给予对症(激素+消炎痛)治愈。无截瘫、无支架内漏、无支架移位,无脑梗死及脏器缺血等并发症。结论对于主动脉穿透性粥样硬化性溃疡患者,我们应采取积极的治疗方案,对于持续性胸痛不缓解、血压控制不满意;溃疡直径≥20 mm或深度≥10 mm;伴发主动脉内壁间血肿患者控制血压、心率治疗2周、复查CTA血肿吸收后;均应行覆膜支架腔内修复术。

Objectives To summarize the surgical timing and effect of transluminal treatment for Stanford type B penetrating atherosclerotic aortic ulcer. Methods Data of 32 cases with Stanford type B penetrating atheroselerotie aortic ulcer who received translumina] stent-grafl placement in Inner Mongolia Medical University Affiliated Hospital from January 2009 to June 2014 were retrospectively analyzed. All the patients recieved the right femoral artery eutdown under strengthened local anesthesia,and transluminal stent-graft placement were performed. Computed tomography angiography （ CTA ） was used to review the patients 1,3,6 and 12 months and each year after operation. Hematoma absorption rate, ulcer repair rate, perioperative presence of spinal cord ischemia and distal stent-related complications of the patients were analyzed. Results All the patients were successfully performed transluminal stent-graft placement, technical success rate was 100% with a total of 36 stents implanted. Ulcer position was comparatively low in 4 patients with muhiple ulcers, two stents were implanted during operation, of which the second stent was tapered stent. Ulcer was located in the left subclavian artery in 4 patients, the left subclavian artery was directly occluded in 2 cases, stent implantation was performed after axillary-axillary bypass in the other 2 cases. No perioperative death occurred. Dysphagia occurred in 1 case （3%） 2 weeks after operation （no compression was observed by esophageal imaging） and the patient died from depletion in 3 months. Distal stent in 1 case （3%） appeared pseudoaneurysms and stent reimplantation was performed. Hematoma was completely absorbed in 1 year in patients with concomitant aortic intramural hematoma. Postoperative fever in 13 cases （40.6%） was cured by indomethaein and hormones. No paraplegia, stent displacement, stent leakage or complications such as cerebral infarction and organ ischemia happened. Conclusions For patients with penetrating atheroselerotic aortic ulcer, we should take active treatment. Transluminal stent-graft placement should be performed in patients with persistent chest pain, unsatisfactory blood pressure control, ulcer diameter≥ 20 mm or depth ≥10 mm and hematoma in the wall of the aorta after controlling blood pressure and heart rate for 2 weeks when hematoma is absorbed shown by CTA.