体外开窗腔内主动脉修复术治疗胸腹主动脉病变的早期结果分析

Early results of fenestrated endovascular aortic repair for the treatment of patients with thoracoabdominal pathologies

目的评估应用术中台上体外改造覆膜支架行开窗腔内动脉修复术（FEVAR）治疗胸腹主动脉病变的早期效果。方法回顾性分析天津医科大学总医院2012年4月至2017年9月按纳入和排除标准收集的19例应用FEVAR技术治疗胸腹主动脉病变的临床资料。分析术中台上体外开窗技术的应用及围手术期并发症情况，并观察早期治疗结果。结果入组患者病变均累及胸腹主动脉，包括近肾腹主动脉瘤12例、胸腹主动脉夹层动脉瘤3例、胸腹主动脉瘤1例、副肾动脉位于腹主动脉瘤（AAA）瘤颈内2例及AAA行主动脉腔内修复术（EVAR）术后I型内漏1例。定制COOK腹主支架1例，术中台上体外开窗18例。其中应用COOK短段覆膜支架（CUFF）2例、COOK腹主支架9例、COOK胸主支架6例及GOREC3支架1例。支架改造中位时间110（90～140）min。手术平均时间为268．0（59．0—334．0）min。平均x线照射时间为66．0（15．0～175．0）min。共50个内脏分支通过开窗或开槽重建，其中有45个分支（90％）置入支架。28个内脏血管置入裸支架，17个内脏血管置入覆膜支架。技术成功率为100％。无内脏血管丢失。围手术期死亡率为5．3％（1／19）。少量Ⅰ型内漏2例，单纯Ⅱ型内漏1例，单纯Ⅲ型内漏1例，2例合并Ⅱ、Ⅲ型内漏，均密切随访观察。2例髂股动脉入路损伤，经髂股动脉内膜剥脱及支架植入术后恢复。2例术后肾功能不全加重，非手术治疗好转。住院平均时间为6．6（2．0～12．0）d。无30d内再介入手术。平均随访时间为11.2（2．0～41．0）个月。1例术后6个月死于肾癌晚期。1例术后2个月右副肾动脉支架闭塞，其余开窗分支血管通畅。结论应用术中台上体外改造覆膜支架行FEVAR是一种安全、有效的治疗胸腹主动脉病变的方法。

Objective To evaluate the early results of fenestrated endovascular aortic repair （FEVAR） using physician-modified stent grafts （PMSGs） for the treatment of patients with thoracoabdominal pathologies. Methods Nineteen consecutive patients who underwent FEVAR using PMSGs between April 2012 and September 2017 were retrospectively reviewed. The modality of FEVAR technique was assessed, perioperative clinical data was recorded and the early results were evaluated. Results Indications were thoracoabdominal aortic pathologies, including juxtarenal abdominal aortic aneurysm （JAAA） （n = 12）, chronic thoracoabdominal aortic dissection with aneurysmal dilatation （n = 3） , thoracoabdominal aortic aneurysm （TAAA） （n = 1 ） , infrarenal AAA with an accessory renal artery in the segment of the aneurysmal neck （ n = 2） and type I endoleak after EVAR for AAA （ n = 1 ）. Nineteen fenestrated stent grafts were deployed , including custom-made Cook Zenith fenestrated stent graft （ n = 1 ） , home-made Cook Zenith Tχ2 fenestrated stent graft（n =6） ,home-made Cook Zenith TFFB fenestrated stent graft （ n = 9 ） , home-made Cook Zenith Cuff fenestrated stent graft （ n = 2 ） , home-made Gore C3 fenestrated stent graft（n = 1 ）. Mean duration for stent graft modification was 110 （90 - 140） min. Mean operative time was 268. 0 （59.0 -334. 0） min, and fluoroscopy time was 66. 0 （ 15.0 - 175.0） min. There were a total of 50 target vessels, of which 45 （95%） were stented. Bare metal stents were used in 28 vessels, and covered stents were used in 17 vessels. Technical success rate was 100%. No intraoperative target vessel loss was observed. Perioperative mortality was 5.3% （1/19）. Endoleaks were persisted even after ballooning in five patients. A small type Ⅰ proximal endoleak and type Ⅲ endoleak were found in 2 and 1 patients, respectively. Type Ⅲ endoleak combined with type II endoleak were observed in 2 patients. All the endoleaks were accepted and needed watching. In two patients, iliofemoral artery problems were resolved after local endarterectomy and stenting. Two patients presented renal deterioration postoperatively and recovered after the conservative therapy. Median length of stay was 6. 6 （2. 0 - 12. 0 ） d. No early reintervention （ 〈 30 days） was performed. The mean duration of follow-up was 11.2 （2. 0 -41.0） months. One patient died 6 months after FEVAR due to advanced renal carcinoma. All target vessels remained patent except for one accessory artery occlusion. Conclusion FEVAR using PMSGs may be a viable alternative for high-risk patients with thoracoabdominal pathologies.