胸主动脉腔内修复术术后近端内漏的治疗

Repair of type Ⅰ a endoleak after thoracic endovascular aortic repair

目的分析胸主动脉腔内修复术(TEVAR)术后近端(Ⅰa型)内漏治疗的技术特点。方法自2009年8月至2016年5月,共治疗TEVAR术后Ⅰa型内漏29例:其中外科手术15例(外科组)、复合手术(Hybrid)6例(Hybrid组)、Cuff术(Cuff组)8例。男25例、女4例,平均年龄41~86(56±10)岁。高血压25例,糖尿病3例,冠心病3例,肺部感染1例,主动脉根部瘤1例,迷走右锁骨下动脉1例。结果外科组无院内死亡,1例术后心包积液行心包开窗引流,1例肺部感染二次气管插管,肾功能不全行肾脏替代治疗。Hybrid组术后残余Ⅰa型内漏1例。Cuff组1例患者术后左颈总动脉血栓,行腋动脉-腋动脉-左颈总动脉转流,脑梗塞死亡,院内总死亡率为3.4%(1/29);1例患者术后左上肢缺血,行腋动脉-腋动脉转流后恢复;1例患者残余微量内漏。随访死亡率为14.2%(4/28)。外科组无严重并发症,Hybrid组发生内漏1例,Cuff组内漏1例。结论根据患者具体状况选择手术方式,近端锚定区足够,可采用Cuff术;如近端锚定区不足,合并心脏和主动脉弓部病变,外科手术可获得满意疗效;如患者高龄不能耐受手术,行Hybrid术可获得满意的近中期临床疗效。

Objective To retrospectively review our experience of correction of type I a endoleak after thoracic endovascular aortic repair（TEVAR）. Methods From August 2009 to May 2016, 29 patients with type I a endoleak after TEVAR （25 males, 4 females at mean age of 56±10 years （range, 41-86 years） underwent treatment： open surgery in 15 patients （an open surgery group）, hybrid aortic arch repair in 6 patients （a hybrid group） and cuff extension in 8 patients（a cuff group）. A history of hypertension was noted in 25 patients, diabetes mellitus in 3 patients, coronary artery disease in 3 patients, lung infection in one patient, aortic root aneurysm in one patient and aberrant right subclavian artery in one patient. Results In the open surgery group, no death was observed. Continuous renal replacement therapy and re-intubation was done in one patient and drainage of pericardial effusion in one patient. No death was noted in the hybrid group and persistent type I a endoleak in one patient. In the cuffgroup, thrombosis of the left common artery was noted in one patient and bypass of the left axillary artery to the left axillary artery and the left common carotid artery was done. Unfortunately, he died of cerebral infarction and total in-hospital death rate was 3.4% （1/29）. Bypass of the left axillary artery to the left axillary artery was done in one patient with left upper limb ischemia. There were 4 （14.2%） deaths during follow-up： 3 deaths in the open surgical group and one death in the cuff group. Endoleak was observed in one patient in the hybrid group and one in the cuff group. Conclusion The corresponding procedure, including open surgery, hybrid aortic arch repair or cuff extension, is scheduled to be done according to the characteristics of type I a endoleak. Satisfactory outcomes are achieved in patients with type I a endoleak.