胸主动脉腔内修复术后支架感染外科治疗分析

Surgical treatment strategy for endograft infection after thoracic endovascular aortic repair

目的探讨胸主动脉腔内修复术(TEVAR)后支架感染外科治疗的效果。方法回顾性分析2016年1月至2018年12月因TEVAR术后支架感染在海军军医大学长海医院心血管外科接受外科治疗的7例患者的临床资料。男性6例,女性1例;年龄(51.5±16.7)岁(范围:25~68岁)。降主动脉瘤5例,Stanford B型主动脉夹层2例;主动脉病变未累及膈肌平面以下的腹主动脉。7例患者中2例术中行左锁骨下动脉"烟囱"技术植入支架。支架感染发生在TEVAR术后5(3)个月[M(QR),范围:1~24个月]。所有患者存在反复发热,血培养阳性者6例。2例合并主动脉-食管瘘伴消化道出血患者行急诊手术,5例行择期手术。所有患者于全身麻醉非体外循环下行人工血管旁路移植+感染血管段切除、局部旷置引流术,合并食管瘘者1例行同期修补,1例行食管局部切除、二期行胃代食管手术。术后继续给予敏感抗菌药物治疗6~8周。结果住院死亡1例,死因为术后早期发生感染性休克。另6例患者术后恢复良好出院。随访6~24个月,曲霉菌感染者术后3个月发生相应胸椎体曲霉菌感染而再次手术,1例患者术后1个月发生髂骨脓肿于骨科接受手术治疗,其余患者随访期间无感染复发。结论TEVAR术后感染行人工血管旁路移植+感染段主动脉切除、局部引流联合后期的正规抗感染治疗可获得良好的预后。对于存在主动脉食管瘘的患者,可根据食管损伤范围及程度行同期修补或二期手术治疗。

Objective To examine the results of surgical treatment for endograft infection after thoracic endovascular aortic repair(TEAVR).Methods Clinical data of 7 patients underwent surgical treatment for endograft infection after TEAVR at Department of Cardiothoracic Surgery,Changhai Hospital,the Navy Medical University between January 2016 and December 2018 were analyzed retrospectively.There were 6 males and 1 female,aging(51.5±16.7)years(range:25 to 68 years).The origin of the aortic disease was descending aortic aneurysm in 5 cases,and Stanford B aortic dissection in 2 cases.Abdominal aorta below the level of the diaphragm was not involved in all patients.Two patients received"chimney technology"for left subclavian artery procedures.Time to infection was 5(3)months(M(QR))(range:1 to 24 months).Aortic endograft infection was diagnosed with a combination of microbiology(positive blood cultures,except one with mycotic),radiological evidence and clinical evidence of sepsis.Two patients suffered from aorto-esophageal fistula received emergency surgery,others were treated with elective surgery.Extra-anatomic prosthetic graft bypass was used for reconstruction of aorta,infected endogarft and aorta was removed,sac drainage was performed.Aorto-esophageal fistula was procedured according to the degree of lesions.All patients received antibiotics with specialist advice for 6 to 8 weeks.Results One patient died due to septic shock.In the follow-time(range:6 to 24 months),1 patient suffered from thoracic infection in 3 months after surgery,an other patient got iliac abscess after a month.Conclusions Endograft infection after TEAVR is high risk but may be curative.Appropriate selection of patients for infected endograft explantation could get a satisfied results.