主动脉腔内修复术中钬激光原位开窗技术的应用(附42例报告)

Application of Holmium Laser in situ Fenestration During Thoracic Endovascular Aneurysm Repair:a Report of 42 Cases

目的探讨钬激光原位开窗技术在主动脉腔内修复术中保留弓上分支动脉的疗效。方法2016年11月~2019年7月对42例紧邻主动脉弓部分支血管、腔内修复治疗近端锚定区不足的主动脉病变在DSA下对胸主动脉行腔内隔绝之后,通过肱动脉或颈动脉逆行导入550μm钬激光光纤,对覆膜支架进行原位开窗,开窗后植入支架,重建左锁骨下动脉和(或)左颈总动脉、无名动脉的血流。术后阿司匹林抗血小板治疗。结果左锁骨下动脉单开窗手术时间(63±14)min,左锁骨下动脉及左颈总动脉双开窗手术时间(127±21)min,左锁骨下动脉、左颈总动脉及无名动脉三开窗手术时间(317±58)min。42例手术成功率为100%,均无Ⅰ型或Ⅱ型内漏发生,无肾衰、感染、截瘫等并发症,围术期无死亡,1例发生左侧脑梗塞,1例发生左视网膜分支动脉栓塞。42例术后随访1~32个月,中位随访时间18.5月,主动脉内支架型人工血管位置无移位,分支动脉开窗支架保持通畅,无移植物相关的狭窄、内漏等现象发生。结论钬激光原位开窗技术为紧邻弓部重要分支动脉附近的主动脉病变患者提供腔内隔绝术治疗的机会,避免主动脉弓部血管重建开放手术导致的创伤,短期随访结果满意。

Objective To investigate the efficacy of holmium laser in situ fenestration in preserving the branch arteries of the aortic arch during the thoracic endovascular aneurysm repair(TEVAR).Methods The clinical data of 42 patients with aortic diseases treated in our hospital from November 2016 to July 2019 were retrospectively analyzed.After endovascular exclusion of thoracic aorta with the help of digital subtraction angiography(DSA),a 550μm holmium laser fiber was inserted through the brachial or carotid artery to implement in situ modified fenestrated stent grafts technology to reconstruct the blood flow of the left subclavian artery and/or left common carotid artery and innominate artery.Aspirin antiplatelet therapy was given postoperatively.Evaluation of surgical success rate and postoperative complications,and CT angiography(CTA)was used to evaluate the patency of branch vessels.Results The average operative time was(63±14)minutes for single fenestration of left subclavian artery cases,(127±21)minutes for double fenestrations of left subclavian artery and left common carotid artery cases,and(317±58)minutes for triple fenestrations of left subclavian artery,left common carotid artery and brachiocephalic artery cases.The success rate of operation in all patients was 100%,without typeⅠorⅡendoleak.No complications such as kidney failure,infection or paraplegia happened,and no deaths during the perioperative period was found.Complications occurred in two cases:one case complicated with left cerebral infarction and one case had complication of left retinal branch artery embolism.During the postoperative follow-ups for 1-32 months(median,18.5 months)in 42 patients,the position of the intra-aortic stent graft was good,the fenestrated stent graft of the branch artery remained unobstructed,and there was no graft-related internal leakage or stenosis.Conclusions The holmium laser in situ fenestrated stent grafts technology can provide the opportunity of endovascular exclusion for patients with this type of aortic disease and avoid the trauma caused by vascular reconstruction of aortic arch.The short-term follow-up results are satisfactory.