急性Stanford B型主动脉夹层真腔次全闭塞治疗——单中心病例系列报道

Treatment for acute Stanford type B aortic dissection complicated by subtotal occlusion of true cavity:a series of reports from a single center

目的总结急性Standford B型主动脉夹层(AD)真腔次全闭塞患者的治疗经验。方法回顾性分析2016年1月至2019年12月湖南省人民医院采用胸主动脉腔内修复术治疗的39例急性B型AD真腔次全闭塞患者临床资料。所有患者均接受主动脉覆膜支架腔内隔绝术,术中根据近端破口位置决定是否同时行左颈动脉或左锁骨下动脉重建修复(含支架开窗、烟囱支架),远端受累分支血管根据AD真腔开通后具体情况选择保守、支架成形术或血液透析治疗。结果39例患者共植入主动脉覆膜支架51枚(植入1枚27例,2枚12例),同时植入腹主动脉裸支架3枚,肠系膜上动脉支架8枚,髂动脉支架12枚,颈动脉原位开窗或烟囱支架9枚,锁骨下动脉开窗或烟囱支架枚17枚。介入治疗技术成功率为100%。围手术期并发症为肾功能不全15例(38.5%);5例一侧肾动脉完全假腔供血遂接受覆膜支架开通;中重度肠道缺血表现8例(20.5%),其中6例接受二次腔内治疗。围手术期死亡率为7.7%(3/39),死因主要为重度肾功能不全和酸中毒多脏器衰竭。术后随访6~25个月,支架段假腔完全血栓化率为80.6%(25/31),其中支架段主动脉完全重塑率为68%(17/25)。结论B型AD真腔次全闭塞一经确诊,建议尽快手术。腔内开通过程需要多种技巧,部分患者两段式支架应用有利于真腔开通,降低假腔压力,促进血管重塑。

Objective To summarize the clinical experience in treating acute Stanford type B aortic dissection(AD) complicated by subtotal occlusion of true cavity. Methods The clinical data of 39 patients with acute Stanford type B AD complicated by subtotal occlusion of true cavity, who were admitted to the Hunan Provincial People’s Hospital of China to receive thoracic endovascular aortic repair(TEVAR) between January2006 and December 2019, were retrospectively analyzed. TEVAR was carried out in all patients, and based on the location of the proximal rupture the simultaneous repair of left carotid artery or left subclavian artery(including stent fenestration, chimney stent) was determined. The distal involved ischemic branch vessels were treated with conservative therapy, stenting angioplasty or hemodialysis according to the specific condition after the aortic true lumen was opened. Results A total of 51 aortic covered stents were implanted in the 39 patients, including one stent in 27 patients and 2 stents in 12 patients, besides, simultaneous implantation of other stents, including abdominal aorta bare stent(n=3), superior mesenteric artery stent(n=8), iliac artery stent(n=12), carotid artery stent(n=9), and subclavian artery stent(n=17) were employed. The technical success rate was 100%. Perioperative complications included renal insufficiency(n=15), complete false lumen formation of unilateral renal artery(n=5), for which covered stent angioplasty had to be carried out, moderate-severe intestinal ischemia(n=8, 20.5%), for which TEVAR had to be adopted again in 6 patients. The perioperative mortality was 7.7%, which was mainly caused by severe renal insufficiency, acidosis and multiple organ failure. The patients were followed up for 6-25 months, the complete thrombosis rate of stent-segment pseudocavity was 80.6%(25/31), in which the total remodeling rate of the stent-segment aorta was 68%(17/25).Conclusion Once the acute Stanford type B AD complicated by subtotal occlusion of true cavity is clinically confirmed, it is recommended that surgery should be performed as soon as possible. Multiple manipulation skills are required to ensure a successful endovascular recanalization procedure. In some patients, the use of two-segmental stenting technique is helpful to open the true lumen, reduce the pressure in false cavity and promote vascular remodeling.(J Intervent Radiol, 2021, 30: 449-453)