腔内修复术治疗急性钝性胸主动脉损伤的结果分析

The Clinical Study of Thoracic Endovascular Aortic Repair for Treatment of Acute Blunt Thoracici Aortic Injury

目的探讨胸主动脉腔内修复术(TEVAR)治疗钝性胸主动脉损伤(BTAI)的临床疗效。方法搜集2016年1月至2019年1月在河南省人民医院血管外科就诊并行TEVAR治疗的19例急性BTAI患者的临床资料,男11例,女8例,平均年龄(44.0±11.9)岁,外伤原因主要为车祸伤。患者均经急诊行主动脉CTA明确诊断并分析主动脉损伤类型制定最优化的治疗方案,在评价患者全身损伤情况的基础上尽早给予TEVAR治疗。评价患者的手术成功率及随访期间的并发症情况。随访至少1年。结果 19例患者中Ⅲ型15例,包含外伤性主动脉夹层6例;Ⅳ型4例,胸主动脉破口位置均在主动脉峡部附近。除1例患者中转开放手术外,其他患者均手术成功,手术成功率94.7%(18/19)。TEVAR术中有3例患者行单分支支架置入,6例患者支架覆盖左锁骨下动脉,2例患者行颈-锁动脉搭桥术,1例患者行颈-颈动脉搭桥术,1例患者行原位开窗术重建左锁骨下动脉。术中共置入20个覆膜支架,置入覆膜支架近端直径(29.6±4.1)mm,平均支架直径扩大率(16.2±7.5)%。术中无死亡及其他严重的手术相关并发症,术后有1例患者出现肾衰竭需要透析治疗,1例截瘫患者无好转。平均随访时间30(11)个月。随访期间无死亡事件,1例I型内漏6个月后消失,1例患者1年后远端腹主动脉假腔仍存在,2例颈-锁搭桥的患者2年后出现桥血管狭窄。结论 TEVAR治疗BTAI具有较高的手术成功率和临床安全性,中期随访结果良好。

Objective To report clinical experience and evaluate the safety, effectiveness and the mid-term results of thoracic endovascular aortic repair(TEVAR) for treatment of acute blunt thoracic aortic injury(BTAI). Methods From January 2016 to January 2019,a total of 19 patients, including 11 men and 9 women of age 44.0±11.9 years, with acute BTAI were treated with TEVAR combined with other endovascular techniques and bypass operations. The mechanism of BTAI was mainly automobile crash.All patients underwent acute computed tomography angiography to determine Type of BTAI and design optimized strategies of TEVAR.Procedural success and procedure-related complications and serious adverse events(SAE) during follow-up were recorded. Follow-up time was > 1 year. Results Type Ⅲ was found in 15 patients with BTAI including 6 patients with traumatic aortic dissection, and type Ⅳ was found in 4 patients. All entry tears were located at the aortic isthmus. Procedural success was 94.7%(18/19) with a patient was converted to open surgery.For improving cerebral blood flow, unibody single-branched stent graft was implanted in 3 patients, bypass operation from right to left carotid artery in a patient and from left carotid artery to left subclavian artery(LSA) in 2 patients, and in situ fenestration were performed in a patient.Stent graft covered LSA in 6 patients. The involved length of thoracic aorta was(50.5± 9.2) mm, and proximal diameter of landing zone was(25.6± 4.8) mm.A total of 20 stent-grafts was implanted and the length of stent-graft was(29.6± 4.1) mm with oversize rate was(16.2±7.5) %.There were no procedure-related complications. Acute renal failure requiring dialysis was found in a patient, and paraplegia in 1 patient after procedure.The follow-up time was 30(11) months.No death occurred during follow-up.Slight type Ⅰendoleak during procedure was found in 1 patient and disappeared at 6 months after procedure.Distal false lumen of abdominal aorta still existed at 1 year after procedure in 1 patient and restenosis in bypass graft was found in 2 patients at 2 years after procedure. Conclusion TEVAR combined with other endovascular techniques and bypass operations for treatment of BTAI may be the optimal choice with favourablesafety, procedural success and effectiveness. Themid-term follow-up results are satisfactory.