腔内修复治疗Stanford A型主动脉夹层的现状与挑战

Current status and challenges of endovascular repair for Stanford type A aortic dissection

急性Stanford A型主动脉夹层(TAAD)起病急、病死率高、手术风险大。虽然开放手术是目前治疗TAAD的首选,但仍有10%~30%的TAAD患者由于手术风险高而选择保守治疗,使患者病死率大大增加。随着腔内技术的进步及各种腔内器具的革新,腔内治疗TAAD有良好的发展前景。虽然胸主动脉腔内修复已成为复杂Stanford B型主动脉夹层的首选治疗,然而其治疗TAAD的证据较少,且 TAAD破口位于升主动脉,封堵破口的同时需要重建弓上分支,亟需更加符合主动脉生理特性的腔内移植物及更安全的输送系统。技术方面,近远端锚定区的选择及术中脑保护等仍是目前的重点和难点问题。同时,在主动脉根部处理、弓上分支重建方面亦缺乏成熟的方案。

Type A aortic dissection(TAAD)is characterized by acute onset,high mortality and high surgical risks.Although open surgery has been the first-line treatment for TAAD in current guidelines,10%to 30%of them will accept conservative treatment due to the high risk of open surgery.In recent years,with the rapid progress of endovascular technology and the innovations of various devices,endovascular repair for TAAD has shown encouraging preliminary results.Thoracic endovascular aortic repair(TEVAR)has become the first-line treatment for complicated type B aortic dissection(TABD).By sealing the primary entry tear and promoting the remodeling of the false lumen,TEVAR is more minimally invasive and efficient compared to open repair.Compared with TBAD,TEVAR for TAAD is not fully elucidated.The primary entry tear is located in the ascending aorta,which has different pathophysiology characteristics from that in TBAD.More suitable and safe stent-graft and delivery system are needed.In terms of technology,the selection of proximal and distal landing zone and intraoperative brain protection are still the key and difficult problems.At the same time,there is a lack of mature programs in the treatment of the aortic root and the reconstruction of the aortic arch branches.