血管转流联合TEVAR杂交技术治疗B型主动脉夹层的临床研究

Clinical Study of Vascular Diversion and TEVAR Hybridisation for the Treatment of type B Aortic Coarctation

目的分析颈-锁骨下动脉转流联合胸主动脉腔内修复术(TEVAR)杂交技术治疗B型主动脉夹层的临床疗效。方法选取2021年9月至2022年9月内蒙古自治区人民医院心脏大血管外科收治的45例B型主动脉夹层患者作为研究对象,根据术式不同将其分为杂交组和预开窗组。杂交组24例,采用颈-锁骨下动脉转流联合TEVAR治疗;预开窗组21例,采用体外左锁骨下动脉(LSA)预开窗技术联合TEVAR治疗。比较两组患者临床特征、围手术期状况、术后并发症情况及生存结局。结果两组患者于术前临床特征基线比较、术中内漏率、手术成功率及术后并发症(脑梗死、左上肢缺血、切口感染)等评价指标差异均无统计学意义(P>0.05);在手术时间、CICU监护时间、住院费用、术中出血量、术后内漏率、脊髓缺血等方面差异有统计学意义(P<0.05)。杂交组术后内漏率、脊髓缺血发生率均低于预开窗组,预开窗组术后疼痛率低于杂交组。术后随访:杂交组1例患者因肾功能衰竭于术后第23日死亡;预开窗组因脑血管意外死亡1例、逆撕性A型主动脉夹层死亡1例。杂交组随访期间病死率与预开窗组相比,差异无统计学意义(χ^(2)=0.014,P=0.905)。结论两种术式均可有效重建左锁骨下动脉血运,但血管转流术可以显著缩短手术时间、减少术中出血量、降低术后内漏率及脊髓缺血情况,使左锁骨下动脉前向血流更通畅,治疗效果良好,具有临床应用和推广价值。

Objective To analyse the clinical efficacy of carotid-subclavian artery diversion combined with thoracic aortic endovascular repair(TEVAR)hybrid technique for the treatment of type B aortic coarctation.Methods A total of 45 patients with type B aortic coarctation admitted to the Department of Cardiac Macrovascular Surgery of the Inner Mongolia Autonomous Region People's Hospital from September 2021 to September 2022 were selected as study subjects.They were divided into hybridisation group and pre-opening group according to the different operation styles.A total of 24 cases in the promiscuous group were treated with carotid-subclavian artery diversion combined with TEVAR;A total of 21 cases in the preopening group were treated with extracorporeal LSA preopening technique combined with TEVAR,and the clinical characteristics,perioperative status,postoperative complications,and survival outcomes of the patients in the two groups were compared.Results There was no significant difference between the two groups in the baseline comparison of preoperative clinical characteristics,intraoperative endoleak rate,surgical success rate,postoperative complications(cerebral infarction,left upper extremity ischemia,and incision infection)and other evaluation indexes(P>0.05);and there were statistically significant differences in the surgical time,CICU custody time,hospital costs,intraoperative bleeding,postoperative endoleak rate,and spinal cord ischemia(P<0.05).The rates of postoperative endoleak and spinal cord ischaemia in the hybrid group were lower than those in the preopening group,and the rate of postoperative pain in the preopening group was lower than that in the hybrid group.Postoperative follow-up:one patient in the hybridisation group died on the 23rd postoperative day due to renal failure;one patient in the preopening group died due to a cerebrovascular accident and one patient in the retrotear type A aortic coarctation.There was no statistically significant difference in mortality during follow-up in the hybridisation group compared with the pre-opening group(χ^(2)=0.014,P=0.905).Conclusion Both procedures can effectively reconstruct the left subclavian artery haemodynamics,but vascular diversion can significantly shorten the operation time,reduce the intraoperative bleeding,reduce the postoperative endoleak rate and spinal cord ischemia,so that the left subclavian artery has a better antegrade blood flow,which demonstrates a good therapeutic effect,and has the value of clinical application and promotion.