旁路手术与单烟囱支架在主动脉弓部分支重建中的疗效分析及评价

Analysis and evaluation of clinical efficacy of hybrid surgery versus single chimney stent in the reconstruction of aortic arch branches

目的总结分析应用旁路手术及烟囱支架在治疗主动脉扩张性疾病中重建左颈总动脉(LCCA)或左锁骨下动脉(LSA)的经验与体会。方法收集2002年1月至2015年4月于本院治疗主动脉扩张性疾病并采用旁路手术或烟囱支架重建LCCA或LSA患者的一般资料、手术资料及随访资料进行分析。结果共49例主动脉弓疾病患者,其中采用旁路手术26例,烟囱支架23例。旁路手术组中LSA重建10例(38.5%),LCCA重建16例(61.5%)。烟囱支架组中LSA烟囱支架植入14例(60.9%),LCCA烟囱支架植入9例(39.1%)。旁路手术及烟囱支架组的技术成功率均为100%。两组均无住院期间死亡病例。杂交组并发症包括Ⅰ型内漏4例(15.4%),Ⅱ型内漏1例(3.8%),脑卒中1例(3.8%);烟囱组并发症包括Ⅰ型内漏9例(39.1%),Ⅱ型内漏3例(13.0%)。杂交组随访时间为(71.2±9.6)个月,人工血管旁路通畅率为96.2%,烟囱组随访时间为(27.2±16.4)个月,烟囱支架通畅率为100%。旁路手术组的相应分支成角(LSA或LCCA成角)均显著大于烟囱支架组;而且有Ⅰ型内漏的患者其目标分支(LSA或LCCA)的成角均显著大于无内漏的患者,若LSA成角大于29.8°,术后Ⅰ型内漏的风险将显著增加,该临界值有统计学意义。结论旁路手术及烟囱支架治疗累及主动脉弓分支的主动脉扩张性疾病均安全可靠,中远期通畅率满意;烟囱支架较适用于急诊患者或弓上分支成角较小的患者;对于主动脉分支成角较大的患者应选用旁路手术,但需特别注意预防脑卒中的发生。

Objectives To summarize the experiences of left common carotid artery(LCCA)or left subclavian artery(LSA)reconstruction using hybrid repair or chimney stent while treating aortic arch diseases.Methods Patients with aortic arch extensive diseases treated in our center between January 2002 to April 2015 were retrospectively collected and the patients treated with LCCA or LSA reconstruction were selected for further analysis.Results Forty-nine cases were collected for final analysis.In hybrid group(n=26),the target branches were 10(38.5%)and 16(61.5%)for LSA and LCCA,respectively.In chimney group(n =23),the target branches were 14(60.9%)and 9(39.1%)for LSA and LCCA,respectively.Technical success was achieved in all cases,and no patient was lost during hospitalization.The complications of hybrid group contained 4 type I endoleak(15.4%),1 type II endoleak(3.8%)and 1 post-operative stroke(3.8%);while 9 type I endoleak(39.1%)and 3 type II endoleak(13.0%)were included in hybrid group.The average follow-up time of hybrid and chimney group were 71.2±9.6 months and 27.2±16.4 months,with a patency rate of 96.2%(21/22)and 100%(21/21),respectively.In addition,both LSA and LCCA angulations were significantly larger in hybrid group than in chimney group,while cases with type I endoleak had significantly larger angulations of target branches(LSA or LCCA)than cases without type I endoleak.If the angle of LSA was larger than 29.8 degrees,the risk of post-operative type I endoleak would have risen significantly.Conclusion Hybrid surgery and chimney stent are safe and reliable treating aortic arch extensive diseases,with favorable mid to long-term patency.Chimney stent implantation is more suitable in emergency occasions or cases with small branch angulation.To cases with large branch angulation,hybrid surgery is more commendatory with the caution of stroke occurrence.