腔内隔绝术治疗Stanford B型主动脉夹层动脉瘤146例临床分析

Endovascular stent-graft exclusion for Stanford B type aortic dissections: a report of 146 patients

目的 探讨StanfordB型主动脉夹层动脉瘤腔内治疗的手术指征、术前评估方法、手术操作技巧、并发症防治原则及临床应用前景。 方法 对 1 4 6例行StanfordB型主动脉夹层动脉瘤腔内隔绝术患者的临床资料进行回顾性分析。术前采用CT血管造影 (CTA)或磁共振血管造影 (MRA)对主动脉夹层动脉瘤进行评估 ,术中在数字减影血管造影 (DSA)监视下经股动脉或髂动脉将移植物导入胸主动脉封闭夹层裂口。 结果 术中移植物成功释放 1 4 5例 ,1例移植物无法释放而转行开胸手术。 1 1 9例仅使用移植物封闭夹层近端裂口 ,2 6例同时封闭夹层近端及远端裂口 ,46例远端夹层裂口旷置。围手术期死亡 6例 ,其余病例术后无心、肺、肾功能衰竭及截瘫等严重并发症。术后 1 1个月猝死 1例 ,2例分别于术后 1 4、2 4个月再发StanfordA型胸主动脉夹层动脉瘤而行升主动脉人工血管置换术 (Bentall手术 ) ,其余患者未出现与夹层动脉瘤及手术相关的并发症。 结论 腔内隔绝术治疗StanfordB型主动脉夹层动脉瘤是一种创伤小、恢复快的新方法 ,短期的随访结果表明该技术安全、有效。内漏是该方法的主要并发症并可能导致术后患者死亡 。

Objective To assess the operation indications, preoperative evaluation, technique essentials and clinical prospect of endovascular stent graft exclusion for aortic dissection. Methods From Septe mber 1998 to April 2003, endovascular stent graft exclusion for aortic dissection (Stanford B) was preformed in 146 patients. CTA or MRA were used as preoperative evaluation methods. Graft was constructed from self expanding Z stents covered with a woven Dacron polyester fabric graft(Talent TM ). The stent grafts were inserted from the femoral or iliac artery to exclude the tear of dissection, and all operations were performed under DSA guidance. Results The grafts were installed successfully in 145 patients. In 119 patients only proximal tears were excluded, and 26 patients who had both the proximal and distal tears were excluded. The mean follow up period was 16 months (1～54 months). Six patients died within the perioperative period, 2 patients died during the follow up, 2 patients had recurrence of aortic dissection (Stanford A) and cured by Bentall operation. The others were in good state. No accidents related to the dissection and operation occurred. Conclusions Endovascular graft exclusion may be a safe and effective treatment for selected patients with thoracic aortic dissection. Endoleak may lead to aneurysmal expansion and rupture. Further follow up is necessary to evaluate its long term effectives.