外科辅助短距离逆行针刺技术在主动脉弓原位开窗中的早期应用效果

doi:10.6040/j.issn.1671-7554.0.2024.0335

摘要/Abstract

摘要： 目的分析观察在主动脉弓部疾病患者中,外科辅助下短距离逆行针刺(short-distance retrograde needle puncture, SDRNP)原位开窗技术在胸主动脉腔内修复术(thoracic endovascular aortic repair, TEVAR)中应用的早期结果。方法回顾性分析2021年3月至2023年3月57例累及主动脉弓部病变患者,接受TEVAR术,同时在外科辅助下行SDRNP原位开窗术和弓上分支重建。其中,主动脉夹层32例、主动脉瘤15例、穿透性溃疡10例。纳入标准为主动脉夹层/瘤、穿透性溃疡等弓部疾病,TEVAR术近端锚定区不足,覆膜支架覆盖弓上分支,至少需单开窗;排除标准为弓部病变累及升主动脉,距离冠状动脉开口小于20 mm,或近端锚定区直径大于45 mm,或左椎动脉优势型,且起源自主动脉弓。结果外科辅助SDRNP技术成功率为98.2%(56/57)。57例患者中单纯左锁骨下动脉(left subclavian artery, LSA)开窗27例,LSA+左颈总动脉(left common carotid artery, LCCA)开窗18例,LCCA+头臂动脉干(brachiocephalic trunk, BCT)开窗1例,LSA+LCCA+BCT开窗11例。SDRNP共98次,其中,LSA 56次、LCCA 30次、BCT 12次。1例A型夹层患者计划行三开窗,LCCA+BCT两开窗后,因LSA扭曲严重,SDRNP失败,在LSA开口处栓塞,行左颈动脉-左腋动脉搭桥术。总体平均手术时间(159.1±69.6)min,LSA开窗病例手术时间(112.4±42.7)min,LSA+LCCA开窗病例手术时间(165.9±45.7)min,LSA+LCCA+BCT开窗病例手术时间(226.5±79.9)min。术后发生截瘫1例、脑梗2例、急性心肌梗死1例、肢体麻木1例。其中,1例因大面积脑梗最终死亡。51例获得术后随访,中位随访时间19个月(13~34个月)。术后复查CTA显示,患者发生内漏5例,其中Ⅰ型内漏1例、Ⅱ型内漏1例、Ⅲ型内漏3例。再干预Ⅲ型内漏2例,行弹簧圈栓塞治疗好转。无院外脑血管事件、死亡等发生。结论外科辅助SDRNP主动脉弓原位开窗在技术上是可行的,具有操作迅速高效、开窗成功率高等优势,在选定的患者队列中产生可接受的短期结果。但为更广泛推广该技术的应用,其长期效果仍需进一步观察。

关键词: 主动脉弓部疾病, 胸主动脉腔内修复术, 针刺原位开窗, 短距离, 外科辅助

Abstract: Objective To analyze the early results of the application of surgically assisted short-distance retrograde needle puncture(SDRNP)technique for in situ fenestration in thoracic endovascular aortic repair(TEVAR)in patients with aortic arch disease. Methods A retrospective analysis was performed on 57 patients with aortic arch diseases between March 2021 and March 2023 who underwent TEVAR, and surgically assisted SDRNP in situ fenestration and reconstruction of the superior arch branches. There were 32 cases of aortic dissection, 15 cases of aortic aneurysm and 10 cases of penetrating ulcer. Inclusion criteria were aortic dissection/aneurysm, penetrating ulcer and other arch diseases, insufficient proximal landing zone for TEVAR, and stent graft covering the superior arch branches, and at least one fenestration. Exclusion criteria were the arch disease involving the ascending aorta, less than 20 mm from the opening of the coronary artery, or the diameter of the proximal landing zone greater than 45 mm, or the dominant left vertebral artery originating from the aortic arch. Results The success rate of the surgically assisted SDRNP technique was 98.2%(56/57). In 57 patients, simple left subclavian artery(LSA)fenestration was in 27 patients, LSA+left common carotid artery(LCCA)fenestration was in 18 patients, LCCA + brachiocephalic trunk(BCT)fenestration was in 1 patient, and LSA+LCCA+BCT fenestration was in 11 patients. SDRNP was performed 98 times, LSA 56 times, LCCA 30 times, and BCT 12 times. One patient with type A dissection was scheduled for triple fenestration. However, due to severe LSA distortion, SDRNP in the LSA failed after LCCA+BCT fenestration, and left carotid to left artery-left axillary artery bypass was performed. The mean operative time was(159.1±69.6)min. The mean operative time was(112.4±42.7)min for LSA fenestrations,(165.9±45.7)min for LSA+LCCA fenestrations, and(226.5±79.9)min for LSA+LCCA+BCT fenestrations. Postoperative complications included 1 paraplegia, 2 cerebral infarctions, 1 acute myocardial infarction and 1 limb numbness. Among them, one patient eventually died because of a massive cerebral infarction. Totally 51 patients were followed up with a median follow-up time of 19 months(ranging from 13 to 34 months). Post-operative CTA showed that 5 patients experienced endoleak, including 1 type Ⅰ, 1 type Ⅱ, and 3 type Ⅲ. Two cases with type Ⅲ endoleak were improved by coil embolization after re-intervention. There were no out-of-hospital cerebrovascular events or deaths. Conclusion Surgically assisted SDRNP in situ fenestration of the aortic arch is technically feasible, with the advantages of rapid and efficient manipulation and high success rate of fenestration, yielding acceptable short-term results in selected patient cohorts. However, the long-term effect still needs to be further monitored before the application of this technology can be popularized.

Key words: Aortic arch disease, Thoracic endovascular aortic repair, In situ needle fenestration, Short-distance, Surgical assistance

中图分类号:

R654.3

张志炜,孟庆友,丁庆伟,张晓宇. 外科辅助短距离逆行针刺技术在主动脉弓原位开窗中的早期应用效果[J]. 山东大学学报 (医学版), 2024, 62(9): 93-100.

ZHANG Zhiwei, MENG Qingyou, DING Qingwei, ZHANG Xiaoyu. Early results of surgically assisted short-distance retrograde needle puncture technique for in situ fenestration of the aortic arch[J]. Journal of Shandong University (Health Sciences), 2024, 62(9): 93-100.

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