摘要
背景与目的:迷走右锁骨下动脉(ARSA)为主动脉弓部的一种先天畸形,Stanford B型主动脉夹层(TBAD)合并ARSA是一种罕见且严重威胁患者生命的疾病。既往临床上对其处理通常采用开放手术或杂交手术。随着血管腔内技术的飞速发展,胸主动脉腔内修复术(TEVAR)已逐渐被应用与TBAD合并ARSA的治疗,并展现出其创伤小,恢复快的优势。但由于ARSA与夹层破口相对位置的不确定性,如何处理夹层破口与ARSA成为了影响其腔内治疗的主要因素,完全腔内治疗这一复杂主动脉弓部病变的安全性和有效性尚不明确。本文旨在探讨TBAD合并ARSA的腔内修复治疗方法,总结初步经验。方法:回顾性分析2012年1月—2019年12月中南大学湘雅二医院血管外科采用TEVAR治疗的16例TBAD合并ARSA患者资料。其中男14例,女2例;平均年龄为(56.1±11.3)岁;13例患者破口位于Z3区,3例位于Z4区;左椎动脉优势14例,右椎动脉优势1例,双侧椎动脉均势1例。根据主动脉夹层破口位置与双侧锁骨下动脉开口位置、椎动脉形态制定手术方案。结果:技术成功率100%,平均手术时间(95.2±38.9)min,无围手术期死亡。2例患者保留双侧锁骨下动脉,5例患者封堵ARSA,7例患者采用烟囱技术重建左锁骨下动脉(LSA),1例患者采用烟囱技术重建LSA并采用潜望镜技术重建ARSA,1例患者采用开窗技术重建LSA。弓部分支动脉重建的患者,术后服用拜阿司匹林(100 mg/d)和氯吡格雷(75 mg/d)3个月。平均随访时间33.2(3~66)个月。无内漏、支架移位等;右上肢缺血2例,保守治疗后逐渐恢复;比较术前和末次随访的主动脉CTA,降主动脉最大直径从(37.1±9.6)mm降至(33.9±8.9)mm,假腔与真腔之比从1.03±0.62降至0.21±0.31。长期随访,所有烟囱支架均保持通畅,未出现弓部分支动脉缺血、锁骨下动脉窃血、脊髓缺血等症状。结论:TEVAR辅以"烟囱"、开窗等技术治疗合并ARSA的TBAD安全可行,可以在保留LSA和(或)ARSA血流的同时良好封堵主动脉夹层破口,且创伤小、住院时间短、围手术期并发症发生率低。具体的手术方式应由夹层破口与双侧锁骨下动脉的相对位置来决定,应至少保证椎动脉优势一侧锁骨下动脉的血流供应。
Background and Aims:Aberrant right subclavian artery(ARSA)is one of the congenital anomalies of the aortic arch.Stanford type B aortic dissection(TBAD)combined with ARSA is extremely rare and life-threatening.Most of them previously were treated by means of conventional open surgery or hybrid operation.With the rapid development of endovascular techniques,thoracic endovascular aortic repair(TEVAR)is being increasingly used in the treatment of TBAD associated with ARSA,which has the advantages of minimal invasive and fast postoperative recovery.Due to the uncertainty of the relative locations of ARSA to the primary entry tear of the TBAD,how to deal with ARSA and primary entry tear must be taken into serious consideration.The efficacy and safety of total endovascular treatment of this complex condition of the aortic arch are uncertain.Therefore,this study was conduct to investigate endovascular repair for TBAD with ARSA,and provide the preliminary experience.Methods:The clinical data of 16 patients with TBAD and combined ARSA undergoing TEVAR in the Second Xiangya Hospital of Central South University from January 2012 to December 2019 were retrospectively analyzed.Of the patients,14 cases were males and 2 cases were females,with an average age of(56±11.3)years;the primary entry tear located in zone 3 in 13 cases,and located in zone 4 in 3 cases;left vertebral artery dominance presented in 14 cases,right vertebral artery dominance was found in 1 case and 1 case had equipotent bilateral vertebral arteries.Personalized operative plans were made according to the locations of the primary entry tear and the opening of bilateral subclavian arteries as well as the pattern of the vertebral arteries.Results:The technical success rate was 100%.The mean operative time was(95.2±38.9)min.There was no perioperative mortality.The blood flow of bilateral subclavian arteries was preserved in 3 patients,5 cases underwent covering of the ARSA,chimney technique was used in 7 patients to preserve the left subclavian artery(LSA),both chimney and periscope techniques were used in one patient to reconstruct the ARSA,and fenestration technique was used in one patient to reconstruct the LSA.Patients undergoing reconstruction of the branches of the aortic arch were administered with aspirin(100 mg/d)and clopidogrel(75 mg/d)for 3 months after operation.The mean follow-up time was 33.2(3–66)months.No endoleak or stent graft migration occurred;right upper limb ischemia occurred in 2 patients,which recovered gradually after conservative treatment;the comparison between preoperative CTA and the last follow-up CTA showed that the mean maximum diameter of the descending aorta was decreased from(37.1±9.6)mm to(33.9±8.9)mm,and the false/true lumen ratio was decreased from 1.03±0.62 to 0.21±0.31.During long-term follow-up,all of the chimney stent grafts were patent,and none of the patients developed symptoms such as ischemia of the branch arteries of the aortic arch,subclavian steal syndrome and spinal cord ischemia.Conclusion:TEVAR combined with chimney or fenestration technique is safe and feasible for TBAD with ARSA,by which,the primary entry tear of the aortic dissection can be effectively covered with simultaneous preservation of the blood flow of the LSA and(or)ARSA,with the advantages of quick recovery,short of hospitalization and low incidence of perioperative complications.The specific operative procedure should be based on the relative locations of ARSA to the primary entry tear,and ensure at least the blood flow of the ipsilateral subclavian artery giving rise to the dominant vertebral artery.
作者
王沫
舒畅
张惟常
王暾
李鑫
何昊
WANG Mo;SHU Chang;ZHANG Weichang;WANG Tun;LI Xin;HE Hao(Department of Vascular Surgery,the Second Xiangya Hospital,Central South University,Changsha 410011,China;Institute of Vascular Disease,Central South University,Changsha 410011,China;Department of Vascular Surgery,Fuwai Hospital,Academy of Medical Sciences,Beijing 100037,China;National Center for Cardiovascular Disease,Beijing 100037,China)
出处
《中国普通外科杂志》
CAS
CSCD
北大核心
2020年第10期1234-1242,共9页
China Journal of General Surgery
关键词
动脉瘤
夹层
主动脉
胸
迷走右锁骨下动脉
血管内操作
Aneurysm,Dissecting
Aorta,Thoracic
Aberrant Right Subclavian Artery
Endovascular Procedures
