激光原位开窗保留左锁骨下动脉治疗主动脉弓部病变的经验与结果

目的探讨TEVAR结合激光原位开窗(in situ laser-generated fenestration,ISLF)保留左锁骨下动脉治疗主动脉弓部扩张性疾病的早、中期疗效。方法回顾性分析山东第一医科大学附属中心医院2017年6月至2019年9月接受TEVAR结合激光原位开窗保留左锁骨下动脉手术的13例患者资料,行CTA评估术后夹层破口封堵情况、重建左锁骨下动脉的通畅情况、主动脉重塑情况和支架相关不良事件发生情况。结果 ISLF在12例患者取得成功,技术成功率92.3%。1例开窗失败而采用"烟囱"技术成功重建左锁骨下动脉;1例因主体覆膜支架释放时覆盖左颈总动脉,同样采用"烟囱"技术重建左颈总动脉。患者围术期未发生因使用激光而导致的并发症,无内漏及脑血管意外。2例患者在撤出主体支架系统时出现髂动脉破裂,1例抢救无效死亡,院内死亡率7.7%。术后随访3~18(9.9±5.2)个月,患者破口封堵完善,主体支架及左锁骨下动脉支架无变形移位,无内漏的发生。1例出现无症状左锁骨下动脉支架近端血栓形成,其余患者左锁骨下动脉支架通畅性良好,通畅率91.7%。夹层胸主动脉段完全血栓化且真腔明显扩大,假腔、壁间血肿厚度明显缩小,差异有统计学意义(P<0.05);穿透性溃疡局部均完全血栓化。结论 TEVAR结合ISLF是治疗主动脉弓部疾病保留左锁骨下动脉安全且有效的选择,技术成功率高,并发症发生率低,有良好的通畅性及主动脉重塑,疗效确切。

Experience and results of in situ laser-generated fenestration to preserve left subclavian artery for aortic arch diseases

Objective To study the early and mid-term efficacy of thoracic endovascular repair(TEVAR)combined with in situ laser-generated fenestration(ISLF)to preserve the left subclavian artery(LSA)for the treatment of aortic arch diseases.Methods The clinical data of 13 patients underwent TEVAR combined with ISLF to preserve LSA in the Central Hospital Affiliated to Shandong First Medical University from June 2017 to September 2019 were analyzed retrospectively.Computed tomography angiography was used to assess the closure of the tear,the patency of the LSA,aortic remodeling and stent-related adverse events.Results The operation was successful in 12 patients and the technical success rate was 92.3%.Fenestration failed in one case and LSA was successfully reconstructed by chimney technique.One case covered left common carotid artery when releasing the main stent,chimney technique was also used to reconstruct left common carotid artery.All patients had no complication associated with laser during the perioperative period.No endoleak and cerebrovascular accidents occurred.Two patients developed iliac artery rupture when withdrawing the main stent system and 1 patient died.The in-hospital mortality rate was 7.7%.During the follow-up time of 3 to 18(9.9±5.2)months,all patients had tears occlusion.The main stent and the branch stent were not deformed or displaced,and no endoleak occurred.One case had asymptomatic thrombosis of the proximal branch stent,while others had good stent patency,with a patency rate of 91.7%.The dissection of the thoracic aortic segment was completely thrombosis and the true cavity was significantly enlarged,the false cavity and the thickness of intermural hematoma was significantly reduced,the difference was statistically significant(P<0.05).Penetrating aortic ulcers were completely thrombotic.Conclusion TEVAR combined with ISLF is a safe and effective option for the treatment of aortic arch diseases to preserve LSA.It has high technical success rate,low complication rate,good patency and aortic remodeling with definite effect.