左颈总动脉-左锁骨下动脉转流技术在胸主动脉腔内修复术中的临床应用

目的 探讨左颈总动脉（LCCA）-左锁骨下动脉（LSA）转流技术在胸主动脉腔内修复术（TEVAR）治疗胸主动脉疾病中的应用效果。方法 回顾性研究。纳入2016年1月—2019年12月南京鼓楼医院心胸外科胸主动脉疾病患者83例,其中男76例、女7例,年龄27~82（55.3±12.0）岁。B型主动脉夹层71例,胸主动脉瘤2例,主动脉溃疡5例,主动脉壁间血肿5例。83例患者行一期LCCA-LSA转流术+TEVAR治疗。观察手术时间、支架放置数量、术中行LSA弹簧圈栓塞情况;围手术期内观察患者死亡、脑梗死发生情况、再手术率及再手术原因;出院后随访期间,观察患者的死亡率、脑梗死发生率,复查主动脉CTA观察转流血管通畅情况、弓部分支血管血供情况以及有无支架移位。结果 83例患者均成功重建LSA。手术时间1.0~7.0（3.2±1.0） h。术中置入胸主动脉支架1个64例、2个17例、3个2例。4例患者出现LSA根部对比剂渗漏,予弹簧圈栓塞后渗漏消失。围手术期内无患者死亡。2例（2.4%,2/83）患者再次手术治疗,其中1例LCCA部分遮盖、1例主动脉逆撕A型夹层,均予相应处理后恢复正常。1例（1.2%,1/83）患者术后出现一过性脑梗死伴左侧肢体肌力一过性下降,保守治疗后好转出院。83例患者术后随访8~46个月,平均25.3个月。随访期间,5例（6.0%,5/83）患者死亡;3例（3.6%,3/83）患者出现脑梗死,保守治疗后好转;主动脉CTA显示,转流血管通畅,弓部分支血管血供良好,无支架移位。结论 LCCA-LSA转流技术重建LSA,可以延长胸主动脉病变近端锚定区,是治疗胸主动脉疾病安全有效的手术方法,可获得良好的近期疗效。

Clinical application of left common carotid artery-left subclavian artery bypass technique in thoracic endovascular aortic repair

Objective This study aimed to investigate the clinical experience of left common carotid artery (LCCA)-left subclavian artery (LSA) bypass in thoracic endovascular aortic repair (TEVAR) for the treatment of thoracic aortic diseases when the proximal anchoring area is insufficient. Methods In this study, a retrospective study design was used. From January 2016 to December 2019, 83 patients with thoracic aortic diseases underwent LCCA-LSA bypass during TEVAR in Nanjing Drum Tower Hospital. A total of 76 males and 7 females were identified. The age of the patients ranged from 27 to 82, with a mean age of (55.3±12.0) years. Indications for TEVAR included 70 cases of type B aortic dissection, 2 cases of thoracic aortic aneurysm, 5 cases of aortic ulcers, and 5 cases of aortic intramural hematoma. All patients were treated with LCCA-LSA bypass during TEVAR. The operation time, the number of stents placed, and whether coil embolization of the LSA was performed during the operation were observed. The incidence of death, cerebral infarction, and causes of reoperation were observed during the perioperative period. After discharge, the patients were followed up to observe the death of the patients and the incidence of cerebral infarction; aortic CTA was examined to observe the patency of the bypass vessel, the condition of branch vessels of the arch, and the presence or absence of stent displacement. Results The operation was successful for all patients. The operation time was 1.0-7.0(3.2±1.0) h. The number of thoracic aortic stents placed during TEVAR was one in 64 cases, two in 17 cases, and three in 2 cases. Contrast agent leakage at the root of the LSA was observed in four patients, and the leakage disappeared after coil embolization. No patient died during the perioperative period. Two patients (2.4%, 2/83) needed reoperation, including one with partial occlusion of the LCCA and one with retrograde aortic dissection, which returned to safety after corresponding treatment. One (1.2%, 1/83) patient developed transient cerebral infarction with a transient decrease in muscle strength of the left limb after surgery, who was discharged after conservative treatment. All 83 patients were followed up for 8 to 46 months, with an average of 25.3 months. Five (6.0%, 5/83) patients died during the follow-up period. Three (3.6%, 3/83) patients developed cerebral infarction during follow-up, which improved after conservative treatment. During the follow-up period, the patient underwent reexamination of aortic CTA, and no patients showed failure in primary patency or stent displacement during follow-up. Conclusion LCCA-LSA bypass can provide an adequate proximal landing zone in the setting of TEVAR, which is a safe and effective surgical method for the treatment of thoracic aortic diseases.