主动脉腔内修复术治疗75例DeBakey Ⅲ型主动脉夹层

目的 总结主动脉腔内修复术(EVAR)治疗DeBakey Ⅲ型主动脉夹层适应证的选择、临床疗效以及探讨并发症的防治原则.方法 2002年12月至2007年6月采用TALENT带膜支架施行EVAR治疗75例DeBakeyⅢ型主动脉夹层患者,男65例,女10例,平均年龄54.4±12.6(29～83)岁.1例29岁女性病因考虑为埃-当综合征,2例年青男性分别继发于原发性醛固酮增多症和外伤车祸.全部患者均经螺旋CT或磁共振血管造影检查确诊.全身麻醉下经股动脉置入带膜血管内支架,封堵原发破口,重复造影检查.结果 75例患者共置入81枚带膜支架.其中2例因近端破口接近左锁骨下动脉,先行颈总动脉-锁骨下动脉旁路移植术,再置入支架,支架近段覆盖左锁骨下动脉.25例支架置入后出现明显内漏,20例予球囊扩张,6例置入1枚短支架后内漏消失.支架置入技术成功率为100％.1例埃-当综合征女性患者术中出现股动脉、髂外动脉、髂总动脉广泛血管撕裂,失血性休克,经抢救好转恢复.2例术后早期死于夹层破裂.术后随访1～24个月,2例(包括1例埃-当综合征患者)术后半年发生猝死,1例术后1年复查CT发现支架远端出现破口,经外科手术治疗后恢复良好;其余存活者复查螺旋CT示假腔径缩小并见腔内血栓形成,真腔径增大,无瘤体破裂、内漏及支架移位等并发症发生.结论 EVAR治疗DeBakeyⅢ型主动脉夹层具有技术可靠、创伤小、术后恢复快、成功率高等优点,尤其适用于不能耐受传统开胸手术的老年高危患者.而对于年轻的主动脉夹层患者要注意排除埃-当综合征等遗传性疾病,用EVAR治疗埃-当综合征的血管并发症,目前尚未见报道,其手术并发症及疗效有待进一步观察.

Endovascular repair for patients with DeBakey Ⅲaortic dissection

Objective To investigate the clinical therapeutic effects of endovascular repair for patients with DeBakey Ⅲ aortic dissection.Methods From December 2002 to June 2007,endovascular TALENT stent-graft exclusion was performed in 75(65 males,mean age 54.4±12.6 years)patients with DeBakey Ⅲ aortic dissection(1 young woman due to Ehlers-Danlos syndrome,2 young men due to primary aldosteronism and trauma respectively).All patients were diagnosed by contrast enhanced computed tomography(CT)or MRI.Stent-grafts were deployed via femoral artery to exclude the tear of dissection.Aortic angiography was performed immediately after procedure.Results Eighty-one stent-grafts were installed in 75 patients successfully without operation related dissection.Endoleakage immediately after stent-graft deploying was evidenced in 25 patients and disappeared after stent placements(n=6)or balloon dilation (n=19).Two patients died from aortic rupture within 2 days after procedure.Iliac artery was torn in a female patient with Ehlers-Danlos syndrome,this patient developed hemorrhagic shock after stent-graft placement and recovered after anti-shock treatments and iliac artery replacement with synthetic artery.During the follow-up of 1-24 months,2 patients(including the woman with Ehlers-Danlos syndrome)suddenly died half a year after procedure.The remaining patients were alive and well.Repeat CT during follow up showed that reduced lumen size and thrombosis in the false lumen.There was no aortic rupture,endoleak and stent migration during the follow-up period except descending aortic dissection distal of the stent-graft in 1 patient 1 year after procedure and the patient were successfully treated surgically without complication.Conclusions Endovasular repair is a safe and effective treatment for patients with DeBakey Ⅲ aortic dissection,suitable for old patients with high risk of surgery.Ehlers-Danlos syndrome should be considered in young DeBakey Ⅲ aortic dissection patients without hypertension.Further studies are warranted on endovasular repair therapy for artery complication of Ehlers-Danlos syndrome.