Ankura主动脉覆膜支架行原位开窗重建弓上分支的应用

背景与目的 胸主动脉腔内修复术（TEVAR）已经成为治疗主动脉弓部病变的首选术式。然而，此术式要求支架近端安全锚定区至少为15 mm，对于锚定区不足者，则通常需重建弓部分支血管以确保手术安全。在目前各种重建技术中，原位开窗技术因其较大程度的保留分支血管以及较低的内漏风险而应用最多。因此，本研究探讨Ankura主动脉覆膜支架进行原位开窗重建弓上分支的可行性及效果。方法 回顾性分析2017年3月—2020年12月中国科学院大学宁波华美医院收治的47例近端锚定区不足的主动脉病变患者的临床资料。其中胸主动脉夹层38例，胸主动脉瘤6例，胸主动脉溃疡3例。根据术前CTA影像资料决定患者的开窗数目、开窗支架规格，术中利用穿刺针对Ankura主动脉覆膜支架进行原位开窗重建弓部分支，术后定期行主动脉CTA复查随访。结果 所有患者均获手术成功，共植入Ankura胸主动脉覆膜支架47枚，Gore Viabahn覆膜支架51枚，Cordis Smart裸支架20枚。4例术中转烟囱支架植入，原位开窗成功率91.5%（43/47），包括左锁骨下动脉（LSA）开窗29例，左颈总动脉（LCCA）开窗+LSA栓塞1例，LSA开窗+左椎动脉烟囱1例，LSA开窗+左LCCA烟囱9例，LCCA+LSA开窗+无名动脉（IA）烟囱1例，LCCA开窗+IA烟囱+LSA栓塞2例。全组患者手术时间160~300 min，平均（200±20）min，术中开窗时间18~45 min，平均（30±8）min；术后内漏（1型）3例，逆撕2例（1例行升主动脉置换后好转，1例死亡），脑梗死2例，截瘫0例。平均随访时间（28.4±14.7）个月，期间2例内漏在随访中消失，1例内漏未进一步增大予以观察随访中，未见开窗分支血管闭塞。结论 利用穿刺破膜技术对Ankura主动脉覆膜支架进行原位开窗重建分支血管是一种切实可行且有效的治疗方式，近期效果良好。

Application of in-situ needle fenestration of Ankura aortic stent graft for revascularization of the supra-aortic branches

Background and Aims Thoracic endovascular repair (TEVAR) has become the first choice for the treatment of aortic arch lesions. However, this procedure requires a proximal landing zone of at least 15 mm in length, so reconstruction of the major branches of the aortic arch is usually necessary to ensure the safety of the operation in those with insufficient landing zone. Among the current reconstruction techniques, in-situ fenestration technique is most frequently used, because of its greater level of the supra-aortic branch preservation and relatively low risk of endoleak. Therefore, this study was to investigate the feasibility and effect of application of in-situ needle fenestration of Ankura aortic stent graft for revascularization of the supra-aortic branches.Methods The clinical data of 47 patients with aortic disease and short proximal landing zone treated in Ningbo Hwa Mei Hospital of University of Chinese Academy of Sciences from March 2017 to December 2020 were retrospectively analyzed. Among them, there were 38 cases of thoracic aortic dissection, 6 cases of thoracic aortic aneurysm, and 3 cases of thoracic aortic ulcer. According to the preoperative CTA image data, the number of fenestrations and the size of the fenestration stent were determined; during the operation, the Ankura aorta stent graft was used to perform in-situ fenestration and reconstruction of the supra-aortic branches. Aortic CTA regularly performed after surgery.Results All patients were successfully operated. A total of 47 Ankura thoracic aorta stent grafts, 51 Gore Viabahn stent grafts, and 20 Cordis Smart bare stents were implanted. Four cases were converted to chimney stent implantation during the operation. The success rate of in-situ fenestration was 91.5% (43/47), which included left subclavian artery (LSA) fenestration, left common carotid artery (LCCA) fenestration+LSA embolization in 1 case, LSA fenestration+ in 29 cases left vertebral artery chimney in 1 case, LSA fenestration+LCCA chimney in 9 cases, LCCA and LSA fenestration+innominate artery (IA) chimney in 1 case, and LCCA fenestration+IA chimney+LSA embolization in 2 cases. The operative time for the whole group of patients was 160-300 min, with an average of (200±20) min, and the operative time for fenestration was 18-45 min, with an average of (30±8) min. Postoperative endoleak (type 1) occurred in 3 cases, retrograde tear occurred in 2 cases (1 case improved after ascending aorta replacement, and 1 case died), cerebral infarction occurred in 2 cases, and no paraplegia occurred. The average follow-up time was (28.4±14.7) months. During the follow-up period, the endoleak disappeared in 2 cases and did not further increase in 1 case, which was treated by observation, and there was no occlusion in the fenestrated branch vessels.Conclusion Using in-situ needle fenestration of Ankura aortic stent graft for revascularization of the supra-aortic branches is a feasible and effective treatment method, with favorable short-term results.