复杂瘤颈的近肾腹主动脉瘤腔内修复中烟囱技术的应用

目的探讨瘤颈解剖复杂的近肾腹主动脉瘤(juxtarenal aortic aneurysms,JAA)腔内修复(endovascular aneurysmrepair,EVAR)中应用烟囱技术的价值。方法 2007年1月～2011年10月,对7例瘤颈复杂的JAA采用EVAR治疗。由于瘤颈解剖结构不适于标准的腔内修复方案,术中自肱动脉穿刺预先于可能被覆膜支架主体覆盖的肾动脉置入导丝,置入修复腹主动脉瘤的覆膜支架主体后造影明确肾动脉覆盖情况,于相应肾动脉置入自膨支架或球囊扩张支架,以延长瘤颈长度使之符合EVAR要求,并有效保护肾动脉(即烟囱技术),然后再完成标准EVAR操作。结果 7例手术全部获成功。7例使用9枚肾动脉支架,其中5枚球扩支架,4枚自膨支架。腔内治疗最后的造影显示:腹主动脉瘤(abdominal aortic aneurysm,AAA)瘤腔隔绝良好,肾动脉血流良好。术中1例近端Ⅰ型内漏,近端增加Cuff后内漏消失;1例造影显示少量的Ⅱ型内漏,无须处理。7例随访1～52个月,平均11.6月:1例术后2个月因心功能衰竭死亡;1例Ⅱ型内漏术后3个月随访内漏消失;肾动脉烟囱支架均保持通畅。结论对于不适宜行开腹手术治疗的瘤颈解剖不佳的JAA,烟囱技术是传统EVAR技术的有效补充,远期效果及肾动脉支架长期通畅性尚需要进一步观察。

Chimney Grafts of Renal Artery for Endovascular Repair of Juxta-renal Aortic Aneurysms with Complex Aneurysm Neck

Objective To investigate the value of chimney grafts of renal artery in endovascular aneurysm repair(EVAR) of Juxta-renal aortic aneurysms(JAA) with complex aneurysm neck.Methods Totally 7 patients with JAA were treated by EVAR with chimney grafts between January 2007 and October 2011 at our department.All the cases were unsuitable for standard endovascular abdominal aortic aneurysm(AAA) repair because of large neck angulation.And they were of high-risk for open repair because of poor health state.During the procedure,by brachial artery puncture,we introduced a guide wire trough the renal artery that could be covered by the stent graft.And then,after the stent was placed,self-expandable stent or balloon expandable stent was inserted so that to lengthen the aneurysm neck for EVAR and protect the renal artery.Results The success rate of the procedure was 100%.Totally 9 renal artery stent were used,including 5 balloon expandable stents and 4 self-expandable stents.Angiography at the end of the operation showed normal renal blood flow into the kidney and well-separated AAA.One patient developed type Ⅰ endoleak,which was cured with a Cuff.One patient showed mild type Ⅱ endoleak without needing treatment.The patients were followed up for a mean of 11.6 months(1-52 months),during which one patient died of heart failure in two months,the type Ⅱ endoleak disappeared in three months,and all the chimney grafts were kept patent through the follow-up.Conclusions The chimney graft of the renal artery is an alternative of conventional EVAR,it is suitable for JAA patients with unfavourable aortic anatomy.Further study is necessary to observe its long-term outcomes.