Stanford B型主动脉夹层杂交和开窗胸主动脉腔内修复术重建左锁骨下动脉技术的有效性和安全性比较

doi:10.3969/j.issn.1005-6483.2020.06.007

摘要/Abstract

摘要： 目的：观察胸主动脉腔内修复术（TEVAR）联合开窗治疗Stanford B型主动脉夹层有效性和安全性。方法：前瞻性队列研究分析，2012年4月～2017年1月于我院收治的Stanford B型主动脉夹层病人81例，根据重建左锁骨下动脉方法不同分为开窗TEVAR组（47 例）和杂交TEVAR组（34例）。比较两组病人临床特点、手术情况、并发症及生存结局。结果：两组病人均无死亡及截瘫，开窗TEVAR组平均手术时间为（128±27）分钟，平均住院时间为（7.5±2.1）天，术后疼痛发生率为17%；杂交TEVAR组分别为（237±47）分钟、（13.3±3.6）天和41.2%，两组比较差异有统计学意义（P<0.05）。开窗TEVAR组脑梗发生率为4.3%、Ia型内漏发生率6.4%、瞻妄发生率10.6%、肾功能不全发生率14.9% ，杂交TEVAR组分别为8.8%、11.8%、23.5%、20.6%。两组比较差异无统计学意义（P>0.05）。开窗TEVAR组植入支架的数目、长度、近远端直径与杂交TEVAR组比较，差异无统计学意义（P>0.05）。随访时间36个月，随访率为 90.1%。随访期间开窗TEVAR组全因死亡率为8.5%，夹层近端逆撕裂发生率为4.3%，胸主动脉远端扩张14.9%，二次手术行腔内修复发生率为4.3%，主动脉重塑发生率为74.5%。杂交TEVAR组分别为8.8%，5.9%，17.6%，2.9%，82.4%，两组比较差异无统计学意义（P<0.05）。结论：与杂交TEVAR组相比，开窗TEVAR组改善远期预后，未增加术后并发症发生率，缩短手术时间、住院时间，减轻术后疼痛。Stanford B型主动脉夹层保留左锁骨下动脉可优先考虑开窗TEVAR。

关键词: 主动脉夹层, 左锁骨下动脉, 胸主动脉腔内修复术, 开窗术

Abstract: Objective：Observe the clinical efficacy and safety of TEVAR combined with fenestration in the treatment of Stanford type B aortic dissection.Methods：The clinical data of 81 patients with Stanford type B aortic dissection were analyzed in a prospective cohort study in our hospital from April 2012 to January 2017.According to different methods of reconstruction of the left subclavian artery，the patients were divided into the fenestration TEVAR group（n=47）and the hybrid TEVAR group（subclavian artery bypass grafting）（n=34）.The clinical characteristics，surgical conditions，complications and survival outcomes of the two groups were compared.Results：There was no death or paraplegia in either group.The mean operative time of the fenestration TEVAR group was（128±27）min，the mean length of hospital stay was（7.5±2.1）d，the incidence of postoperative pain was 17%.While data of the hybrid TEVAR group were （237±47）min，（13.3±3.6）d and 41.2%，respectively.In the fenestration TEVAR group，the incidence of proximal reverse dissection was 4.3%，the incidence of type Ia leakage was 6.4%，prospective incidence was 10.6%，incidence of renal insufficiency was 14.9%.While in the hybrid TEVAR group was 8.8%、11.8%、23.5%、20.6%，respectively.There was no statistically significant difference between the two groups（P>0.05）.Compared with the hybrid TEVAR group，the number，length and proximal and distal diameters of the scaffolds implanted in the windowed TEVAR group were not statistically significant（P>0.05）.The followup time was 36 months，and the followup rate was 90.1%.During the followup period，in the fenestration TEVAR group，the allcause mortality rate was 8.5%，the incidence of proximal reverse dissection was 4.3%the distal thoracic aorta distended was 14.9%，the incidence of intraoperative repair was 4.3%，and the incidence of aortic remodeling was 74.5%.In the hybrid TEVAR group，the data were 8.8%，5.9%，17.6%，2.9%，82.4%，respectively.Conclusion：Compared with the hybrid TEVAR group，the fenestration TEVAR group improved the longterm prognosis，did not increase the incidence of postoperative complications，shortened the operation time，hospital stay and reduced postoperative pain.Stanford type B aortic dissection may give preference to the fenestration TEVAR for preservation of LSA.

Key words: aortic dissection, left subclavian artery, thoracic endovascular aortic repair, fenestration

刘华, 张军, 刘斌等. Stanford B型主动脉夹层杂交和开窗胸主动脉腔内修复术重建左锁骨下动脉技术的有效性和安全性比较[J]. 临床外科杂志, 2020, 28(6): 522-526.

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