胸主动脉瘤及夹层腔内修复术中左锁骨下动脉的处理  

Treatment of left subclavian artery in endovascular repair of thoracic aortic aneurysm and thoracic aortic dissection

作　　者：杨代华[1] 郭伟[1] 刘小平[1] 张国华[1] 梁发启[1] 盖鲁粤[2] 尹太[1] 贾鑫[1] 张宏鹏[1] 

机构地区：[1]解放军总医院血管外科,北京100853 [2]解放军总医院心内科,北京100853

出　　处：《中华外科杂志》2007年第3期175-178,共4页Chinese Journal of Surgery

摘　　要：目的探讨胸主动脉瘤及夹层腔内修复术中左锁骨下动脉的处理方法。方法 2000年6月至2005年12月,54例胸主动脉瘤及夹层患者的近端锚定区小于15 mm,需处理左锁骨下动脉。腔内修复术在 X 线透视下进行,支架型血管通过输送系统携带到病变部位,根据病变特点对左锁骨下动脉采取一期完全覆盖(40例)、部分覆盖(3例)、完全覆盖后腔内重建(1例)、完全覆盖前外科重建(10例)等方法处理,观察治疗后效果。结果所有患者术中均应用数字减影血管造影进行脑循环评估。40例一期完全覆盖左锁骨下动脉;10例腔内覆盖前行右锁骨下动脉-左锁骨下动脉或左颈总动脉-左锁骨下动脉旁路术;3例覆盖左锁骨下动脉开口1/2～4/5后再通过球囊扩张、支架植入重建左锁骨下动脉;1例完全覆盖左锁骨下动脉后应用腔内人造血管开窗技术重建左锁骨下动脉。所有辅助技术均取得成功,未出现严重脑及上肢并发症。腔内修复术后近端Ⅰ型内漏发生率17%(9/54)。一期完全覆盖左锁骨下动脉患者术后早期窃血综合征发生率20%(8/40),左肱动脉平均收缩压(63±24)mm Hg(1 mm Hg=0.133 kPa)。结论通过辅助腔内或腔外技术,可对短颈胸主动脉瘤及夹层病变进行有效的腔内修复术;对左锁骨下动脉的处理方式根据椎基底动脉、Willis 环及双侧颈动脉状况来确定。Objective To investigate the treatments of left subclavian artery （LSA）in endovascnlar repair（EVR） of thoracic aortic aneurysm（TAA） and thoracic aortic dissection（TAD）. Methods In 54 TAD or TAA cases,all of the proximal landing zone（PLZ） were less than 15 mm and only the LSA was needed to be treated in EVR, the following methods and techniques were used in the treatments of LSA ： complete cover, partial cover, endovascular reconstruction following complete cover, surgical reconstruction before complete cover. Results DSA was used to evaluate the condition of cerebral circulation in all cases. Forty left subclavian arteries were covered completely. Ten were covered completely after right subclavian artery （RSA）-LSA or left common carotid artery（LCCA）-LSA bypass. PTA and stent in LSA was clone in 3 cases. In 1 case, LSA was covered completely first, and then the graft was punctured and bare stent was fixed after inflation by cutting balloon. All of the ancillary techniques were enforced successfully. No severe complications were found in brain and upper extremity. The proximal endoleak rate was 17% （9/54）. In the 40 cases whose LSA were not reconstructed, the primary left subclavian steal syndrome （LSSS） happened in 8 cases （20%） and the primary average systolic pressure of left brachial artery was 63 ± 24 mm Hg. Conclusions EVR can be enforced safely and efficiently in TAA and TAD with short PLZ by some ancillary endovascnlar or surgical techniques. The methods to treat the LSA depend on the condition of the cerebral circulation.

关 键 词：胸主动脉瘤 夹层动脉瘤 支架 血管假体植入 锁骨下动脉 

分 类 号：R654.3[医药卫生—外科学]