摘要
目前,开窗技术已被广泛应用于各种胸主动脉疾病的治疗。开窗技术可分为原位开窗与体外预开窗,两者具有各自的特点和优缺点。本研究对比分析原位开窗与体外预开窗技术用于不良(短或不健康)近端锚定区主动脉弓病变左锁骨下动脉(LSA)重建的早期及中期疗效,并总结开窗方式的选择经验。
回顾性分析2019年3月—2022年3月郑州大学第一附属医院利用原位开窗或体外预开窗技术重建LSA治疗的215例主动脉弓部病变患者的临床资料。其中114例采用原位开窗(原位开窗组),101例采用体外预开窗(体外预开窗组),对比分析两组间技术成功率、围手术期及随访期不良事件发生情况及病死率等。
原位开窗组技术成功率为93.9%(开窗失败3例、Ia型内漏3例、入路血管损伤1例);1例术后4 d发生双侧多发急性脑梗死,经保守治疗后患者恢复良好;30 d内主动脉相关死亡3例,2例分别于术后10 d和25 d死于夹层累及内脏动脉导致的多器官功能衰竭,1例术后2 d死于腹主动脉夹层破裂。体外预开窗组技术成功率为94.1%(1例因支架移位LSA被覆盖、Ⅲ型内漏3例、Ⅰa型内漏2例);1例术后1 d发生右侧急性脑梗死,经内科治疗后患者恢复良好;无主动脉相关死亡。中位随访时间为原位开窗组26(10~46)个月、体外预开窗组19(10~44)个月。随访期间原位开窗组术后6个月发生分支支架闭塞1例、术后3个月Ⅰa型内漏2例;体外预开窗组术后3个月近端夹层动脉瘤形成1例、术后3个月Ⅰa型内漏2例,两组均未发生主动脉相关死亡。两组技术成功率、围术期及随访期不良事件发生率和病死率差异均无统计学意义(均P>0.05)。
胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)是目前常用的一种治疗胸主动脉疾病的方法,包括主动脉瘤、夹层、穿透性溃疡以及壁间血肿。有研
回顾性收集2019年3月—2022年3月郑州大学第一附属医院采用原位开窗技术或体外预开窗技术治疗不良近端锚定区主动脉弓病变的215例患者的临床资料,根据开窗方式的不同分为原位开窗组114例和体外预开窗组101例。纳入标准:⑴ 存在主动脉弓部病变行TEVAR的患者;⑵ 主动脉弓部病变近端健康锚定区<15 mm(包括胸主动脉夹层破口距离LSA开口>15 mm,但夹层逆撕至LSA根部的患者);⑶ 采用激光原位开窗技术或体外预开窗技术重建LSA者。排除标准:⑴ 病变累及升主动脉;⑵ 使用去分支技术、平行支架技术或一体化分支支架技术重建LSA者;⑶ 起源于主动脉弓的优势左椎动脉。本研究经郑州大学第一附属医院伦理委员会批准并严格遵守赫尔辛基宣言的伦理原则(审批号:2023-KY-0072-002)。
经股动脉引入主动脉覆膜支架,造影确认位置后释放,覆盖LSA。经左侧肱动脉入路置入可调弯鞘配合激光光纤开窗成功后,行小球囊预扩张,再行递增性扩张破口至满意,之后释放分支支架。最后造影确认支架位置良好,无内漏。激光原位开窗技术参数如下:VELAS 30半导体激光仪,输出功率18 W,光纤直径400 μm,激光工作模式为间断模式(作用时间1 s,间隔1 s,共3次)。对于开窗口出现对位偏差的可能性越高的病例,本中心倾向于选择原位开窗技术重建LSA(

图1 原位开窗技术 A:CTA提示B型夹层病变距LSA开口较近;B:利用原位开窗技术成功重建LSA;C:术后半年复查主动脉CTA见支架形态良好,血管通畅
Figure 1 In situ fenestration technique A: CTA indicating a type B dissection with a relatively close distance to the opening of the LSA; B: Successful reconstruction of the LSA using in situ fenestration technique; C: Follow-up arterial CTA six months postoperatively showing a well-formed stent with clear vascular patency
将胸主动脉覆膜支架于体外释放,根据术前CTA测量数据或3D打印模型标记LSA开窗位置及窗孔的大小,利用手术尖刀或电刀进行开窗,之后将去毛弹簧圈连续缝合于窗孔边缘进行加固并标记。最后将支架装回输送鞘内。经股动脉引入主体支架至主动脉弓,部分释放支架露出开窗孔。造影确认支架位置良好后完全释放支架。引入球囊扩张开窗口至满意后,释放分支支架。最后造影示支架释放满意,无内漏。对于LSA起始角度<45°及主动脉Ⅲ型弓,本中心优先选用体外预开窗技术重建LSA(

图2 体外预开窗技术 A:CTA提示穿透性主动脉溃疡病变位于弓部小弯侧且LSA与主动脉夹角<45°;B:采用体外开窗技术成功选入开窗口;C:术后半年复查CTA,近端病变封闭良好,无内漏,分支支架通畅
Figure 2 In vitro fenestration technique A: CTA indicating a penetrating aortic ulcer located on the concavity of the aortic arch, with the angle between LSA and the aorta <45°; B: Successful selection of the fenestration site using in vitro fenestration technique; C: Follow-up arterial CTA six months postoperatively showing a well-closed proximal lesion without endoleak, with no endoleak, and unobstructed patency of the branch stent
分别于术后3、6、12个月及以后每年通过门诊或住院对患者进行随访,行CTA检查评估分支支架通畅性、缺血事件和主动脉相关并发症的发生率,如内漏、逆行A型主动脉夹层和支架引起的新的远端破口。观察指标包括技术成功率(被定义为完全隔绝弓部病变,LSA被成功重建,术中造影无Ⅰ型或Ⅲ型内漏发生)、并发症发生率、病死率。
两组患者基线资料、合并症与吸烟史方面差异均无统计学意义(均P>0.05)(
资料 | 原位开窗 (n=114) | 体外预开窗 (n=101) | P | |
---|---|---|---|---|
男性[n(%)] | 99(86.8) | 90(89.1) | 0.259 | 0.611 |
年龄(岁,) | 55.2±12.7 | 54.7±12.7 | 0.325 | 0.746 |
合并症[n(%)] | ||||
高血压 | 91(79.8) | 78(77.2) | 0.215 | 0.643 |
血脂异常 | 29(25.4) | 29(28.7) | 0.291 | 0.589 |
冠心病 | 12(10.5) | 13(12.9) | 0.287 | 0.592 |
脑卒中 | 6(5.3) | 8(7.9) | 0.621 | 0.431 |
糖尿病 | 7(6.1) | 8(7.9) | 0.262 | 0.609 |
肾功能不全 | 2(1.8) | 4(4.0) | 0.961 | 0.327 |
心功能不全 | 5(4.4) | 5(5.0) | 0.038 | 0.844 |
吸烟史[n(%)] | 47(41.2) | 48(47.5) | 0.861 | 0.353 |
诊断[n(%)] | ||||
B型主动脉夹层 | 88(77.2) | 70(69.3) | 3.068 | 0.381 |
胸主动脉瘤 | 16(14.0) | 15(14.9) | ||
穿透性溃疡 | 2(1.8) | 5(5.0) | ||
主动脉壁间血肿 | 8(7.0) | 11(10.9) |
使用的近端主体支架包括:Valiant(美国Metronic公司)、Zenith(美国Cook公司)、Ankura(中国深圳先健公司)、TAG(美国Gore公司)、E-vita(德国JOTEC公司)、Hercules(中国上海微创公司)。使用的分支动脉支架在原位开窗组包括:Fluency Plus覆膜支架(美国Bard公司)109个,Palmaz Blue裸支架(美国Cordis公司)5个;在体外预开窗组包括:Fluency Plus覆膜支架46个,Viabahn覆膜支架(美国Gore公司)3个,Express LD裸支架(美国Boston Scientific公司)1个,51例未放置分支支架。两组之间的LSA起始角度和主动脉弓形态均存在明显差异(均P<0.05)。这是由于LSA起始角度、主动脉弓形态是影响开窗方式选择的主要因素,当LSA起始角度<45°或主动脉Ⅲ型弓时,优先选择体外开窗技术进行LSA的重建。因不同开窗方式适合选用的主体支架类型不同,导致两组之间的主体支架使用类型同样存在差异(P<0.05)。原位开窗组技术成功率为93.9%,开窗失败3例,均采用烟囱支架技术补救;术中发生即刻Ia型内漏3例,内漏量少均未做处理,术后3个月随访内漏消失;1例术后4 d发生双侧多发急性脑梗死,经保守治疗后患者恢复良好;发生肱动脉部位血肿1例;30 d内主动脉相关死亡3例,2例分别于术后10 d和25 d死于夹层累及内脏动脉导致的多器官功能衰竭,1例术后2 d死于腹主动脉夹层破裂。体外预开窗组技术成功率为94.1%,1例因支架旋转导致LSA开口被覆盖,术中采用烟囱支架置入重建其血流,术中发生即刻内漏5例(Ⅲ型内漏3例,Ⅰa型内漏2例),1例Ⅲ型内漏术中采用弹簧圈栓塞假腔后内漏消失,4例术中未处理,1例随访期仍存在Ⅲ型内漏,二次手术利用弹簧圈填塞假腔后内漏消失,其余3例3个月后随访内漏消失;1例术后1 d发生右侧急性脑梗死,经内科治疗后患者恢复良好;非主动脉疾病相关死亡1例(术后3 d死于全身多发伤导致的失血性休克)。两组技术成功率及围术期主要并发症发生率差异无统计学意义(均P>0.05),两组的住院时间无明显差异(P>0.05),但原位开窗组的手术费用高于体外预开窗组(P<0.05)(
资料 | 原位开窗(n=114) | 体外预开窗(n=101) | P | |
---|---|---|---|---|
手术技术成功[n(%)] | 107(93.9) | 95(94.1) | 0.004 | 0.951 |
手术时间(min,) | 130.0±38.0 | 147.7±64.5 | 2.213 | 0.028 |
锚定区主动脉直径(mm,) | 31.7±3.7 | 31.1±3.9 | 1.157 | 0.249 |
LSA起始角度[°,n(%)] | ||||
<45 | 8(7.0) | 19(18.8) | 6.784 | 0.009 |
≥45 | 106(93.0) | 82(81.2) | ||
主动脉弓形态[n(%)] | ||||
Ⅰ | 84(73.7) | 65(61.3) | 6.533 | 0.038 |
Ⅱ | 24(21.1) | 23(21.7) | ||
Ⅲ | 6(5.3) | 18(17) | ||
主体支架类型[n(%)] | ||||
Ankura | 27(23.7) | 85(84.2) | 84.782 | <0.001 |
Valiant | 43(37.7) | 11(10.9) | ||
Zenith | 3(2.6) | 0(0.0) | ||
E-vita | 10(8.8) | 0(0.0) | ||
TAG | 26(22.8) | 1(1.0) | ||
Hercules | 5(4.4) | 4(4.0) | ||
开窗失败[n(%)] | 3(2.6) | 1(1.0) | 0.790 | 0.370 |
并发症[n(%)] | 10(8.8) | 9(8.9) | 0.001 | 0.971 |
内漏 | 3(2.6) | 5(5.0) | 0.804 | 0.370 |
急性脑梗死 | 1(0.9) | 1(1.0) | 2.279 | 0.131 |
入路血管损伤 | 1(0.9) | 0(0.0) | 0.890 | 0.345 |
30 d内死亡[n(%)] | 3(2.6) | 1(1.0) | 0.887 | 0.375 |
住院时间(d,) | 14.2±7.5 | 15.2±7.1 | 1.061 | 0.290 |
手术费用(万元,) | 16.807±10.424 | 11.235±3.447 | 5.129 | <0.001 |
开窗技术因其成功率高、并发症发生率低、适用范围广以及分支血管远期通畅性良好等特点而被广泛应用于LSA血运重
根据患者具体情况选择合适的开窗方式是提高手术成功率及减少相关并发症发生的关键。在选择开窗方式时需要考虑的因素总结如下:⑴ LSA与主动脉弓的解剖条件是影响对开窗方式选择的首要因素。原位开窗技术成功的关键在于确保激光光纤或者说鞘管头端稳定地抵至主体支架覆膜上,当LSA与主动脉弓的夹角过锐时鞘管头端很难稳定抵在覆膜上,光纤抵至覆膜进行开窗时就容易产生偏移或滑脱,此时容易导致血管壁的损伤及开窗失败;当Ⅲ型弓或LSA开口位于主动脉弓的侧壁时,容易出现LSA与主动脉弓的夹角过小的情况,此时会增加开窗的难度,在这些情况下,笔者中心优先选用体外预开窗技术重建LSA,因此在两组之间基线资料对比中,体外开窗组的LSA起始角度<45°及主动脉Ⅲ型弓的比例明显高于原位开窗组。而当存在累及LSA的夹层、LSA存在狭窄或迂曲、LSA开口与左侧椎动脉距离过短时,可能会使原位开窗难度增加而导致手术复杂化,此时应谨慎选
在本研究中,原位开窗3例失败病例均是由于LSA起始于主动脉的角度过锐导致鞘管头端很难稳定抵在覆膜上,因而开窗失败;而体外开窗组1例失败病例是由于支架在体内的错误旋转导致窗孔对位失败,两组技术失败病例均与主体支架的类型无关。在本研究中,原位开窗组Ankura、Valiant及TAG三种支架应用比例均较高。Li
本研究的不足之处在于单中心研究、样本量较小、随访时间短,受患者解剖条件、主观选择、经济因素及术者熟练度等因素影响存在选择性偏倚。不能排除学习曲线的影响,开窗失败及内漏多发生于学习曲线的早期。对于两项技术的临床效果的对比还需要随访时间更长的大样本随机对照研究来检验。
原位开窗与体外预开窗技术重建LSA应用于TEVAR治疗主动脉弓部病变中均具有良好的安全性与有效性,短期随访结果均令人满意。两种技术各自技术特点不同,根据患者解剖条件及疾病情况进行个体化术式选择可提高手术成功率并减少并发症的发生。
作者贡献声明
周保宁参与研究选题与设计,数据收集整理,数据统计分析,论文初稿撰写,论文核修;化召辉参与研究选题与设计,手术实施,论文写作指导,论文核修,行政、技术或材料支持,指导,支持性贡献;张帅、马珂参与手术实施,数据收集整理,数据统计分析;李震参与研究选题与设计,手术实施,论文写作指导,对文章的知识性内容作批阅性审阅,论文核修,行政、技术或材料支持,指导,支持性贡献。
利益冲突
所有作者均声明不存在利益冲突。
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