Criado Frank J, Clark Nancy S, Barnatan Marcos F
Center for Vascular Intervention, Division of Vascular Surgery, Union Memorial Hospital/MedStar Health, 3333 N. Calvert Street, Ste 570, Baltimore, MD 21218, USA.
J Vasc Surg. 2002 Dec;36(6):1121-8. doi: 10.1067/mva.2002.129649.
Thoracic aortic aneurysms (TAAs) and type B aortic dissections (ADs) are relatively frequent, serious conditions that are often managed nonoperatively because of perceived poor outcome of standard surgical reconstruction. Recently developed stent graft techniques represent a more attractive, less invasive option. We sought to determine the technical feasibility and safety of endovascular repair in the thoracic aorta with a retrospective review of our experience with such an approach.
Forty-seven patients received thoracic stent graft implants during the 4-year period ending March 31, 2002. All patients signed an Institutional Review Board-approved informed consent. Thirty-one patients had TAAs, and 16 had ADs. Device design and implant strategy were on the basis of evaluation of morphology with angiography and computed tomographic scan. The procedures were done with fluoroscopic guidance, with local anesthesia in five cases, spinal anesthesia in 19 cases, and general anesthesia in 23 cases. Endovascular access was achieved with femoral cutdown in 41 cases and a temporary iliac conduit in six cases. A Talent patient-specific device, with 4-mm to 6-mm oversize, was used in all. Proximal endograft attachment was in the descending thoracic aorta in 16 cases, parasubclavian in 21 cases, and the suprasubclavian aorta in 10 cases. Eight patients had adjunctive cervical reconstruction to transpose or revascularize the left subclavian or left common carotid arteries, enabling more proximal endograft attachment in the aortic arch.
Access failure occurred in one patient (2.1%). One patient (2.1%) died within 30 days of access-related iliac artery rupture. Another death occurred at 60 days from a ruptured thoracoabdominal aneurysm with type I endoleak. No instances of paraplegia, stroke, or surgical conversion were seen. Five patients (TAA) were found to have endoleak on 30-day computed tomographic scan. Repair of type I endoleak was undertaken in three cases at 1, 4, and 6 months. Eight patients (17%) had adverse events within the first 30 days. Length of follow-up ranged from 1 to 44 months, with a mean of 18 months. Two patients were lost to follow-up, and one withdrew from the study. Four additional mortalities were observed, none related to the endograft or aortic pathology.
Stent graft repair of TAA and AD is feasible and can be achieved with technical success and relatively low rates of perioperative morbidity and mortality. The Talent customized design proved versatile in various morphologies. More information is needed on indications, clinical efficacy, and long-term results.
胸主动脉瘤（TAAs）和B型主动脉夹层（ADs）相对常见且病情严重，由于标准外科重建手术的预后较差，通常采用非手术治疗。最近开发的支架移植物技术是一种更具吸引力、侵入性较小的选择。我们通过回顾性分析这种方法的经验，试图确定胸主动脉腔内修复的技术可行性和安全性。
在截至2002年3月31日的4年期间，47例患者接受了胸主动脉支架移植物植入。所有患者均签署了经机构审查委员会批准的知情同意书。31例患者患有胸主动脉瘤，16例患有主动脉夹层。根据血管造影和计算机断层扫描对形态的评估来确定器械设计和植入策略。手术在透视引导下进行，5例采用局部麻醉，19例采用脊髓麻醉，23例采用全身麻醉。41例通过股动脉切开实现血管腔内入路，6例通过临时髂动脉导管入路。均使用尺寸大4至6毫米的Talent定制器械。16例近端移植物附着于降主动脉，21例附着于锁骨下动脉旁，10例附着于锁骨上主动脉。8例患者进行了辅助性颈部重建，以移位或重建左锁骨下动脉或左颈总动脉的血运，从而使近端移植物能更靠近主动脉弓附着。
1例患者（2.1%）出现入路失败。1例患者（2.1%）在入路相关的髂动脉破裂后30天内死亡。另1例死亡发生在60天时，死于胸腹主动脉瘤破裂合并I型内漏。未出现截瘫、中风或转为开放手术的情况。5例胸主动脉瘤患者在术后30天的计算机断层扫描中发现有内漏。3例患者分别在术后1、4和6个月对I型内漏进行了修复。8例患者（17%）在术后30天内出现不良事件。随访时间为1至44个月，平均18个月。2例患者失访，1例退出研究。另外观察到4例死亡，均与移植物或主动脉病变无关。
胸主动脉瘤和主动脉夹层的支架移植物修复是可行的，技术成功率较高，围手术期发病率和死亡率相对较低。Talent定制设计在各种形态下都证明具有通用性。关于适应证、临床疗效和长期结果，还需要更多信息。
