Peterson Mark D, Wheatley Grayson H, Kpodonu Jacques, Williams James P, Ramaiah Venkatesh G, Rodriguez-Lopez Julio A, Diethrich Edward B
Division of Cardiovascular Surgery, Arizona Heart Institute, Phoenix, Ariz 85006, USA.
J Thorac Cardiovasc Surg. 2008 Nov;136(5):1193-9. doi: 10.1016/j.jtcvs.2008.05.036. Epub 2008 Sep 6.
Increasing experience with thoracic aortic stent grafts has led to a more aggressive approach to thoracic aortic pathologies in the distal aortic arch and proximal descending thoracic aorta. To increase the length of the proximal landing zone, it is sometimes necessary to cover the left subclavian artery with the thoracic stent-graft, introducing the risk of retrograde filling of the excluded aorta from the left subclavian artery. It is currently unclear how best to manage these patients to prevent persistent risk of aneurysm expansion or rupture. We report our experience with a minimally invasive endovascular repair of the covered left subclavian artery.
We reviewed prospectively gathered data on all investigational device exemption-approved patients undergoing thoracic aortic stent grafting at the Arizona Heart Institute from 2000 to 2006 (n = 289 patients). Patients had surveillance with a contrast-enhanced computed tomography scan on the first postoperative day and during follow-up at 1, 6, and 12 months.
A total of 289 patients received thoracic stent grafts during the study: Medtronic Talent (Medtronic, Minneapolis, Minn) (n = 25) or Gore TAG (WL Gore & Associates Inc, Flagstaff, Ariz) (n = 261). The left subclavian artery was covered in 23% of patients (n = 66), of whom 17% had preoperative carotid-subclavian bypass (n = 11/66). Among patients with left subclavian artery coverage, the 30-day mortality was 6.1% (n = 4), procedure-related strokes developed in 3 patients (n = 3, 4.6%), and the incidence of left arm claudication was 7.6% (n = 5), necessitating postoperative carotid-subclavian bypass in 2 patients. Twelve patients (18%) had a type I (n = 6) or II (n = 7) endoleak. Coverage of the left subclavian artery accounted for 71% of the type II endoleaks (n = 5), whereas patent intercostals accounted for the rest (n = 2). Type II endoleaks associated with left subclavian artery coverage were successfully treated by retrograde coil embolization from the left brachial artery (n = 3) or left subclavian artery ligation (n = 1).
Coverage of the left subclavian artery during thoracic aortic stent grafting is associated with a low incidence of arm complications and type II endoleaks. All type II endoleaks were successfully treated by retrograde coil embolization or ligation of the left subclavian artery. Successful treatment of endoleaks may reduce the risk of aneurysm expansion or rupture.
随着胸主动脉覆膜支架应用经验的增加，对于主动脉弓远端和胸降主动脉近端的病变，人们采取了更积极的治疗方法。为增加近端锚定区的长度，有时需要用胸主动脉覆膜支架覆盖左锁骨下动脉，这会带来被隔绝的主动脉从左锁骨下动脉逆行灌注的风险。目前尚不清楚如何最佳地处理这些患者以预防动脉瘤持续扩张或破裂的风险。我们报告了我们对被覆盖的左锁骨下动脉进行微创血管腔内修复的经验。
我们回顾了2000年至2006年在亚利桑那心脏研究所接受胸主动脉覆膜支架植入术的所有研究性器械豁免批准患者的前瞻性收集数据（n = 289例患者）。患者在术后第1天以及随访的1、6和12个月时接受增强CT扫描监测。
在研究期间，共有289例患者接受了胸主动脉覆膜支架：美敦力Talent（美敦力公司，明尼阿波利斯，明尼苏达州）（n = 25）或戈尔TAG（WL戈尔联合公司，弗拉格斯塔夫，亚利桑那州）（n = 261）。23%的患者（n = 66）左锁骨下动脉被覆盖，其中17%的患者术前进行了颈动脉 - 锁骨下动脉搭桥术（n = 11/66）。在左锁骨下动脉被覆盖的患者中，30天死亡率为6.1%（n = 4），3例患者发生了与手术相关的卒中（n = 3，4.6%），左臂间歇性跛行的发生率为7.6%（n = 5），2例患者术后需要进行颈动脉 - 锁骨下动脉搭桥术。12例患者（18%）发生了I型（n = 6）或II型（n = 7）内漏。左锁骨下动脉覆盖导致的II型内漏占71%（n = 5），其余由肋间动脉通畅导致（n = 2）。与左锁骨下动脉覆盖相关的II型内漏通过经左肱动脉逆行弹簧圈栓塞（n = 3）或左锁骨下动脉结扎（n = 1）成功治疗。
胸主动脉覆膜支架植入术中覆盖左锁骨下动脉与手臂并发症和II型内漏的发生率较低相关。所有II型内漏均通过逆行弹簧圈栓塞或左锁骨下动脉结扎成功治疗。内漏的成功治疗可能降低动脉瘤扩张或破裂的风险。
