Kawaguchi Satoshi, Yokoi Yoshihiko, Shimazaki Taro, Koide Kenji, Matsumoto Masataka, Shigematsu Hiroshi
Department of Vascular Surgery, Center for Minimally Invasive Treatment of Cardiovascular Diseases, Tokyo Medical University, Tokyo, Japan.
J Vasc Surg. 2008 Dec;48(6 Suppl):24S-29S; discussion 29S. doi: 10.1016/j.jvs.2008.08.037.
In the West, stent grafts for endovascular repair of thoracic aortic aneurysms have been commercially available for several years, whereas in Japan, a manufactured stent graft was not approved for this application until March 2008. Nevertheless, endovascular thoracic intervention began to be performed in Japan in the early 1990s, with homemade devices used in most cases. Many researchers have continued to develop homemade devices. We have participated in joint design and assessment efforts with a stent graft manufacturer, focusing primarily on fenestrated stent grafts used in repairs at the distal arch, a site especially prone to aneurysm.
From 1995 to February 2008, we performed about 1100 endovascular procedures to treat thoracic aortic aneurysms and 682 cases were performed at Tokyo Medical University. In 435 out of 682 the aneurysm was located in the area from the distal arch to the proximal descending aorta. Fenestrated stent grafts were inserted in 288 cases. Computed tomography scans were performed at 3, 6, and 12 months postoperatively and annually thereafter.
The initial success rate in the entire series was 95.2%. Complications included 26 cerebral infarctions (3.8%), six of which (0.9%) resulted in serious paralysis and changes in consciousness. Among patients who received fenestrated stent grafts, paraplegia occurred in 2.6%, aortic injury in 1.2%, and iliofemoral artery injury in 6.0%. No complications resulted from occlusion of aortic arch branches. At >/=2 years after intervention, aneurysm diameter was reduced in 62% of patients, 33% had no change, and 5% had a diameter enlargement. The stent graft complication rate during follow-up was 8.4%, the device fracture rate was 1.4%, and the device migration rate was 7%. The 5-year survival rate was 62.4%, with follow-up in 96.8% of the patients.
Endovascular repair has promising results in the descending thoracic aortic region, although some stent grafts and their delivery systems can still be improved. Additional commercial developments and available stent grafts designed for use in the distal arch are urgently needed.
在西方，用于胸主动脉瘤血管腔内修复的覆膜支架已上市数年，而在日本，直到2008年3月才批准一种国产覆膜支架用于该用途。尽管如此，日本在20世纪90年代初就开始进行胸主动脉腔内介入治疗，大多数情况下使用的是自制装置。许多研究人员一直在持续研发自制装置。我们与一家覆膜支架制造商共同参与了设计和评估工作，主要关注用于远段主动脉弓修复的开窗覆膜支架，该部位特别容易发生动脉瘤。
1995年至2008年2月，我们共进行了约1100例胸主动脉瘤血管腔内治疗手术，其中682例在东京医科大学进行。682例患者中，435例动脉瘤位于远段主动脉弓至近段降主动脉区域。288例患者植入了开窗覆膜支架。术后3个月、6个月和12个月以及此后每年进行计算机断层扫描。
整个系列的初始成功率为95.2%。并发症包括26例脑梗死（3.8%），其中6例（0.9%）导致严重瘫痪和意识改变。接受开窗覆膜支架治疗的患者中，截瘫发生率为2.6%，主动脉损伤发生率为1.2%，髂股动脉损伤发生率为6.0%。主动脉弓分支闭塞未导致并发症。干预后≥2年，62%的患者动脉瘤直径缩小，33%无变化，5%直径增大。随访期间覆膜支架并发症发生率为8.4%，装置断裂率为1.4%，装置移位率为7%。5年生存率为62.4%，96.8%的患者接受了随访。
胸降主动脉区域的血管腔内修复取得了令人满意的结果，尽管一些覆膜支架及其输送系统仍有待改进。迫切需要更多的商业开发以及适用于远段主动脉弓的覆膜支架。
