Kotelis Drosos, Geisbüsch Philipp, Hinz Ulf, Hyhlik-Dürr Alexander, von Tengg-Kobligk Hendrik, Allenberg Jens R, Böckler Dittmar
Department of Vascular and Endovascular Surgery, University of Heidelberg, Heidelberg, Germany.
J Vasc Surg. 2009 Dec;50(6):1285-92. doi: 10.1016/j.jvs.2009.07.106. Epub 2009 Oct 17.
To analyze the sequelae of the intentional left subclavian artery (LSA) coverage during thoracic endovascular aortic repair (TEVAR).
Retrospective analysis of prospectively collected data in a single center. Between March 1997 and October 2008, 88 of 220 patients (40%) had thoracic aortic lesions that required LSA coverage during TEVAR. Thirty-four of our patients (39%) were treated under urgent or emergent conditions for acute pathologies. The proximal landing zone was zone 0 in 10 patients (11%), zone 1 in 24 patients (27%), and zone 2 in 54 patients (61%). Debranching procedures of the supra-aortic vessels were performed in patients who were to undergo zone 0 or zone 1 deployment. Primary LSA revascularization was performed in 22 of the 88 patients (25%) at a median of 6 days before TEVAR. Median follow-up was 26.4 months (1-98 months).
Technical success was achieved in 97%. Five primary (9%) and two secondary (4%) type Ia endoleaks in patients who underwent zone 2 deployment were observed and required further interventions. Fourteen (16%) primary type II endoleaks were observed; 10 of them fed by the LSA. Paraplegia rate was lower in patients with LSA coverage without revascularization than in other patients (1.5% vs 1.9%; odds ratio [OR], 0.774; 95% confidence interval [CI], 0.038-6.173; P = 1.000). Prior or concomitant infrarenal aortic replacement (P = .0019), renal insufficiency (glomerular filtration rate < 90 mL/min/1.73 m(2)) (P = .0024) and long segment aortic coverage (>200 mm) (P = .0157) were associated with significant higher risk of postoperative paraplegia. Stroke rate was lower in patients with LSA coverage without revascularization than in other patients (3% vs 3.9%; OR, 0.570; 95% CI, 0.118-2.761; P = .7269). Two patients (3%) developed left upper extremity symptoms and another two patients (3%) subclavian steal syndrome and required secondary LSA revascularization. The technical success rate for LSA revascularization was 94%.
By using a selective approach to the LSA revascularization, coverage of the LSA can be used to extend the proximal seal zone for TEVAR without increasing the risk of spinal cord ischemia or stroke. Indications for revascularization include long segment aortic coverage, prior or concomitant infrarenal aortic replacement, and renal insufficiency. In addition, a hypoplastic right vertebral artery, a patent left internal mammary artery graft, and a functioning dialysis fistula in the left arm would also be indications to perform revascularization.
分析胸主动脉腔内修复术（TEVAR）期间故意覆盖左锁骨下动脉（LSA）的后遗症。
对单中心前瞻性收集的数据进行回顾性分析。1997年3月至2008年10月期间，220例患者中有88例（40%）患有胸主动脉病变，在TEVAR期间需要覆盖LSA。我们的34例患者（39%）因急性病变在紧急或急诊情况下接受治疗。近端锚定区在10例患者（11%）中为0区，24例患者（27%）中为1区，54例患者（61%）中为2区。对于将接受0区或1区植入的患者，进行了主动脉弓上血管的去分支手术。88例患者中有22例（25%）在TEVAR前中位时间6天进行了原发性LSA血运重建。中位随访时间为26.4个月（1 - 98个月）。
技术成功率为97%。在接受2区植入的患者中观察到5例原发性（9%）和2例继发性（4%）Ia型内漏，并需要进一步干预。观察到14例（16%）原发性II型内漏；其中10例由LSA供血。未进行血运重建而覆盖LSA的患者截瘫率低于其他患者（1.5%对1.9%；优势比[OR]，0.774；95%置信区间[CI]，0.038 - 6.173；P = 1.000）。既往或同期肾下腹主动脉置换（P = .0019）、肾功能不全（肾小球滤过率<90 mL/min/1.73 m²）（P = .0024）以及长节段主动脉覆盖（>200 mm）（P = .0157）与术后截瘫风险显著升高相关。未进行血运重建而覆盖LSA的患者卒中率低于其他患者（3%对3.9%；OR，0.570；95% CI，0.118 - 2.761；P = .7269）。2例患者（3%）出现左上肢症状，另外2例患者（3%）出现锁骨下动脉窃血综合征，需要进行继发性LSA血运重建。LSA血运重建的技术成功率为94%。
通过采用选择性LSA血运重建方法，覆盖LSA可用于扩展TEVAR的近端密封区，而不增加脊髓缺血或卒中风险。血运重建的指征包括长节段主动脉覆盖、既往或同期肾下腹主动脉置换以及肾功能不全。此外，右椎动脉发育不全、左乳内动脉移植血管通畅以及左臂有功能的透析瘘也将是进行血运重建的指征。
