Department of Surgery, Prince of Wales Hospital, Sydney, Australia.
J Endovasc Ther. 2013 Apr;20(2):242-8. doi: 10.1583/1545-1550-20.2.242.
To describe a case of a fenestrated aortic stent-graft device malfunction in the aortic arch, which left the stent-graft deployed and almost irretrievable had it not been for an escalating series of endovascular salvage maneuvers.
A 47-year-old man presented with a rapidly enlarging 6.9-cm thoracic aneurysm that was a complication of a chronic type B aortic dissection. A 2-piece, custom-made, tapered, fenestrated thoracic endoprosthesis (innominate scallop plus single carotid) was planned to seal from the innominate origin to immediately above the celiac axis after staged left carotid to subclavian bypass. Blood pressure control with rapid ventricular pacing aided deployment of the proximal, fenestrated stent-graft component with both openings accurately positioned over their respective branch vessel ostia. Attempted retrieval of the nosecone was hampered by a release failure of the single conformance tie that connects the stent-graft to its central cannula. This left the stent-graft fully deployed with the nosecone irretrievable beyond a point immediately distal to the small fenestration. A series of endovascular salvage maneuvers ensued, ranging from simple actions to manipulate and balloon dilate the graft through to more complex attempts to break the tie and lasso the nosecone using snares. Finally, attempts at antegrade retrieval of the nosecone straightened the device and released the offending tie, allowing case completion.
This is a rare but cautionary example of the potential pitfalls of translating endograft technology from the abdominal aorta to the hostile environment of the aortic arch. It is likely that a combination of the arch curvature and hemodynamic forces, combined with the narrowed true lumen, contributed to failure of the trigger-wire tie release mechanism. Consideration of these endovascular salvage maneuvers may benefit interventional specialists who treat such diseases of the aortic arch.
描述一例主动脉弓部开窗型主动脉支架移植物装置故障，由于一系列连续的血管内挽救措施，支架移植物得以展开，否则几乎无法挽回。
一名 47 岁男性，因慢性 B 型主动脉夹层的并发症出现迅速增大的 6.9cm 胸主动脉瘤。计划采用 2 件式、定制的、锥形、开窗胸主动脉内假体（无名动脉扇贝加单颈动脉），在分期左颈动脉至锁骨下旁路后，从无名动脉起源处密封至腹腔干上方。快速心室起搏控制血压有助于近端开窗支架移植物组件的展开，两个开口准确地位于各自分支血管口上方。试图取回鼻锥时，由于将支架移植物与其中央套管连接的单一致性系绳释放失败而受阻。这导致支架移植物完全展开，鼻锥无法从紧邻小开窗远端的一点取回。随后进行了一系列血管内挽救措施，从简单的操作以操纵和球囊扩张移植物到更复杂的尝试，使用套索打破系绳并套住鼻锥。最后，尝试经前向取回鼻锥使装置伸直并释放有问题的系绳，完成手术。
这是一个罕见但值得警惕的例子，说明将内脏移植物技术从腹主动脉转化到主动脉弓部敌对环境中可能存在潜在的陷阱。可能是弓部曲率和血液动力学力的结合，加上真腔狭窄，导致触发线系绳释放机制失败。考虑这些血管内挽救措施可能有益于治疗主动脉弓部疾病的介入专家。
