Department of Vascular Surgery, The Third Xiangya Hospital of Central South University, Changsha, China; Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT, USA; The Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
Department of Vascular Surgery, The Third Xiangya Hospital of Central South University, Changsha, China.
Eur J Vasc Endovasc Surg. 2015 Oct;50(4):450-9. doi: 10.1016/j.ejvs.2015.04.035. Epub 2015 Jun 19.
This study evaluates the safety and efficacy of pre-placement of a distal bare stent as an adjunct to thoracic endovascular aortic repair (TEVAR) in the setting of complicated acute Stanford type B aortic dissection (cTBAD).
The records of all patients diagnosed with cTBAD at the institution between 2010 and 2013 were reviewed. Indications for the pre-placement of a distal bare stent included symptomatic malperfusion and/or radiological evidence of true lumen collapse. Computed tomography angiography was performed post-operatively to assess aortic remodeling.
148 patients were treated for cTBAD: 113 patients (76.4%) were treated with standard TEVAR and 35 (23.6%) were treated by combined proximal TEVAR with pre-placement of an adjunctive distal bare stent. Primary technical success was 95.9%. The 30 day mortality rate was 4.1% and was not different between groups. The 30 day morbidity included transient renal failure (10.1%), endoleak (7.4%), and paraplegia (2.7%), and was not different between groups. The mean follow up was 10 months (range 2-12 months). No late stent complications were observed; patients with an adjunctive bare stent had less distal re-dissection (0% vs. 15%; p = .01) and fewer endovascular re-interventions (5.7% vs. 20.4%; p = .04). At 1 year, patients treated with TEVAR and an adjunctive distal bare stent had increased true lumen volume (166 vs. 110 mL; p = .022), decreased false lumen volume (60 vs. 90 mL; p = .043), and increased complete false lumen thrombosis in the thoracic (76.5% vs. 29.5%; p < .001) and abdominal (20.6% vs. 3.8%; p = .002) segments.
Combined pre-placement of a distal bare stent as an adjunct to proximal TEVAR to treat cTBAD restricts oversizing of the distal stent graft, reducing the potential for distal true lumen collapse and visceral malperfusion, and improving remodeling of the dissected thoracic aorta. Long-term follow up and prospective studies are needed to assess the overall effectiveness of this treatment strategy.
本研究评估在复杂急性 Stanford 型 B 型主动脉夹层（cTBAD）中，胸主动脉腔内修复术（TEVAR）前放置远端裸支架作为辅助治疗的安全性和有效性。
回顾了 2010 年至 2013 年期间在该机构诊断为 cTBAD 的所有患者的记录。放置远端裸支架的指征包括症状性灌注不良和/或真腔塌陷的影像学证据。术后行计算机断层血管造影术评估主动脉重塑情况。
148 例患者接受了 cTBAD 治疗：113 例（76.4%）接受了标准 TEVAR 治疗，35 例（23.6%）接受了近端 TEVAR 联合辅助远端裸支架治疗。主要技术成功率为 95.9%。30 天死亡率为 4.1%，两组间无差异。30 天发病率包括短暂性肾功能衰竭（10.1%）、内漏（7.4%）和截瘫（2.7%），两组间无差异。平均随访时间为 10 个月（2-12 个月）。未观察到晚期支架并发症；接受辅助裸支架治疗的患者远端再夹层发生率较低（0% vs. 15%；p =.01），血管内再介入治疗较少（5.7% vs. 20.4%；p =.04）。1 年时，接受 TEVAR 和辅助远端裸支架治疗的患者真腔容积增加（166 vs. 110 mL；p =.022），假腔容积减少（60 vs. 90 mL；p =.043），胸主动脉（76.5% vs. 29.5%；p <.001）和腹主动脉（20.6% vs. 3.8%；p =.002）节段完全假腔血栓形成。
近端 TEVAR 前联合放置远端裸支架治疗 cTBAD 可限制远端支架移植物的过度扩张，减少远端真腔塌陷和内脏灌注不良的发生，并改善夹层胸主动脉的重塑。需要长期随访和前瞻性研究来评估这种治疗策略的总体效果。
