Quatromoni Jon G, Orlova Ksenia, Foley Paul J
Division of Vascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
Semin Intervent Radiol. 2015 Sep;32(3):289-303. doi: 10.1055/s-0035-1558825.
Advances in endovascular technology, and access to this technology, have significantly changed the field of vascular surgery. Nowhere is this more apparent than in the treatment of abdominal aortic aneurysms (AAAs), in which endovascular aneurysm repair (EVAR) has replaced the traditional open surgical approach in patients with suitable anatomy. However, approximately one-third of patients presenting with AAAs are deemed ineligible for standard EVAR because of anatomic constraints, the majority of which involve the proximal aneurysmal neck. To overcome these challenges, a bevy of endovascular approaches have been developed to either enhance stent graft fixation at the proximal neck or extend the proximal landing zone to allow adequate apposition to the aortic wall and thus aneurysm exclusion. This article is composed of two sections that together address new endovascular approaches for treating aortic aneurysms with difficult proximal neck anatomy. The first section will explore advancements in the traditional EVAR approach for hostile neck anatomy that maximize the use of the native proximal landing zone; the second section will discuss a technique that was developed to extend the native proximal landing zone and maintain perfusion to vital aortic branches using common, off-the-shelf components: the snorkel technique. While the techniques presented differ in terms of approach, the available clinical data, albeit limited, support the notion that they may both have roles in the treatment algorithm for patients with challenging proximal neck anatomy.
血管内技术的进步以及获得该技术的途径，显著改变了血管外科领域。这一点在腹主动脉瘤（AAA）的治疗中最为明显，在适合解剖结构的患者中，血管内动脉瘤修复术（EVAR）已取代了传统的开放手术方法。然而，大约三分之一表现为AAA的患者因解剖学限制被认为不适合标准EVAR，其中大多数涉及近端动脉瘤颈部。为了克服这些挑战，已经开发了一系列血管内方法，以增强近端颈部的支架移植物固定，或扩大近端着陆区，以允许与主动脉壁充分贴合，从而排除动脉瘤。本文由两个部分组成，共同探讨治疗近端颈部解剖结构复杂的主动脉瘤的新血管内方法。第一部分将探讨针对恶劣颈部解剖结构的传统EVAR方法的进展，以最大限度地利用天然近端着陆区；第二部分将讨论一种使用常见的现成组件来扩大天然近端着陆区并维持对重要主动脉分支灌注的技术：通气管技术。虽然所介绍技术的方法不同，但现有的临床数据（尽管有限）支持这样一种观点，即它们在近端颈部解剖结构具有挑战性的患者的治疗算法中可能都有作用。
