Shijo Takayuki, Kuratani Toru, Torikai Kei, Shimamura Kazuo, Sakamoto Tomohiko, Kudo Tomoaki, Masada Kenta, Takahara Mitsuyoshi, Sawa Yoshiki
Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
Eur J Cardiothorac Surg. 2016 Aug;50(2):257-63. doi: 10.1093/ejcts/ezw020. Epub 2016 Feb 4.
In recent years, supra-aortic rerouting and thoracic endovascular aortic repair (TEVAR) for treating aortic arch pathology have emerged as a less invasive option for high-risk patients. This study aimed to assess our strategy for preventing stroke and improving late outcomes after supra-aortic rerouting and TEVAR.
Between July 2008 and July 2015, we performed 280 cases of TEVAR for arch pathologies, using manufactured stent grafts. This study reviewed 101 patients who underwent supra-aortic rerouting and TEVAR for degenerative distal arch aneurysms (80 men, mean age 73.1 years, Zone 1/Zone 2 = 48/53). Since 2011, we have routinely used the brain protection method, which comprises blocking native forward flow from the left common carotid artery (LCA) and left subclavian artery (LSA) for zone 1 cases and the LSA for zone 2 cases before TEVAR.
The mean operation time was 178 ± 65 min. The stroke and 30-day death rates were 3 and 1%, respectively. Before the brain protection method was introduced, the perioperative risk factor for stroke was atheroma Grade ≥III (P = 0.035). Proximal landing zone (P = 0.58) and LSA sacrifice (P = 1.00) were not risk factors for stroke. No strokes occurred after using the brain protection method (before protection: 6% and after protection: 0%). Regarding late results, the rate of freedom from aorta-related death at 1 and 4 years was 97 and 95%, respectively. The rate of freedom from aortic events at 1 and 4 years was 91 and 86%, respectively. During follow-up, no type Ia endoleak developed and one type A dissection was observed.
Our strategy for supra-aortic rerouting and TEVAR showed satisfactory early and late results. The chief risk factor for perioperative stroke was atheroma, and blocking native forward flow from the LCA and the LSA prior to the TEVAR procedure helped prevent stroke.
近年来，用于治疗主动脉弓病变的主动脉弓上血管改道和胸主动脉腔内修复术（TEVAR）已成为高危患者侵入性较小的选择。本研究旨在评估我们预防主动脉弓上血管改道和TEVAR术后中风及改善远期预后的策略。
2008年7月至2015年7月期间，我们使用定制的覆膜支架对280例主动脉弓病变患者实施了TEVAR。本研究回顾了101例行主动脉弓上血管改道和TEVAR治疗退行性远端主动脉弓动脉瘤的患者（80例男性，平均年龄73.1岁，1区/2区=48/53）。自2011年以来，我们常规采用脑保护方法，即对于1区病例，在TEVAR前阻断来自左颈总动脉（LCA）和左锁骨下动脉（LSA）的正向血流，对于2区病例，阻断LSA的正向血流。
平均手术时间为178±65分钟。中风率和30天死亡率分别为3%和1%。在引入脑保护方法之前，围手术期中风的危险因素是动脉粥样硬化分级≥III级（P=0.035）。近端锚定区（P=0.58）和牺牲LSA（P=1.00）不是中风的危险因素。采用脑保护方法后未发生中风（保护前：6%，保护后：0%）。关于远期结果，1年和4年时主动脉相关死亡的无事件生存率分别为97%和95%。1年和4年时主动脉事件的无事件生存率分别为91%和86%。随访期间，未发生Ia型内漏，观察到1例A型夹层。
我们的主动脉弓上血管改道和TEVAR策略显示出令人满意的早期和远期结果。围手术期中风的主要危险因素是动脉粥样硬化，在TEVAR手术前阻断LCA和LSA的正向血流有助于预防中风。
