Department of Radiology, University Hospital of Wales, Cardiff, UK.
Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK.
Asian Cardiovasc Thorac Ann. 2021 Jul;29(6):524-531. doi: 10.1177/02184923211008074. Epub 2021 Apr 4.
Thoracic endovascular aortic repair (TEVAR) has become an accepted treatment for thoracic aortic disease. However, the principal complications relate to coverage of the thoracic aortic wall and deliberate occlusion of aortic branches over a potentially long segment. Complications include risk of stroke, spinal cord ischaemia (SCI) and arterial insufficiency to the left arm (left arm ischaemia (LAI)). This study specifically scrutinised the development of SCI and LAI after TEVAR for interventions for thoracic aortic disease from 1999 to 2020. In particular, those who underwent extra-anatomical bypass (both immediate and late) were compared to the length of thoracic aortic coverage by the stent graft.
Ninety-eight patients underwent TEVAR. The presenting symptoms, pathology, procedural and follow-up data were collected prospectively with particular evidence of stroke, SCI and LAI both immediate onset and after 48 h of graft placement.
Fifty underwent TEVAR for an aneurysm (thoracoabdominal aortic aneurysm), 22 for dissection, 19 for acute transection and 7 for intramural haematoma/pseudoaneurysm of the thoracic aorta. Twenty-nine (30%) required a debranching procedure to increase the proximal landing zone (1 aorto-carotid subclavian bypass, 10 carotid/carotid subclavian bypass and 18 carotid/subclavian bypass). Ten patients (10%) died within 30 days of TEVAR. Twenty-four grafts covered the left subclavian artery origin without a carotid/subclavian bypass. Five required a delayed carotid/subclavian bypass for LAI (4) and SCI (1). Six developed immediate signs of SCI after TEVAR and these 11 (group i) had a mean (SD) length of coverage of the thoracic aorta of 30.2 (10.6) cm compared to 21.5 (11.2) cm (group g) in those who had no LAI or SCI post TEVAR, < 0.05.
In this series, delayed carotid/subclavian bypass may be required for chronic arm ischaemia and less so for SCI. The length of coverage of thoracic aorta during TEVAR is a factor in the development of delayed SCI and LAI occurrence. Carotid subclavian bypass is required for certain patients undergoing TEVAR (particularly if greater than 20 cm of thoracic aorta is covered).
胸主动脉腔内修复术（TEVAR）已成为治疗胸主动脉疾病的一种公认方法。然而，主要并发症与胸主动脉壁的覆盖和主动脉分支的故意闭塞有关，这可能会涉及到很长的一段血管。并发症包括中风、脊髓缺血（SCI）和左臂动脉供血不足（左臂缺血（LAI））的风险。本研究专门研究了 1999 年至 2020 年期间，因胸主动脉疾病而接受 TEVAR 治疗的患者发生 SCI 和 LAI 的情况。特别是，比较了那些接受体外旁路（包括即刻和晚期）的患者与支架移植物覆盖的胸主动脉长度。
98 名患者接受了 TEVAR 治疗。前瞻性地收集了患者的症状、病理、手术过程和随访数据，特别关注了即刻和支架置入后 48 小时内的中风、SCI 和 LAI 等情况。
50 名患者因动脉瘤（胸腹主动脉瘤）、22 名患者因夹层、19 名患者因急性破裂和 7 名患者因胸主动脉壁内血肿/假性动脉瘤而接受 TEVAR 治疗。29 名（30%）患者需要进行去分支手术以增加近端着陆区（1 例主动脉-颈动脉锁骨下旁路，10 例颈动脉-颈动脉锁骨下旁路和 18 例颈动脉-锁骨下旁路）。10 名患者（10%）在 TEVAR 后 30 天内死亡。24 个支架覆盖了左锁骨下动脉起点，没有进行颈动脉-锁骨下旁路。5 名患者因 LAI（4 例）和 SCI（1 例）需要进行延迟颈动脉-锁骨下旁路。6 名患者在 TEVAR 后立即出现 SCI 症状，这 11 名患者（组 i）的胸主动脉覆盖长度平均为 30.2（10.6）cm，而 TEVAR 后无 LAI 或 SCI 的患者（组 g）的覆盖长度为 21.5（11.2）cm，差异有统计学意义（p<0.05）。
在本系列中，慢性手臂缺血可能需要进行延迟的颈动脉-锁骨下旁路，而 SCI 则较少需要。TEVAR 过程中胸主动脉的覆盖长度是延迟发生 SCI 和 LAI 的一个因素。对于某些接受 TEVAR 治疗的患者（特别是如果覆盖的胸主动脉长度大于 20cm），需要进行颈动脉-锁骨下旁路。
