Weng Xiang, Zhang Teng, Hu YiLiang, Li XianGui, Zhou Weimin
Department of Vascular Surgery, the Second Affiliated Hospital, Jiangxi Medical College, Nanchang University.
Medicine (Baltimore). 2024 Nov 22;103(47):e40623. doi: 10.1097/MD.0000000000040623.
Stanford type B aortic dissection involving the left subclavian artery (LSA) poses significant clinical challenges. The Castor single-branch stent graft and in situ fenestration are commonly used techniques, but the better endovascular treatment remains debated. This study evaluates the clinical effects of the Castor single-branched stent graft versus in situ fenestration in treating Stanford type B aortic dissection involving the LSA. We selected 75 patients with Stanford type B aortic dissection involving the LSA, admitted to the Second Affiliated Hospital of Nanchang University from January 2018 to May 2022. All patients underwent thoracic endovascular aortic repair; 34 received the Castor single-branched stent graft, while 41 underwent in situ fenestration. Clinical efficacy and perioperative complications were compared. The technical success rate of the Castor single-branch stent graft was significantly higher than that of in situ fenestration (97.06% vs 80.49%, P = .04). The Castor group exhibited significantly better outcomes in operative time (136.45 ± 25.53 min vs 157.08 ± 18.14 min), LSA blood flow recovery time (6.8 ± 2.3 min vs 20.1 ± 9.8 min), blood loss (29.03 ± 9.78 mL vs 35.69 ± 10.77 mL), contrast medium usage (288.71 ± 72.70 mL vs 352.78 ± 81.02 mL), and immediate postoperative endoleaks (1/34 vs 7/41) (P < .05). Stroke incidence (1/34 vs 2/41) and perioperative mortality (0/34 vs 1/41) were similar (P > .05). Hospital stays were comparable (15.71 ± 6.04 days vs 14.22 ± 5.01 days, P = .28). However, the cost of medical supplies (154,168.62 ± 28,288.44 CNY vs 119,589.72 ± 34,199.67 CNY) and total hospital expenses (192,665.88 ± 40,027.99 CNY vs 153,920.47 ± 42,670.87 CNY) were significantly higher in the Castor group (P < .05). The median follow-up time was 9 months (1-60 months). Follow-up showed similar 30-day postoperative mortality (1/41 vs 0/34, P = 1.00), stent patency (33/34 vs 39/41, P = .67), and stent migration rates (0/34 vs 1/41, P = 1.00). However, the endoleak rate was significantly higher in the in situ fenestration group (11/41 vs 1/34, P = .01). Both the Castor single-branch stent graft and the in situ fenestration technique effectively protect and reconstruct the LSA in Stanford type B aortic dissection, with the Castor single-branch stent graft showing higher technical success and fewer complications, indicating better clinical potential.
累及左锁骨下动脉（LSA）的Stanford B型主动脉夹层带来了重大的临床挑战。Castor单分支支架移植物和原位开窗术是常用的技术，但哪种更好的血管内治疗方法仍存在争议。本研究评估了Castor单分支支架移植物与原位开窗术治疗累及LSA的Stanford B型主动脉夹层的临床效果。我们选择了2018年1月至2022年5月在南昌大学第二附属医院住院的75例累及LSA的Stanford B型主动脉夹层患者。所有患者均接受胸主动脉腔内修复术；34例接受Castor单分支支架移植物治疗，41例接受原位开窗术。比较了临床疗效和围手术期并发症。Castor单分支支架移植物的技术成功率显著高于原位开窗术（97.06%对80.49%，P = 0.04）。Castor组在手术时间（136.45 ± 25.53分钟对157.08 ± 18.14分钟）、LSA血流恢复时间（6.8 ± 2.3分钟对20.1 ± 9.8分钟）、失血量（29.03 ± 9.78毫升对35.69 ± 10.77毫升）、造影剂用量（288.71 ± 72.70毫升对352.78 ± 81.02毫升）和术后即刻内漏（1/34对7/41）方面表现出显著更好的结果（P < 0.05）。中风发生率（1/34对2/41）和围手术期死亡率（0/34对1/4）相似（P > 0.05）。住院时间相当（15.71 ± 6.04天对14.22 ± 5.01天，P = 0.28）。然而，Castor组的医疗耗材成本（154,168.62 ± 28,288.44元对119,589.72 ± 34,199.67元）和总住院费用（192,665.88 ± 40,027.99元对153,920.47 ± 42,670.87元）显著更高（P < 0.05）。中位随访时间为9个月（1 - 60个月）。随访显示术后30天死亡率相似（1/41对0/34，P = 1.00）；支架通畅率相似（33/34对39/41，P = 0.67），支架移位率相似（0/ vs 1/41，P = 1.00）。然而，原位开窗术组的内漏率显著更高（11/41对1/34，P = 0.01）。Castor单分支支架移植物和原位开窗术技术均能有效保护和重建累及LSA的Stanford B型主动脉夹层中的LSA，Castor单分支支架移植物显示出更高的技术成功率和更少的并发症，具有更好的临床潜力。
