摘要
目的总结应用主动脉腔内支架置入术治疗StanfordB型主动脉夹层术后早期选择性抗凝处理的经验。方法2006年6月至2011年6月，应用主动脉腔内支架置入术治疗StanfordB型主动脉夹层75例，其中男65例，女10例；年龄22-81岁，平均（59．1±13．5）岁。术前采用CT血管造影对主动脉夹层病变情况进行评估，左锁骨下动脉开口处胸降主动脉直径为22-42mm，平均（30．3±4．0）mm，夹层破口距左锁骨下动脉〉1．5cm29例（均为右椎动脉优势），〈1．5cm46例（左椎动脉优势2例）。术中根据CT血管造影检查结果，对左椎动脉优势且术中需要封闭左锁骨下动脉的患者，先常规行左锁骨下动脉重建术。术后对支架近端完全或部分封闭左锁骨下动脉（无内漏且远端无残余破口）者，支架置入术后第2天开始予阿司匹林100mg／天抗凝，维持3个月。术后早期观察患者有无神经系统疾病的症状或体征；术后3个月行头颅及胸腹部CT，了解支架位置、假腔内血栓形成、主要分支血管血流情况及有无神经系统并发症发生。结果75例患者均成功手术，术中主动脉支架直径26-46mm，平均（34．3±4．0）mm。2例术前评估为左椎动脉优势，术中同期行左锁骨下动脉重建术。术中左锁骨下动脉开口完全或部分封闭58例，完全封闭19例，开口2／3封闭15例，开口1／2封闭24例；其中56例无内漏及残余破口，术后早期进行抗凝治疗，预防椎动脉血栓形成。术后早期死亡2例（2．7％），分别死于肾功能衰竭和夹层破裂，其余患者均成功治愈出院，术后住院时间4-19天，平均（7．9±3．5）天，无脑梗死或截瘫病例。随访6-66个月，1例死于呼吸系统疾病，1例于术后19月再发StanfordA型夹层行升主动脉及主动脉弓置换术，1例于术后4年因支架近端新发夹层再次行腔内支架置入术。随访期未发生脑梗死、截瘫等神经系统并发症。结论对主动脉腔内支架置入术中完全或部分封闭左锁骨下动脉的患者，术后早期抗凝可安全、有效的预防与椎动脉血栓形成相关的神经系统并发症。
Objective To summarize the preliminary experience of early anticoagulant therapy after endovascular stent- graft exclusion for Stanford B type aortic dissection. Methods From June 2006 to June 2011,75 patients[ 65 males, 10 fe- males, mean age （59. 1± 13.5 ） years, range 22 -8 l years ] underwent endovascular stent-graft exclusion for Stanford B type aortie dissection in Shanghai Xinhua Hospital. Computed tomagraphy angiography （CTA） was used to evaluate the lesions of aortic dissection before endovascular stent-graft exclusion. The descending thoracic aortic diameters were 22 mm to 42 mm [ mean（30. 3±4. 0）mm]. The distance from the breakage of dissection to the left vertebral artery（LSA） was longer than 1.5 mm in 29 eases, and shorter than 1.5 em in 46 cases. During the operation, left subclavian artery revascularization was per- formed to patient, whose left vertebral artery was advantage and needs to be fully or partially covered. From the second day after operation, asprin was given to patient, whose left subclavian artery was fully or partially coverd by endovaseular stent-graft （no endoleak and residual distal tear）. Early anticoagulant therapy lasted 3 months. The symptoms or signs about nervous systemwere observed in the early stage of postoperation, and the CTA was examined at postoperative 3 months. Results The opera- tion succeeded in 75 patients. The diameters of aortic stent were 26ram to 46ram [ mean （34. 3 ± 4. 0） mm ]. Left subclavian ar- tery revaseularization was carried out for 2 cases of all patients. The left subclavian artery was fully or partially coverd in 58 pa- tients （fully covered in 19 cases, 2/3 covered in 15 cases, 1/2 covered in 24 cases） , and 56 patints （no endoleak and residual distal tear） were given anticoagulant therapy to prevent vertebral artery thrombosis. 2 patients（2.7% ） died in the early stage after operation. 1 patient died of renal failure, 1 patient died of dissection rupture. The duration of hospitalization was 4 to 19 days[ mean （7.9± 3.5 ） days]. No neurological complications occurred in hospital. The follow-up period was 6 to 66 months. 1 patient died during the follow-up, 1 patient had recurrence of Stanford A type aortic dissection and was cured by ascending a- orta and aortic arch replacement, 1 patient had recurrence of Stanford B type aortic dissection and was cured by second endo- vascular stent-graft exclusion. All patients had no neurological complications, such as cerebral infarction and paraplegia. Con- elusion Early anticoagulant therapy could safely and effectively prevent the neurological complications （such as cerebral in- farction and paraplegia） related to vertebral artery thrombosis for Stanford B type aortic dissection patients whose left subclavian artery was fully or partially coverd by endovascular stent-graft.
出处
《中华胸心血管外科杂志》
CSCD
北大核心
2012年第6期324-327,共4页
Chinese Journal of Thoracic and Cardiovascular Surgery
基金
上海市科学技术委员会科研计划项目（1052nm05500）
关键词
主动脉
动脉瘤
夹层
支架
腔内支架置入术
抗凝治疗
Aorta
Aneurysm, dissection
Stents
Endovascular stent-graft exclusion
Anticoagulation
