【作者】 王晓栋；

【导师】 张鸿坤；

【作者基本信息】 浙江大学 ， 临床医学（专业学位）， 2017， 博士

【摘要】 研究背景随着血管腔内技术的快速发展和进步,目前胸主动脉腔内修复术(Thoracic Endovascular Aortic Repair,TEVAR)已逐渐成为治疗降主动脉疾病的一线治疗方式,但也逐渐出现了不少新的挑战,其中之一就是主动脉弓上分支的保留问题。约40%患者的降主动脉原发病变靠近左锁骨下动脉,此时行TEVAR治疗就需要覆盖左锁骨下动脉。覆盖左锁骨下动脉会带来额外的风险,包括脑缺血(如脑梗塞、短暂性脑缺血发作、可逆性缺血性神经功能障碍等)、脊髓缺血症状(如截瘫)和左上肢缺血症状等。但由于不同研究的研究人群和涵盖病种不同,不同作者所报道的结果也不相同。对于血管重建技术在降主动脉疾病TEVAR术中覆盖左锁骨下动脉患者中的作用评价,主要基于两个要素:重建获益和重建风险。现有研究结果中的血管重建技术基本上以颈动脉一左锁骨下动脉旁路、左锁骨下动脉移植术等外科血管重建技术为主。而对于以烟囱支架技术、体外开窗技术、体内开窗技术等为代表的腔内重建技术在TEVAR术中覆盖左锁骨下动脉后重建中的作用及不同腔内重建技术之间的比较均无明确阐述。研究目的1.观察并分析降主动脉疾病腔内修复术中左锁骨下动脉覆盖及覆盖后重建对临床结果的影响。2.观察并分析不同腔内重建技术在降主动脉疾病腔内修复术中的应用及临床结果。研究方法1患者资料本回顾性研究选取2014年12月至2017年6月期间,连续在我院中心诊断为降主动脉疾病并接受TEVAR治疗的患者资料。腔内重建技术研究则选择2014年12月至2017年6月期间,连续在我院中心诊断为降主动脉疾病并接受TEVAR及左锁骨下动脉腔内血管重建治疗的患者资料。2影像学诊断及测量主要通过全主动脉计算机断层扫描三维血管成像(Computed tomography angiography,CTA)来确诊,并通过CTA检查评估原发疾病、降主动脉病变近端锚定区直径,双侧椎动脉直径、主动脉最大直径等。3治疗方式内科治疗:所有患者入院后均接受积极内科治疗,包括绝对卧床、控制血压(收缩压控制在90-110mmHg),控制心率(60次/分左右),镇痛、镇静、保持大小便通畅等对症处理。胸主动脉腔内修复术(TEVAR手术):主动脉覆膜支架直径的选择根据左侧锁骨下动脉开口附近胸主动脉正常段直径,一般在其基础上增加10～20%。左锁骨下动脉血管重建术:包括外科重建技术(左颈总动脉一左锁骨下动脉旁路术)和腔内重建技术(烟囱技术、体外开窗技术、体内开窗技术)。4随访术后1月、6月、12月及每年随访患者临床情况,并进行全主动脉CTA检查。5统计学处理采用SPSS21.0(IBM,美国)统计软件进行统计分析,其中计数资料以频数或百分比表示,连续性计变量以均数±标准差表示。P<0.05认为差异有统计学意义。结果1 一般情况及术前资料总共262例患者,男性193例,女性69例,其中血管保留组156例,单纯覆盖组27例,覆盖重建组79例。血管保留组的平均年龄(59.92±12.45 vs 55.22±13.80)大于覆盖重建组,而覆盖重建组男性比例(84.81%vs 68.59%vs 70.37%)大于其他两组。覆盖重建组术前左椎动脉直径大于右椎动脉直径(3.80±0.89 vs 3.03±0.69)。P<0.05有统计学意义。2手术及术后30天结果总共262例患者接受TEVAR术,技术成功率100%;79例患者接受血管重建术,技术成功率93.67%。术后30天内,共发现脑缺血事件4例,脊髓缺血1例,上肢缺血2例,其它并发症12例;再次相关手术7例,死亡3例。覆盖重建组的手术时间(161.32±59.31vs71.55±28.83vs76.67±29.54)大于血管保留组和单纯覆盖组。血管保留组的主动脉支架直径(33.00±3.46vs35.04±3.86 vs 34.43±3.60)和长度(171.38±31.52 vs 188.04±18.75 vs 184.29±31.48)均小于单纯覆盖组和血管保留组。单纯覆盖组术后住院时间(7.93±6.4 vs 5.66±1.9 vs 6.00±2.05)明显长于血管保留组和覆盖重建组。P<0.05有统计学意义。单纯覆盖组的脑缺血事件发生率(11.11%vs0%vs 1.26%)和术后30天内总不良事件发生率(29.63%vs 5.13%vs 7.59%)高于血管保留组和覆盖重建组。P<0.05有统计学意义。3随访结果平均随访534.45天(48～973天),术后30天后再次相关手术8例,死亡21例,三组间比较均无明显差异。单纯覆盖组术后右椎动脉直径(4.34±0.56 vs 3.07±0.76 vs 2.96±0.64)大于血管保留组和覆盖重建组。单纯覆盖组术后右椎动脉直径大于术前右椎动脉直径(4.34±0.56 vs 3.62±0.61)。P<0.05 有统计学意义。4生存分析及影响因素1年(365天)累积生存率:血管保留组94.87%,单纯覆盖组92.60%,覆盖重建组96.20%;2年(730天)累积生存率:血管保留组90.38%,单纯覆盖组88.89%,覆盖重建组93.67%。三组间没有统计学差异。影响术后总生存率的因素有:年龄(大于65岁)。术后30天内脑缺血事件发生的影响因素:脑血管疾病史和覆盖左锁骨下动脉。5腔内重建研究的一般资料总共76例患者,男性65例,女性11例,其中烟囱支架组39例,体外开窗组10例,体内开窗组27例。体外开窗组术前左椎动脉直径(2.88±1.25 vs 3.96±0.82 vs 3.82±0.54)和左椎动脉优势比例(40.00%vs80.05%vs 85.19%)小于烟囱支架组和体内开窗组。P<0.05有统计学意义。6腔内重建手术及30天结果总共76例患者接受TEVAR术及腔内血管重建,总体技术成功率93.42%,其中烟囱支架组技术成功率92.31%,体外开窗组技术成功率100%,体内开窗组技术成功率92.59%。术后30天内,共发现并发症6例;再次相关手术2例,无死亡。烟囱支架组的平均手术时间(130.26±41.74vs 199.30±74.87vs 183.59±49.23)小于体外开窗组和体内开窗组,但术中球囊后扩比例(2.56%vs 70.00%vs55.56%)小于体外开窗组和体内开窗组。体内开窗组术后球囊预扩比例(92.59%vs 0%vs 10%)大于烟囱支架组和体外开窗组。体内开窗组的术后住院时间(8.10±2.92 vs 5.56±1.29)大于烟囱支架组。P<0.05有统计学意义。7腔内重建研究临床随访、生存分析及影响因素平均随访412.86天(48～966天),术后30天后再次相关手术4例,死亡5例,发现内漏5例,三组间比较均无明显差异。2年(730天)累积生存率:烟囱支架组92.20%,体外开窗组90.00%,体内开窗组95.70%。术后总生存时间的影响因素为:脑血管疾病史。结论1、在降主动脉疾病患者TEVAR术中覆盖左锁骨下动脉会增加脑缺血事件和上肢缺血事件的发生率,延长患者术后住院时间,但不会增加脊髓缺血事件的发生率。2、降主动脉疾病患者TEVAR术中覆盖左锁骨下动脉会导致术后右椎动脉直径的增加。3、对于在TEVAR术中需要覆盖左锁骨下动脉的降主动脉疾病患者进行血管重建会增加手术时间,但能降低术后30天的脑缺血事件和术后30天内不良事件发生率。4、在降主动脉疾病TEVAR治疗中覆盖左锁骨下动脉与血管重建并不直接影响患者的术后总生存时间。影响术后总生存时间的因素有:年龄>65岁;而影响术后30天脑缺血事件发生的因素有:脑血管疾病史和术中覆盖左锁骨下动脉。5、常规使用腔内技术进行TEVAR术中左锁骨下动脉覆盖后重建具有良好的技术成功率和安全性,且不受急诊/限期手术的影响。6、不同腔内技术在TEVAR术中左锁骨下动脉覆盖后重建中有着各自的优缺点,选择不同的腔内技术进行重建并不影响患者的术后总生存时间。更多还原

【Abstract】 BackgroundWith the rapid development and progress of endovascular technology,thoracic Endovascular Aortic Repair(TEVAR)has gradually become a first-line treatment for the descending thoracic aortic disease(DTAD),but there have been many new challenges,one of which is the branch reservation of the aortic arch.The primary lesions of approximately 40%of patients with DTAD are very close to the left subclavian artery,then the left subclavian artery has to be covered to complete the TEVAR.Covering the left subclavian artery will bring additional risks,including cerebral ischemia(such as cerebral infarction,transient ischemic attack,reversible ischemic neurological dysfunction,etc.),spinal cord ischemic(such as paraplegia)and left Upper limb ischemia.However,the results reported by different authors are not the same due to the different research groups and different diagnosis of the disease.The role of revascularization for the left subclavian artery coverage during TEVAR is mainly based on two factors:benefit and risk.The current results of the revascularization study are basically in the area of open surgical technology,including carotid artery-left subclavian artery bypass,left subclavian artery transplantation and so on.The role of endovascular revascularization technology,such as the chimney stent technology/in vitro fenestration technology/in vivo fenestration technology were not clearly stated,as the same as the difference between the different endovascular revascularization technologies.Objectives1 To observe and analyze the effect of the left subclavian artery coverage and reconstruction on the clinical outcome during the TEVAR of DTAD.2 To observe and analyze the application and clinical results of different envascular reconstruction techniques in TEVAR of DTAD.MethodThis retrospective study selected patients with DTAD receiving TEVAR from December 2014 to June 2017,diagnosis of the DTAD depends on the computed tomography angiography(CTA),The primary lesion location,the proximal aortic diameter of descending thoracic aortic lesions,the diameters of bilateral vertebral artery,the aortic maximum diameter were also recorded from the CTA images.All patients received conservative treatments and TEVAR treatment,with or without left subclavian artery revascularization.Follow-up with CT scan was conducted one month,6 months,12 months,and yearly after TEVAR.Statistical analysis was conducted using SPSS 21.0(IBM,USA)software.Results General characteristics262 patients with DTAD were involved in the retrospective study,including 193 males and 69 females.There were 156 patients in the uncovered group(UCD group),27 patients in covered without revascularization group(COR group),79 patients in covered with revascularization group(CWR group).The mean age in the UCD group(59.92 ±12.45 vs 55.82)were significantly bigger than that of the CWR group.The male percentage(84.81%vs 68.59%vs 70.37%)in the CWR group were significantly bigger than that in the other two groups.The mean diameter of the left vertebral artery(3.80 ±0.89 vs 3.03 ± 0.69)in CWR group were significantly bigger than the mean diameter in the right vertebral artery of the CWR group.P values of the above were all less than 0.05 with statistical significance.Treatment and early resultsAll the 262 patients received TEVAR,the technical success rate is 100%;79 patients received left subclavian artery revascularization,the technical success rate is 93.67%.There were 19 major complications,7 re-operations and 3 deaths within 30 days after TEVAR treatment.The mean operation time(161.32±59.31 vs 71.55±28.83 vs 76.67±29.54)of CWR group were bigger than that in the other two groups.The diameter(33.00±3.46 vs 35.04±3.86 vs 34.43±3.60)and length(171.38±31.52 vs 188.04±18.75 vs 184.29±31.48)of the stent-graft in the UCD group were smaller than that of the other two groups.The postoperative hospital stay(7.93±6.4 vs 5.66±1.9 vs 6.00±2.05)of the COR group were bigger than that in the other groups.The incidence of cerebral ischemic events(11.11%vs 0%vs 1.26%)and the total events(major complications + death)(29.63%vs 5.13%vs 7.59%)in the COR group were bigger than that of the other two groups.P values of the above were all less than 0.05 with statistical significance.Follow-up resultsThe mean follow-up time was 534.45 days with extent of 48 to 973 days.There were another 8 re-operations and 21 deaths during the follow-up.There was no significant difference between three groups.The mean post-operative diameter of right vertebral artery(4.34±0.56 vs 3.07±0.76 vs 2.96±0.64)in the COR group were bigger than that of the other two groups.The mean post-operative diameter of right vertebral artery(4.34±0.56 vs 3.62±0.61)in the COR group were bigger than the mean pre-operative diameter of right vertebral artery in the COR group.P values of the above were all less than 0.05 with statistical significance.Survival analysisThe 1-year overall cumulative survival rate was 94.87%in UCD group,92.60%in COR group and 96.20%in CWR group.2-year overall cumulative survival rate was 90.38%in UCD group,88.89%in COR group and 93.67%in CWR group.There was no significant difference between three groups.The risk factor influencing overall survival was:age(older than 65 years).The risk factors influencing cerebral ischemic events within 30 days after TEVAR treatment were:the history of cerebrovascular disease and coverage of left subclavian artery.General characteristics of endovascular revascularization research76 patients with DTADwereinvolved in the retrospective study,including 65 males and 11 females.There were39 patients in thechimney stent group,lOpatients in the in vitro fenestrationgroup,27patients in vivo fenestration group.The pre-operative diameter of left vertebral artery(2.88±1.25 vs 3.96±0.82 vs 3.82±0.54)and the percentage of left vertebral artery dominance(40.00%vs 80.05%vs 85.19%)in the in vitro fenestrationgroup were smaller than that of the other two groups.P values of the above were all less than 0.05 with statistical significance.Operations and early results of endovascular revascularizationAll the 76 patients received TEVAR with left subclavian artery revascularization,the total technical success rate is 93.42%.The technical success rateis 92.31%in the chimney stent group,100%in the in vitro fenestration group,92.59%in the vivo fenestration group.There were 6 major complications,2 re-operations and no deaths within 30 days after TEVAR treatment.The mean operation time(130.26±41.74 vs 199.30±74.87 vs 183.59±49.23)in the chimney stent group were bigger than that in the other groups,while the percentage of post-dilation(2.56%vs 70.00%vs 55.56%)in the chimney stent group were smaller than the other two groups.The percentage of pre-dilation(92.59%vs 0%vs 10%)in the vivo fenestration group were bigger than that in the other groups.The postoperative hospital stay(8.10±2.92 vs 5.56±1.29)in the the vivo fenestration group were bigger than that of the chimney stent group.P values of the above were all less than 0.05 with statistical significance.Follow-up results of endovascular revascularization researchThe mean follow-up time was 412.86 days with extent of 48 to 966 days.There were another 4 re-operations,5 deaths and 5 endoleak during the follow-up.There was no significant difference between three groups.Survival analysis of endovascular revascularization researchThe 2-year overall cumulative survival rate was 92.20%in chimney stent group,90.00%in the in vitro fenestration group and 95.70%in the vivo fenestration group.Conclusion1.The coverage of left subclavian artery during the TEVAR for the patients with DTAD will increase the incidence of cerebral ischemia events and upper limb ischemic events,and also extend the hospital stay after surgery.But it will not increase the incidence of spinal cord ischemic events.2.The coverage of left subclavian artery during the TEVAR for the patients with DTAD will increase the postoperative diameter of right vertebral artery.3.For patients with DTAD who need to cover the left subclavian artery during TEVAR,revascularization will significantly prolong the operation time,but it can reduce postoperative incidence of cerebral ischemic events and adverse events rate within the 30 day of the TEVAR.4.Both the coverage and the revascularization of the left subclavian artery do not affect the overall survival time after surgery.The risk factor that affect the overall survival time was:age>65 years;and the risk factors influencing cerebral ischemic events within 30 days after TEVAR treatment were:the history of cerebrovascular disease and coverage of left subclavian artery.5.Routine use of endovascularrevascularization techniques for TEVAR surgery after left subclavian artery coverage is safe and has a good technical,and will not affected by emergent/urgent surgery.6.Different endovascular revascularization techniques have their own advantages and disadvantages,the choice of different endovascular techniques for the revascularization does not affect the overall survival time of patients after TEVAR surgery.更多还原