合并严重冠心病的短锚定区主动脉弓降部疾病的腔内修复
| 作者: |
1罗明尧,
1朱梦依,
1方坤,
1陈祖君,
1吕滨,
1孙晓刚,
1侯志辉,
1欧阳晨曦,
1魏以桢,
1,2舒畅
1 中国医学科学院阜外医院 国家心血管病中心，北京 100037 2 中南大学湘雅二医院 血管外科，湖南 长沙 410011 |
| 通讯: |
舒畅
Email: Changshu01@yahoo.com |
| DOI: | 10.3978/.2017.12.005 |
| 基金: | 北京市科技重大专项（D171100002917004）； 中国医学科学院医学与健康科技创新工程(重大协同创新项目)基金资助项目（2016-I2M-1-016）。 |
摘要
目的：探讨合并严重冠心病，已经接受或近期可能接受冠状动脉旁路移植手术须保留左锁骨下动脉，且近端锚定区又不足的主动脉弓降部疾病患者腔内修复治疗的策略及注意事项。
方法：回顾性分析2016年4月—2016年7月期间阜外医院血管外科中心收治的9例合并严重冠心病、近端锚定区不足的主动脉弓降部疾病患者资料，其中男7例，女2例，平均年龄60（37~76）岁，均行胸主动脉腔内修复术治疗，均需保留左锁骨下动脉，从而保留作为冠脉前降支桥血管最佳来源的左侧乳内动脉。
结果：手术成功率100%，无手术死亡，所有患者左侧乳内动脉均保留成功。术后发生I型内漏1例（1/9），随访3个月后内漏消失；术后4个月因冠状动脉回旋支狭窄行经皮冠状动脉成形术1例（1/9）。所有患者均获得门诊或电话随访，随访时间6（4~7）个月，所有患者临床症状消失或明显减轻，生活质量改善，无随访死亡病例。
结论：对于已经接受左侧乳内动脉-冠脉前降支搭桥或即将接受冠脉搭桥手术的主动脉弓降部疾病患者，在实施胸主动脉腔内修复手术时可采取个性化措施保留左锁骨下动脉，进而保留左乳内动脉，必要时可以采用“烟囱”等技术辅助。
关键词：
主动脉疾病；冠心病；血管成形术；冠状动脉旁路移植术，非体外循环；锁骨下动脉
方法：回顾性分析2016年4月—2016年7月期间阜外医院血管外科中心收治的9例合并严重冠心病、近端锚定区不足的主动脉弓降部疾病患者资料，其中男7例，女2例，平均年龄60（37~76）岁，均行胸主动脉腔内修复术治疗，均需保留左锁骨下动脉，从而保留作为冠脉前降支桥血管最佳来源的左侧乳内动脉。
结果：手术成功率100%，无手术死亡，所有患者左侧乳内动脉均保留成功。术后发生I型内漏1例（1/9），随访3个月后内漏消失；术后4个月因冠状动脉回旋支狭窄行经皮冠状动脉成形术1例（1/9）。所有患者均获得门诊或电话随访，随访时间6（4~7）个月，所有患者临床症状消失或明显减轻，生活质量改善，无随访死亡病例。
结论：对于已经接受左侧乳内动脉-冠脉前降支搭桥或即将接受冠脉搭桥手术的主动脉弓降部疾病患者，在实施胸主动脉腔内修复手术时可采取个性化措施保留左锁骨下动脉，进而保留左乳内动脉，必要时可以采用“烟囱”等技术辅助。
Endovascular repair of proximal descending aortic disease with insufficient proximal landing zone in patients with concomitant severe coronary heart disease
CorrespondingAuthor:SHU Chang Email: Changshu01@yahoo.com
Abstract
Objective: To investigate the strategies and attention points for endovascular repair of proximal descending aortic disease with an insufficient proximal landing zone in patients with concomitant severe coronary heart disease who have undergone or were soon likely to receive coronary artery bypass grafting surgery requiring preservation of the left subclavian artery.
Methods: The clinical data of 9 patients with proximal descending aortic disease, who had concomitant severe coronary heart disease and insufficient proximal landing zone, undergoing thoracic endovascular aortic repair in Vascular Surgery Center of Fuwai Hospital from April 2016 to July 2016 were retrospectively analyzed. Of the patients, 7 cases were male and 2 cases were female, with an average age of 60 (37–76) years. All patients underwent thoracic endovascular aortic repair, with preservation of the left subclavian artery for preserving the left internal mammary artery that was the best choice for bypass of the diseased left anterior descending coronary artery.
Results: The surgical success rate was 100%, no surgical death occurred, and the left subclavian artery was preserved in all patients. Type I endoleak occurred in one patient (11.1%) after operation, which disappeared 3 months later, and one patient (11.1%) underwent percutaneous coronary angioplasty 4 months after operation due to stenosis of the left circumflex coronary artery. All patients received follow-up by outpatient visits or telephone. The clinical symptoms disappeared or were significantly alleviated, the quality of life was improved in all patients and no death occurred during the follow-up period for an average of 6 (4–7) months.
Conclusion: In patients who have undergone coronary artery bypass grafting with left internal mammary artery to the left anterior descending artery, or will undergo coronary artery bypass surgery soon, the left subclavian artery can be preserved by personalized measures during thoracic endovascular aortic repair, and thereby to preserve the left internal mammary artery. Adjunctive techniques such as chimney-stenting can be used when necessary.
Keywords：
Aortic Diseases; Coronary Disease; Angioplasty; Coronary Artery Bypass
Off-Pump; Subclavian Artery
Methods: The clinical data of 9 patients with proximal descending aortic disease, who had concomitant severe coronary heart disease and insufficient proximal landing zone, undergoing thoracic endovascular aortic repair in Vascular Surgery Center of Fuwai Hospital from April 2016 to July 2016 were retrospectively analyzed. Of the patients, 7 cases were male and 2 cases were female, with an average age of 60 (37–76) years. All patients underwent thoracic endovascular aortic repair, with preservation of the left subclavian artery for preserving the left internal mammary artery that was the best choice for bypass of the diseased left anterior descending coronary artery.
Results: The surgical success rate was 100%, no surgical death occurred, and the left subclavian artery was preserved in all patients. Type I endoleak occurred in one patient (11.1%) after operation, which disappeared 3 months later, and one patient (11.1%) underwent percutaneous coronary angioplasty 4 months after operation due to stenosis of the left circumflex coronary artery. All patients received follow-up by outpatient visits or telephone. The clinical symptoms disappeared or were significantly alleviated, the quality of life was improved in all patients and no death occurred during the follow-up period for an average of 6 (4–7) months.
Conclusion: In patients who have undergone coronary artery bypass grafting with left internal mammary artery to the left anterior descending artery, or will undergo coronary artery bypass surgery soon, the left subclavian artery can be preserved by personalized measures during thoracic endovascular aortic repair, and thereby to preserve the left internal mammary artery. Adjunctive techniques such as chimney-stenting can be used when necessary.