Stanford B型主动脉夹层腔内修复术一段式与两段式对主动脉重塑的影响比较

摘要

目的 比较Stanford B型主动脉夹层腔内修复术一段式与两段式对主动脉重塑的影响.方法 回顾性纳入2012年1月至2013年12月首都医科大学附属北京安贞医院收治B型主动脉夹层患者100例.所有患者均行Stanford B型主动脉夹层腔内修复术治疗,根据手术方式的不同,将患者分为一段式组和二段式组,各50例.一段式组行一段式手术,采用常规手术方式;两段式组行两段式手术,造影后分别测量近端锚定区与远端锚定区主动脉直径,并根据近端锚定区不足选择烟囱技术或血管重建技术.分析比较2组患者术前及术后主动脉形态学及变化.结果 所有患者腔内治疗操作成功率100％.一段式组的平均主动脉覆盖长度明显短于两段式组[(191±14)mm比(261 ±7)mm] (P＜0.01);一段式组的平均锥度明显小于两段式组[1.9(0.0,4.0)mm比9.0(8.0,10.0) mm] (P ＜0.01).术后3个月所有患者支架段血栓化率为88.0％(88/100),一段式组的血栓化率与两段式组比较,差异无统计学意义[92.0％(46/50)比84.0％ (42/50)] (P ＞0.05).2组患者术前与术后的近端锚定区直径、左心房水平主动脉直径、膈肌水平主动脉直径、肾动脉水平主动脉直径差异均无统计学意义(均P ＞0.05).术前两段式组远端锚定区直径、左心房水平真腔直径、膈肌水平真腔直径、肾动脉水平真腔直径和术前肾动脉水平真腔直径/假腔直径比值(R1)均小于一段式组[(11 ±4)mm比(14±4) mm、(11.8±2.6) mm比(13.7 ±3.4)mm、(12 4)mm比(14 ±4)mm、(8.5 ±2.7)mm比(10.8±2.9)mm、(0.7±0.4)比(0.9±0.4)](均P＜0.05),术后2组左心房水平真腔直径、膈肌水平真腔直径、肾动脉水平真腔直径及肾动脉水平真腔直径与假腔直径比值(R2)比较,差异均无统计学意义(均P＞0.05).术后支架段真腔均明显扩张,两段式组左心房水平、膈肌水平、肾动脉水平真腔扩张率及R(R2/R1)明显高于一段式组[(2.0±0.5)％比(1.7±0.4)％、(1.7±0.5)％比(1.4±0.6)％、(1.50±0.50)％比(1.10±0.20)％、(1.9±0.8)比(1.3±0.7)](均P ＜0.05).手术相关并发症方面,两段式组出现短暂截瘫1例,术后及时行脑脊液引流后症状减轻;一段式组术后出现近端少量内漏1例,未予特殊处置,随访过程中内漏减轻,继续随访观察.围术期及术后3个月内无死亡及灌注不良综合征发生.结论 Stanford B型主动脉夹层腔内修复术的一段式与两段式治疗均能使支架段真腔扩张及假腔血栓化,对于术前降主动脉真腔明显受压及腹主动脉真腔纤细的患者,两段式近期能获得更好的支架段真腔扩张率及支架以远腹主动脉重塑效果.%Objective To analyze the effects of endovascular repair for Stanford B aortic dissection with one-stent graft implantation and two-stent graft implantation on aortic remodeling.Methods Totally 100 patients with Stanford B aortic dissection who had endovascular repair from January 2012 to December 2013 in Beijing Anzhen Hospital,Capital Medical University had one-stent graft implantation (one-stent group,50 cases) and two-stent graft implantation (two-stent group,50 cases).The aortic diameter was measured at proximal landing zone and distal landing zone,the application of chimney technique or vascular reconstruction technique was base on the condition of proximal landing zone.Aortic morphological changes were analyzed before and after operation.Results All patients were successfully operated.The mean length of aortic coverage in one-stent group was significantly shorter than that in two-stent group[(191 ± 14) mm vs (261 ±7) mm] (P ＜0.01).The mean cone angle of holder in one-stent group was significantly less than that in two-stent group [1.9 (0.0,4.0) mm vs 9.0 (8.0,10.0) mm] (P ＜ 0.01).The stent thrombus 3 month after operation was 88.0％ (88/100) in all patients;there was no significant difference between one-stent group and two-stent group [92.0％ (46/50) vs 84.0％ (42/50)] (P ＞ 0.05).Aortic diameters at proximal landing zone,left atrial horizontal,diaphragm horizontal and renal artery horizontal had no significant differences between groups(P ＞ 0.05).The aortic diameter at distal landing zone,aortic true lumen diameters at left atrial horizontal,diaphragm horizontal,renal artery horizontal and aortic true lumen diameter/false lumen diameter rate(R1) at renal artery horizontal in two-stent group were significantly less than those in one-stent group before treatment[(11 ±4) mm vs (14 ± 4) mm,(11.8 ± 2.6) mm vs (13.7 ± 3.4)mm,(12±4)mmvs (14±4)mm,(8.5±2.7)mmvs (10.8±2.9)mm,(0.7 ±0.4) vs (0.9±0.4)] (P ＜ 0.05);aortic true lumen diameters and aortic true lumen diameter/false lumen diameter rate (R2) had no significant differences between groups after operation (P ＞ 0.05).Dilation rates of aortic true lumen at left atrial horizontal,diaphragm horizontal,renal artery horizontal and the value of R2/R1 in two-stent group were significantly higher than those in one-stent group [(2.0 ± 0.5) ％ vs (1.7 ± 0.4) ％,(1.7 ± 0.5) ％ vs (1.4 ± 0.6) ％,(1.50 ± 0.50) ％ vs (1.10 ± 0.20) ％,(1.9 ± 0.8) vs (1.3 ± 0.7)] (P ＜ 0.05).Two-stent group had 1 case of transient paraplegia and the symptom was alleviated after cerebrospinal fluid drainage.One-stent group had 1 case of mild proximal inner leakage.There were no death and malperfusion complications during 3 months after operation.Conclusions Both endovascular repair for Stanford B aortic dissection with one-stent and two-stent implantation are effective.Two-stent implantation is good for aortic true lumen dilation in patients with tenuity of aortic artery.