李召水 牛兆倬 毕晓磊 孙展发 黄强 池一凡

[摘要] 目的 探讨腔内隔绝术治疗Standford B型夹层或动脉瘤直接封堵左锁骨下动脉（LSA）而不进行血运重建的安全性。方法 回顾性分析主动脉夹层腔内隔绝手术（TEVAR）病人156例的临床资料，其中84例完全封堵了LSA，72例未封堵LSA。随访1～7年，比较两组病人术后上肢缺血、脊髓缺血、卒中、死亡以及是否需要行血运重建等指標差异。结果 手术后封堵组与未封堵组上肢持续缺血发生率、椎动脉窃血发生率、脑卒中发生率、再次血运重建率及病死率比较，差异均无统计学意义（P>0.05）。结论 对于需要行TEVAR且颈动脉、椎基底动脉及Wills环均正常病人，当近端胸主动脉病变与LSA距离<15 mm时，为获得足够安全锚定区而封堵LSA是安全可行的。

[关键词] 动脉瘤，夹层;腔内修复术;锁骨下动脉;治疗结果

[中图分类号] R543.16  [文献标志码] A  [文章编号] 2096-5532（2020）02-0217-04

doi：10.11712/jms.2096-5532.2020.56.026 [开放科学（资源服务）标识码（OSID）]

[网络出版] http：//kns.cnki.net/kcms/detail/37.1517.R.20200303.1348.001.html;2020-03-04 12：28：01

[ABSTRACT] Objective To investigate the safety of simultaneous occlusion of the left subclavian artery （LSA） without revascularization during thoracic endovascular aortic repair （TEVAR） for the treatment of Stanford type B dissection or aneurysm. Methods A retrospective analysis was performed for the clinical data of 156 patients who underwent TEVAR for aortic dissection， and among these patients， 84 underwent complete occlusion of the LSA and 72 did not receive such occlusion. The patients were followed up for 1-7 years， and the two groups were compared in terms of upper limb ischemia， spinal cord ischemia， stroke， death， and the need for revascularization after surgery.  Results There were no significant differences in the incidence rates of persistent upper limb ischemia， vertebral artery steal， and stroke， the rate of revascularization， and mortality rate between the two groups （P>0.05）.  Conclusion For patients who need TEVAR and have normal carotid artery， vertebrobasilar artery， and Wills ring， when the distance between proximal thoracic aortic lesion and the LSA is less than 15 mm， it is safe and feasible to occlude the LSA in order to obtain a sufficient safe anchoring area.

[KEY WORDS] aneurysm， dissecting; endovascular repair; subclavian artery; treatment outcome

主动脉夹层及主动脉瘤严重威胁病人的生命安全，突发主动脉夹层通常病情凶险、进展较快、病死率较高，是心外科最严重的急症之一[1]，病人24 h病死率可达到50%以上[2]。主动脉瘤一旦发生破裂将带来灾难性后果[3]。因此，及时有效的外科干预对治疗主动脉夹层及主动脉瘤并减少死亡率尤为重要[4-5]。随着医学科技及治疗手段的发展，腔内隔绝术（TEVAR）已成为治疗主动脉夹层及主动脉瘤尤其是Standford B型夹层及胸降主动脉瘤的重要手段[6-10]。对于B型夹层破口或动脉瘤病变近端距左锁骨下动脉（LSA）小于15 mm的病人，为了获得足够锚定区，通常需要封堵LSA，但封堵LSA的安全性仍未得到准确的结论[11]。为探……