髂动脉分支支架拓展应用保留单侧髂内动脉的可行性与安全性
作者:
作者单位:

1.复旦大学附属中山医院厦门医院 血管外科,福建 厦门 361015;2.复旦大学附属中山医院厦门医院 放射科,福建 厦门 361015;3.复旦大学附属中山医院 血管外科, 上海 200030

作者简介:

黄玉龙,复旦大学附属中山医院厦门医院主治医师,主要从事腹主动脉瘤及其分支再通和保留方面的研究。

通信作者:

王利新,Email: wang.lixin@zs-hospital.sh.cn

基金项目:

厦门市科技局医疗卫生指导性基金资助项目(3502Z20214ZD1062);复旦大学附属中山医院厦门医院院级孵化课题基金资助项目(2020ZSXMYS11)。


Feasibility and safety of extended application of iliac branch device for unilateral internal iliac artery preservation
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Affiliation:

1.Department of Vascular Surgery, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, Fujian 361015, China;2.Department of Radiology, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, Fujian 361015, China;3.Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200030, China

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    摘要:

    背景与目的 对于主-髂动脉瘤合并双侧髂内动脉瘤(IIAA)的患者,髂动脉分支支架(IBD)是目前保留单侧髂内动脉(IIA)首选治疗方式,但商业化的IBD因个体化解剖差异而应用受限,难以满足所有患者情况,因此,本研究探讨IBD拓展应用保留单侧IIA的可行性与安全性。方法 回顾性分析2021年4月—2021年6月复旦大学附属中山医院厦门医院行腹主动脉瘤腔内修复(EVAR)中采用不同方法拓展应用G-iliacTM IBD保留单侧IIA的3例主-髂动脉瘤合并双侧IIAA患者临床资料。结果 3例患者均为男性,年龄66~70岁;腹主动脉瘤(AAA)最大直径29~56 mm,保留侧IIA主干有效腔管径及扩张处最大直径分别为10~11 mm和17~20 mm。保留侧髂总动脉(CIA)及髂外动脉(EIA)直径分别为15~28 mm和13~18 mm,栓塞侧IIA主干扩张处最大直径25~37 mm。3例患者均接受EVAR,采用G-iliacTM IBD保留IIAA相对较小的一侧,弹簧圈栓塞IIAA较大一侧,技术成功率100%。保留单侧IIA拓展策略包括:将IIA桥接支架锚定于其主干相对健康管腔处,以及利用球扩式覆膜支架远端后扩放大特性,加强支架与扩张IIA远端密封性。围手术期无心梗、脑梗、出血及死亡等重大并发症发生。1例发生保留侧IIA来源Ib型内漏,球囊扩张后内漏消失;1例出现肠系膜下动脉来源II型内漏,出院前及术后3个月随访无明显改变;1例术后随访期间出现栓塞侧IIA分支来源II型内漏,术后3个月内漏消失。均未出现臀肌跛行症状,无支架断裂、移位、血栓等支架相关并发症。结论 对于合并双侧髂内动脉瘤样扩张的主-髂动脉瘤患者,采用不同策略,拓展IBD应用以保留单侧IIA短期内可行、安全,其中远期效果需进一步随访。

    Abstract:

    Background and Aims For patients with aorto-iliac aneurysm accompanied by bilateral internal iliac artery aneurysms (IIAA), iliac branch device (IBD) is the first choice for preserving unilateral internal iliac artery (IIA) at present time. However, the application of commercialized IBD is limited by the individual anatomical differences, so it difficult to meet the conditions of all patients. Therefore, this study was performed to investigate technical feasibility and safety of unilateral IIA preservation by extended application of IBD.Methods The clinical data of 3 patients with aorto-iliac aneurysm including bilateral IIAA whose unilateral IIA was preserved by extended application of G-iliacTM IBD with different approaches during endovascular abdominal aortic aneurysm repair (EVAR) in Department of Vascular Surgery, Xiamen Branch, Zhongshan Hospital, Fudan University from April 2021 and June 2021 were retrospectively analyzed.Results All the 3 patients were males, aged from 66 to 70 years. The maximum diameter of abdominal aortic aneurysm (AAA) was 29-56 mm, and the valid and maximum diameter of lumen of the preserved IIA was 10-11 mm and 17-20 mm, respectively. The diameter of the common iliac artery (CIA) and external iliac artery (EIA) in the preserved side was 15-28 mm and 13-18 mm, and the maximum diameter of the dilated portion of the embolized IIA was 25-37 mm. In the 3 patients, EVAR was performed, and using the G-iliacTM IBD, the side with relatively small IIAA was preserved, while the other side with relatively large IIAA was embolized. The technical success rate was 100%. The extended strategies for preserving unilateral IIA included using the bridging stents of IIA to anchor the relatively healthy lumens of its main branches, and utilizing the enlargement characteristic after post-dilation of the distal end of the balloon expandable covered stent to strengthen the sealing area between the stent and the distal end of the dilated IIA. There were no major adverse events such as myocardial infarction, cerebral infarction, massive bleeding, or death occurred during perioperative period. A type Ib endoleak from the preserved IIA occurred in one patient, which disappeared after balloon post-dilation, a type II endoleak from the inferior mesenteric artery occurred in one patient, which showed no obvious change before discharge and on 3 months after operation, and a type II endoleak from the embolized IIA occurred during follow-up in one patient, which disappeared on 3 months after operation. No symptoms of buttock claudication and stent-related complications such as stent fracture, migration, and embolization were noted in all patients during follow-up period.Conclusion For patients with aorto-iliac aneurysm accompanied by bilateral IIA aneurysmal dilation, the extended application of IBD with multiple appropriate strategies for preserving unilateral IIA device is safe and feasible during short-term period. The mid- and long-term results require further follow-up observation.

    表 2 3例患者的临床资料Table 2 Clinical date of 3 cases
    表 1 患者CTA数据Table 1 CTA data of patients
    表 3 手术及随访数据Table 3 Surgical variables and follow-up data
    图1 患者1资料 A-C:术前CTA影像;D:G-iliacTM短分支开口定位于左侧EIA及EIA分叉上方;E:分支支架定位、释放;F:分支支架释放后见Ib型内漏;G-H:行分支支架内后扩,后扩后内漏消失;I-K:术后3个月随访CTA影像Fig.1 Data of case 1 A-C: Perioperative CTA images; D: The ostium of the short G-iliacTM branches positioned above the bifurcation of the left side EIA and IIA; E: Positioning and deployment of the IBD; F: Type Ib endoleak after IBD deployment; G-H: Absence of the type Ib endoleak disappeared after balloon post-dilation; I-K: CTA images on 3 months after operation
    图2 患者2资料 A-D:术前CTA影像;E:G-iliacTM短分支开口定位于右侧EIA及IIA分叉上方;F:分支支架定位、释放;G-I:行分支支架内后扩及造影;J-N:术后3个月随访Fig.2 Data of case 2 A-D: Perioperative CTA images; E: The ostium of the short G-iliacTM branches positioned above the bifurcation of the right side EIA and IIA; F: Positioning and deployment of the IBD; G-I: Intra-IBD post-dilation and DSA; J-N: Images on 3 months after operation
    图3 患者3资料 A-C:术前CTA影像;D:G-iliacTM短分支开口定位于左侧EIA和IIA分叉上方;E:分支支架定位、释放;F-G:分支支架开口狭窄,行分支支架内后扩后造影;H-K:术后3个月随访Fig.3 Data of case 3 A-C: Preoperative CTA images; D: The ostium of the short G-iliacTM branches positioned above the bifurcation of the left side EIA and IIA; E: Positioning and deployment of the IBD; F-G: Stenosis in the opening of the IBD, and radiography after post-dilation ; H-K: Images on 3 months after operation
    图4 IIA多枚支架桥接,远端支架锚定于IIA分支,锚定区周围分支栓塞Fig.4 Using multiple bridging stents to anchor the major IIA branches and embolization of branches around thee anchoring area
    图5 IIA桥接支架锚定于主干健康管腔段Fig.5 Using the bridging stent of IIA to anchor the lumen of healthy segment
    图6 利用Lifestream后扩可放大特性,使其远端呈喇叭口样扩张,贴附瘤样扩张管壁Fig.6 Utilizing the enlargement characteristic after post-dilation of the Lifestream stent to induce the flared expansion of its distal end to closely attach the luminal wall of the aneurysmal dilation
    图1 患者1资料 A-C:术前CTA影像;D:G-iliacTM短分支开口定位于左侧EIA及EIA分叉上方;E:分支支架定位、释放;F:分支支架释放后见Ib型内漏;G-H:行分支支架内后扩,后扩后内漏消失;I-K:术后3个月随访CTA影像Fig.1 Data of case 1 A-C: Perioperative CTA images; D: The ostium of the short G-iliacTM branches positioned above the bifurcation of the left side EIA and IIA; E: Positioning and deployment of the IBD; F: Type Ib endoleak after IBD deployment; G-H: Absence of the type Ib endoleak disappeared after balloon post-dilation; I-K: CTA images on 3 months after operation
    图2 患者2资料 A-D:术前CTA影像;E:G-iliacTM短分支开口定位于右侧EIA及IIA分叉上方;F:分支支架定位、释放;G-I:行分支支架内后扩及造影;J-N:术后3个月随访Fig.2 Data of case 2 A-D: Perioperative CTA images; E: The ostium of the short G-iliacTM branches positioned above the bifurcation of the right side EIA and IIA; F: Positioning and deployment of the IBD; G-I: Intra-IBD post-dilation and DSA; J-N: Images on 3 months after operation
    图3 患者3资料 A-C:术前CTA影像;D:G-iliacTM短分支开口定位于左侧EIA和IIA分叉上方;E:分支支架定位、释放;F-G:分支支架开口狭窄,行分支支架内后扩后造影;H-K:术后3个月随访Fig.3 Data of case 3 A-C: Preoperative CTA images; D: The ostium of the short G-iliacTM branches positioned above the bifurcation of the left side EIA and IIA; E: Positioning and deployment of the IBD; F-G: Stenosis in the opening of the IBD, and radiography after post-dilation ; H-K: Images on 3 months after operation
    图4 IIA多枚支架桥接,远端支架锚定于IIA分支,锚定区周围分支栓塞Fig.4 Using multiple bridging stents to anchor the major IIA branches and embolization of branches around thee anchoring area
    图5 IIA桥接支架锚定于主干健康管腔段Fig.5 Using the bridging stent of IIA to anchor the lumen of healthy segment
    图6 利用Lifestream后扩可放大特性,使其远端呈喇叭口样扩张,贴附瘤样扩张管壁Fig.6 Utilizing the enlargement characteristic after post-dilation of the Lifestream stent to induce the flared expansion of its distal end to closely attach the luminal wall of the aneurysmal dilation
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黄玉龙,黄国强,符伟国,王利新,卢伟锋,洪翔,洪诗钗,陈刚,陈艺辉,林越,谢新胜.髂动脉分支支架拓展应用保留单侧髂内动脉的可行性与安全性[J].中国普通外科杂志,2022,31(6):782-791.
DOI:10.7659/j. issn.1005-6947.2022.06.011

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  • 收稿日期:2022-04-17
  • 最后修改日期:2022-05-26
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  • 在线发布日期: 2022-07-11