复杂主动脉腔内修复术围手术期严重并发症的预防与处理

Prevention and management of severe perioperative complications after complex endovascular aortic repair

摘要:

随着腔内技术及器械的发展，胸主动脉腔内修复术和腹主动脉腔内修复术的应用已由相对标准化治疗逐步拓展至开窗支架、分支支架、平行支架及医师改装支架等复杂多分支重建。与标准腔内修复术相比，复杂主动脉腔内修复术通常涉及更长范围的主动脉覆盖、更多靶血管重建、更频繁的导丝导管操作及更高的器械依赖性，其围手术期严重并发症谱亦随之改变。除内漏和支架移位等传统并发症外，靶血管丢失或损伤、入路损伤、心脑血管事件、脊髓缺血、主动脉破裂或新发夹层，以及器械故障等，均可显著影响患者的围手术期安全性和远期预后。复杂主动脉腔内修复术的成功不仅取决于手术方案设计和技术实施，更依赖于对并发症的风险识别、预防和及时救援。本文聚焦复杂主动脉腔内修复术围手术期严重并发症，结合近年来指南、文献证据及临床实践，对其发生机制、高危因素、预防策略和处理原则进行综述，强调建立以精准术前评估、规范术中操作、动态围手术期监测及多学科协作为核心的全流程管理体系，以提高复杂主动脉腔内修复术的安全性和临床疗效。

Abstract:

With advances in endovascular techniques and devices, thoracic endovascular aortic repair and endovascular aneurysm repair have evolved from relatively standardized procedures to complex multibranched reconstruction strategies, including fenestrated, branched, parallel-graft, and physician-modified endograft techniques. Compared with standard endovascular repair, complex endovascular aortic repair usually involves longer aortic coverage, incorporation of multiple target vessels, more frequent guidewire and catheter manipulations, and greater device dependence. Accordingly, the spectrum of perioperative severe complications has changed substantially. In addition to conventional complications such as endoleak and stent-graft migration, target-vessel loss or injury, access-related vascular injury, cardiac and cerebrovascular events, spinal cord ischemia, aortic rupture or new-onset dissection, and device-related failure may markedly compromise procedural safety and long-term outcomes. The success of complex endovascular aortic repair depends not only on appropriate procedural planning and technical execution, but also on the ability to identify, prevent, and promptly manage complications. This review focuses on severe perioperative complications associated with complex endovascular aortic repair. Based on recent guidelines, published evidence, and clinical experience, it summarizes the mechanisms, risk factors, preventive strategies, and management principles of major complications. A whole-process management strategy centered on meticulous preoperative assessment, standardized intraoperative manipulation, dynamic perioperative monitoring, and multidisciplinary collaboration is emphasized to improve the safety and clinical effectiveness of complex endovascular aortic repair.