TEVAR and covering the celiac artery. Is it safe or not?
TEVAR and covering the celiac artery. Is it safe or not?
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TEVAR 并覆盖腹腔动脉。
DOI：
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发表时间：
2010
期刊：
影响因子：
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通讯作者：
M. Delle
中科院分区：
文献类型：
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作者：
M. Falkenberg;L. Lönn;T. Schroeder;M. Delle
胸主动脉腔内修复术(TEVAR)是胸降主动脉瘤(TAA)的首选治疗方法。然而，并不是所有的TAA患者都能用血管内技术治疗。近端和/或远端封闭区不足是这些患者进行开放手术的最常见原因。如果腹腔轴上方的远端封闭区太短，有几种血管内治疗方法可供选择：TEVAR和开放旁路至腹膜动脉的混合手术，定制的带瓣或开窗的腹膜动脉支架移植物，或故意覆盖腹膜动脉。在后一种情况下，向上消化道提供足够的侧支供应是至关重要的。在慢性腹膜狭窄或闭塞的患者中，连接腹膜动脉和肠系膜上动脉的侧支动脉具有很好的特征。这些侧支通路是否也足以导致医源性的腹腔动脉突然闭合？通过对肠系膜上动脉进行术前血管造影术，并暂时闭塞腹腔动脉，可以提前测试两条血管之间的侧支容量。大型胸腔内支架移植物远端的准确定位可能具有挑战性，需要特殊的考虑和技术。文献中的大多数病例系列都支持有意识的腹部遮盖的有效性和安全性。然而，也有可能与该手术相关的缺血性前肠并发症的报道。综上所述，在大多数患者中，似乎只要事先证明了足够的侧支功能，就可以安全地进行有意的腹腔覆盖。
Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for descending thoracic aortic aneurysms (TAA). However, not all patients with TAA can be treated with the endovascular technique. Insufficient proximal and/or distal sealing zone is the most common reason for open surgery in these patients. If the distal sealing zone above the celiac axis is too short, several endovascular alternatives are possible; hybrid procedures with TEVAR and open by-pass to the celiac artery, custom made stent-grafts with scallop or fenestration for the celiac artery, or intentional coverage of the celiac artery. In the latter case, adequate collateral supply to the upper gastrointestinal tract is crucial. Collateral arteries joining the celiac and the superior mesenteric arteries are well characterized in patients with chronic celiac stenosis or occlusion. Are these collateral pathways sufficient also for sudden iatrogenic closure of the celiac artery? By performing a preoperative angiography of the superior mesenteric artery with temporary balloon occlusion of the celiac artery, collateral capacity between the two vessels can be tested in advance. Exact positioning of the distal end of a large thoracic stent-graft can be challenging and require special considerations and techniques. Most case series in the literature support the efficacy and the safety of intentional celiac covering. However, there are also reports of ischemic foregut complications that could be associated to the procedure. Taken together, in the large majority of patients, it appears that intentional celiac coverage can be done safely provided that sufficient collateral function have been demonstrated in advance.