南方医科大学学报

南方医科大学学报 ›› 2014, Vol. 34 ›› Issue (05): 747-.

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血管缝合器预缝合技术完全经皮穿刺途径完成主动脉腔内修复术后的股动脉中长期随访结果

叶鹏，陈勇，曾庆乐，何晓峰，李彦豪，赵剑波   

  • 出版日期:2014-05-20 发布日期:2014-05-20

Long-term follow-up of the femoral artery after total percutaneous endovascular aortic
repair with preclose technique using a vascular closure device

  • Online:2014-05-20 Published:2014-05-20

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摘要： 目的探讨采用血管缝合器（vascular closure device, VCD）预缝合技术完全经皮穿刺途径完成主动脉腔内修复术
（endovascular aortic repair, EVAR）的股动脉中长期随访结果。方法自2009年7月~2012年7月，113例主动脉瘤或夹层患者行
EVAR，其中男性106例，女性7例，年龄29~85（59.4±13.5）岁。Stanford B型主动脉夹层60例，胸主动脉瘤3例，肾下型腹主动脉
瘤48例，另有2例同时发现胸及腹主动脉瘤。65例胸主动脉的EVAR术分别缝合1条股动脉，50例腹主动脉的EVAR术分别缝
合2条股动脉，共缝合165条股动脉。均采用VCD（Perclose ProGlide, 美国Abbott）预缝合技术经皮穿刺途径完成EVAR术。术
后采用CT或彩超随访股动脉，评价双侧股动脉缺血情况。结果113名患者成功完成115例次EVAR术（其中2名合并胸腹主动
脉瘤患者分期共行4次EVAR术），共采用347枚VCD修复165条股动脉。使用支架输送器外径包括14 Fr 38例，16 Fr 12例，18
Fr 25例，20 Fr 24例，22 Fr 29例，24 Fr 37例。其中1条股动脉缝合失败，2条缝合后出现即时急性闭塞，1例术后1月出现右股
动静脉瘘，均行外科处理痊愈，缝合成功率为97.6%（161/165）。分组统计2枚VCD缝合成功率，结果显示≤18Fr 组缝合成功率
明显优于≥20Fr组（分别为98.7%和81.1%，P=0.0003）。分组统计前后50%病例的2枚VCD缝合成功率，结果分别为82.9%和
95.2%（P=0.013）。术后随访12~50（26±9）月未发现下肢动脉缺血症状发生，CT或彩超提示未见有明显股动脉狭窄。结论采
用VCD预缝合技术完全经皮穿刺途径完成EVAR术安全可行，对于合适的病例，在度过学习曲线后可作为传统股动脉切开的
备选方法。输送器外鞘外径大于或等于20Fr可能是缝合失败需转外科处理和需2枚以上VCD缝合的影响因素。

Abstract: Objective To evaluate the long-term outcome of the femoral artery following total percutaneous endovascular aortic
repair (EVAR) with preclose technique using a vascular closure device (VCD). Methods From July, 2009 to July, 2012, total
percutaneous EVAR was performed in 113 patients (106 males, 7 females; mean age 59.4±13.5 years) with pre-close technique,
including 60 with Stanford type B aortic dissection, 3 with thoracic aortic aneurysm, and 48 with infra-renal abdominal aortic
aneurysm, and 2 with thoracic and abdominal aortic aneurysms. The Technical success and complication rates were evaluated,
and the outcomes of the femoral artery were followed up with computed tomography or color Doppler ultrasound. Results
The overall technical success rate was 97.6% (161/165) with conversion to open surgery in 4 cases. The size of the sheaths used
were 24Fr (n=37), 22Fr (n=29), 20Fr (n=24), 18Fr (n=25), 16Fr (n=12) and 14 Fr (n=38), and 347 VCDs were used for hemostasis of
165 femoral sites; 147 femoral sites were closed using 2 VCDs. Four access-related adverse events, including femoral
arterial-venous fistula, acute femoral thrombosis, bleeding, and lower extremity ischemia, occurred in 4 (2.4%) of the 165 cases.
In cases using ≤18Fr sheaths, the success rate of closure using 2 VCDs was 98.7%, as compared to 81.1% in cases using larger (≥
20Fr) sheaths (P=0.0003). The success rate of the 82 anterior sites was lower than that of the 82 posterior sites (82.9% vs 95.2%,
P=0.013). No lower extremity ischemia was observed, nor was femoral artery stenosis detected during the follow-up for 26±9
months (12-50 months) in these cases. Conclusion Total percutaneous EVAR with preclose technique using VCD provides a
safe and effective alternative to open femoral surgery. The sheath size can be a predictor of percutaneous access failure to
require conversion to open femoral surgery or using more than 2 devices for suture. Total percutaneous endovascular aortic
repair using VCD with preclose technique is safe and effective, which can be adopted as an alternative technique of surgically
femoral arterial cut-down operation when the surgeon reduce the learning curve.