腹主動脈瘤微創治療新趨勢

New Era of Mini-invasive Treatment of Abdominal Aortic Aneurysm

繼Parodi等專家於1990年初首次報導主動脈瘤內套膜支架治療動脈瘤技術後，相較於傳統手術，此項新興的微創手術已被視為較不具侵襲性另一種治療選擇。而且其初步成果令人鼓舞且大被看好。兩個近期大型隨機臨床試驗(dutch randomisedendovascular aneurysmmanagement,DREAM)及the EndovascularAneurysmRepair Trial-1(EVAR-1))顯示相較於傳統手術，接受內套膜支架治療病人30天內死亡率，有令人印象深刻地改善(由4.6-4.7%下降至1.2-1.7%)，且對於高風險病患，此微創手術具有莫大好處。國內內套膜支架治療發展起始於1999年8月2日台北榮總成功完成首例的腹主動脈瘤治療，接著91年陸續地6例成功的臨床實驗。至94年7月法規通過內套膜支架治療法為治療腹主動脈瘤的常規手術，95年10月修正通過治療胸主動脈瘤為常規手術。至今本院心臟血管外科已累績七十四例連續成功的內套膜支架治療胸、腹主動脈瘤的臨床經驗。無論是病例數或手術經驗皆居於台灣各醫學中心的領先地位。根據這些初期的臨床經驗也驗證了血管腔內內套膜支架手術是老年及高危險群的胸、腹主動脈瘤患者的優先治療選擇。本文將介紹此新興微創技術應用於治療腹主動脈瘤手術方法的發展與進步。

Endovascular repair was first proposed by Parodi and Volodos in the early 1990s. It is a lessinvasive alternative to conventional open surgery. The initial results of endovascular repair werepromising and encouraging. Two major recent studies (theDutch Randomised EndovascularAneurysmManagement (DREAM) trial and the Endovascular Aneurysm Repair Trial-1 (EVAR-1))demonstrated impressive improvements in 30 day mortality in patients (4.6-4.7 %drop to 1.2-1.7%)undergoing endovascular repair when compared with traditional open repair. Although the initialadvantage seemed only to last a short period (months) after operation, but did benefit high-riskpatients with these less traumatic endovascular techniques.Back to our institute history, we had implanted the first endograft for abdominal aortic repair inTaiwan with Vanguard II device on August 2, 1999, followed by another consecutive 6 patients forclinical trial with Zenith® AAA Endovascular Graft in 2001. But until July 2005, EVAR finallybecame "legal" procedure for AAA treatment and until October 2006 for TAA treatment, and werestarted EVAR for treating AAA 3 months later. After that, EVAR became our OR routine andsurgeon-independent procedure. By then, there were 45 patients, who received endovascularrepair of abdominal aortic aneurysm (AAA) and 29 patients, who received endovascular repair ofthoracic aortic aneurysm(AAA) in TaipeiVGH. The preliminary results were summarized as follows.All the patients received three-piece ModularDesign of Zenith® AAAEndovascularGraft. Inthe same year, almost 50% of the abdominal aortic aneurysm were anatomically suitable and treatedwith aortic endograf. The procedure success rate was 100%with no surgical mortality for endograftonly.In this preliminary result, endovascular repair is associated with lower in-hospital mortality,fewer postoperative complications and a shorter length of stay. However, long-term follow-up isneeded for further evaluation, new era of more less-invasive treatment of abdominal aortic aneurysmis in sight.