右鎖骨下動脈瘤を合併した弓部大動脈瘤に対するハイブリッド治療

Hybrid Treatment for Aortic Arch Aneurysm Concomitant with Right Subclavian Artery Aneurysm

鎖骨下動脈瘤は末梢動脈瘤の中でもまれな疾患であり1，2），外科的治療に関してはその原因や発生部位によって手術アプローチが異なるため検討が必要である．また，鎖骨下動脈瘤はほかの動脈瘤を合併する率が33～47％と比較的高く3，4），特に右鎖骨下動脈瘤に弓部大動脈瘤を合併する場合，一期的外科治療の際には両側反回神経麻痺の危険がある．われわれは右鎖骨下動脈瘤を合併した弓部大動脈瘤に対してハイブリッド治療を行い，良好な結果を得られた症例を経験したので，文献的考察を加えて報告する．

A 78-year-old man was hospitalized for aortic arch aneurysm concomitant with right subclavian artery aneurysm. Maximum diameter of each aneurysm was 65 mm and 40 mm, respectively. Both aneurysms clearly needed to be treated. However, simultaneous surgery of total arch replacement （TAR） and right subclavian artery grafting carries both technical difficulty of surgical exposure and considerable risk of bilateral recurrent nerve palsy. Thus, to avoid these serious problems, we chose hybrid treatment. TAR was performed as the 1st procedure, followed by stent graft placement to right subclavian artery aneurysm. At the 1st procedure, an 8 mm graft was anastomosed to right common carotid artery in end to side fashion. This was used for cerebral perfusion, and after that, another end of this graft was anastomosed to a branch of quadrant graft which was anastomosed to brachiocephalic artery. Then, right common carotid artery was ligated at proximal portion to create a proximal landing zone. As the 2nd procedure, excluder leg was deployed via right axillary artery without difficulty. He was discharged with uneventful postoperative course.