アクセス困難な胸部大動脈瘤に対して弓部分枝デブランチによるステントグラフト内挿術を施行した1例

Hybrid Aortic Arch Debranching for Challenging Access Following Abdominal Aorta Resection：Report of a Case

はじめに　近年，大動脈疾患に対するステントグラフトを用いた治療は低侵襲な治療法として幅広く行われるようになった．基本的にステントグラフトの挿入は腸骨動脈や大腿動脈から行われるのが一般的であり，アクセスが困難な症例については適応外とされることも多い．われわれはアクセス困難な胸部大動脈瘤に対して胸骨正中切開アプローチで弓部分枝を再建した後，ステントグラフトの留置を行った症例を経験したので報告する．

Eight years previously, a 76-year-old man underwent an open surgical repair of an infectious abdominal aortic aneurysm through a median laparotomy. The abdominal aorta was resected, and blood flow to the lower extremities was reconstructed using an extra-anatomical bypass from the right axillary artery to the bilateral femoral arteries. A computed tomography （CT） scan revealed a distal aortic arch aneurysm just below the left subclavian artery, with a maximum diameter of 58 mm. Given the high-risk nature of an open surgery, we opted for an endovascular intervention. However, accessing the aneurysm from the iliac and femoral arteries was challenging. Therefore, we accessed the ascending aorta after total debranching. A median sternotomy was performed under general anesthesia. Total debranching of the supra-aortic vessels was accomplished without cardiopulmonary bypass by using a side clamp on the ascending aorta. After total debranching, Gore TAG grafts were positioned from zone 0 to Th10. The postoperative course was uneventful, without any complications, and the postoperative enhanced CT revealed no endoleaks.