人工血管バイパスグラフト内の狭窄に対してステントによる血行再建を行った脳梗塞発症の1例

A Case of Percutaneous Transluminal Angioplasty and Stenting for Dacron Bypass Graft Stenosis with Cerebral Infarction

Ⅰ．はじめに

　近年，胸腹部の大動脈瘤や大動脈解離に対する血管内治療としてステントグラフト内挿術が発展している²⁾．今回われわれは大動脈解離に対して弓部にステントグラフトを留置し，同時に鎖骨下動脈と総頚動脈に人工血管でバイパスを施行された症例で，2年後に脳梗塞を来し，塞栓源の可能性となり得た人工血管の狭窄に対してpercutaneous transluminal angioplasty（PTA）およびstentingを施行し，良好な経過を経験したので報告する．

　A 62-year-old man presented to the emergency room with mild dysarthria and right motor weakness. The patient was diagnosed with aortic dissection（DeBakey type Ⅲ）in the cardiovascular department of our institution two years ago and was then treated with left carotid-bilateral subclavian bypass with collagen-seated Dacron graft followed by thoracic endovascular aortic repair（TEVER）with stent-graft placement. Magnetic resonance imaging on admission showed cerebral infarction with left proximal middle cerebral artery occlusion in the left cerebral hemisphere. Three-dimensional computed tomography angiography（3D-CTA）demonstrated a stenotic lesion at the anastomosis of the right subclavian artery and the bypass graft. It also showed the partial left common carotid artery, suggestive of an endoleak in the thoracic stent graft. The patient was diagnosed with artery-to-artery embolism due to bypass graft stenosis or endoleak in the thoracic stent graft and was treated with conservative therapy. He gradually recovered from the neurological deficit and underwent endovascular angioplasty with a balloon-expandable stent for bypass graft stenosis by using the distal balloon protection method and the left proximal common carotid artery occlusion with coils 1 month later. One-year follow-up 3D-CTA showed good patency of the stent in the bypass graft. No recurrence of cerebral infarction was observed during the postoperative course.