開窓型ステントグラフトを用いた弓部大動脈ステントグラフト内挿術後の動脈瘤感染およびⅠ型エンドリークに対する開胸手術の1例

Open Aortic Arch Surgery for TypeⅠEndoleak after Thoracic Endovascular Aortic Repair Using Fenestrated Stent Graft；Report of a Case

はじめに　近年，胸部大動脈瘤に対する胸部ステントグラフト内挿術（TEVAR）の良好な早期成績および低い周術期合併症率が報告されるようになり，TEVARの適応は拡大している．しかし，エンドリークやステントグラフト感染などに対してTEVAR後に追加治療が必要となる症例が散見され，開胸手術を必要とする症例も少なくない1）．開胸手術の際に定型化された戦略はなく，初回手術としての開胸手術より難易度が上がることが多い．われわれは，カワスミNajuta胸部ステントグラフトシステム（川澄化学工業社，東京）を用いたTEVAR後に生じた感染性動脈瘤に対し感染組織郭清術を行い，その約2年半後にⅠ型エンドリークによる瘤径拡大を認め，弓部大動脈全置換術（TAR）とオープンステントグラフトによるfrozen elephant trunk法（FET）を施行し，良好な経過をたどった症例を経験したので，若干の知見を加え報告する．

Thoracic endovascular aortic repair （TEVAR） has become a major procedure for thoracic aortic aneurysm and its indication is expanding. On the other hand, TEVAR specific complication is rather critical and its treatment is of increasing interest. Especially, open repair after TEVAR is sometimes demanding and case based strategy is mandatory. We experienced a case of open repair for aneurysm infection and endoleak after fenestrated TEVAR in 76-year-old man. He underwent initial aneurysmal repair using fenestrated graft 2 years ago. Five months later, debridment of infected tissue was performed because of aneurysmal infection. TypeⅠendoleak appeared after the surgery and expansion of the aneurysm made us decide extensive open repair. The operation was done under hypothermic circulatory arrest and selective cerebral perfusion. Partial removal of stent-graft and insertion of the open stent-graft, replacement of ascending aorta and reconstruction of neck vessels were done. Postoperative course was smooth. Open repair after TEVAR is often demanding. Sophisticated strategy for each case has to be planned.