開窓術を併用した解離性大動脈瘤人工血管置換末梢側吻合部の瘤拡大に対しステントグラフト治療が奏功した1例  [in Japanese] Endovascular Repair of Chronic Aortic Dissection Expansion from Distal Fenestration in Previous Graft Replacement  [in Japanese]

症例は58歳,男性.慢性解離性大動脈瘤に対して胸部下行人工血管置換術が施行された6年後,末梢側吻合部の瘤拡大を認め手術目的に入院となった.前回の手術では,末梢側吻合部の真腔が狭小化しており真腔への吻合が困難であったため,intimal flapを切除し偽腔にも開窓する二連重(double-barreled)吻合が行われていた.治療は前回の手術後MRSA膿胸を併発していたため,胸腔内の癒着により左開胸が困難と判断し,開窓部を閉鎖するステントグラフト内挿術を施行した.術後神経学的合併症も見られず,術後18ヵ月目のCTにて最大径58mmであった瘤が38mmにまで縮小した.慢性解離性大動脈瘤において手術によって切除された内膜欠損部を慢性期にステントグラフトによって閉鎖し,瘤の縮小が得られた症例を報告した.

A 58-year-old man was admitted because of enlargement in diameter of the descending thoracic aorta. Six years previously, he had undergone graft replacement of the proximal descending aorta due to a chronic dissecting aneurysm. During that surgery, distal fenestration involving resection of the intimal flap of the distal anastomotic site and graft replacement with distal anastomosis of the true and false lumen were performed. Our preoperative enhanced computed tomography (eCT) revealed a thoracic aortic aneurysm 58mm in diameter at the site of distal fenestration. Graft replacement through left lateral thoracotomy was considered difficult because of previous occurrence of methicillin-resistant Staphylococcus aureus (MRSA) empyema after the previous operation: hence, endovascular repair was done using a handmade stent graft to interrupt blood flow into the false lumen. The postoperative course was uneventful. Postoperative eCT showed the thrombosed false lumen and the shrinkage of the aneurysm from 58 to 38mm in diameter over a period of 18 months.