What should be done when the proximal anchorage area of a thoracic aortic aneurysm or stenosis is inadequate? In aortic aneurysm and AD endoluminal repair, the exact anchorage of the artificial endovascular stent (SG) proximal to the lesion is critical for successful lumen closure or primary breach closure. In this article, the proximal anchorage zone is defined as the distance between the proximal end of the aneurysm and the opening of the left subclavian artery in Stanford type B AD primary breach or thoracic descending aortic aneurysm (DTAA), which is considered ideal by both Dake and Criado to be ≥20 mm; if it is <15 mm, the proximal anchorage of the SG is not exact, and the anatomic pattern of the curved aortic arch, the high pressure and high velocity flow, and the lesion itself cause The primary rupture in type B AD is mostly located in the aortic isthmus, near the opening of the left subclavian artery, and the proximal anchorage zone is <15 mm in a minority of cases, making it difficult to perform endoluminal treatment without measures. Countermeasures: (1) Direct coverage of the left subclavian artery, i.e., without any arterial reconstruction, the SG is released immediately distal to the opening of the left common carotid artery and directly covers the left subclavian artery. This method is suitable for patients with a proximal anchorage zone <15 mm and a distance of ≥15 mm from the opening of the left common carotid artery to the primary AD breach or the proximal end of the DTAA, and preoperative imaging evaluation of the carotid and vertebral arteries and Willis ring is essential. This method has the potential risk of causing cerebral or left upper extremity ischemia, but can mostly be avoided by compensating with the contralateral vertebral artery, Willis ring, and thoracic wall and periapical arteries. (2) Auxiliary arterial bypass (right-left common carotid, left common carotid-left subclavian artery bypass, transection of the proximal left common carotid artery, ligation of the proximal left subclavian artery) combined with endoluminal repair. It is indicated for a distance <15 mm from the left common carotid artery to the primary AD rupture or proximal DTAA. Two weeks after bypass, the SG was released immediately distal to the opening of the innominate artery. three cases of type B AD and one case each of DTAA and aneurysm of the aortic arch were treated by this method in the Department of Vascular Surgery of Zhongshan Hospital. Among them, the DTAA patients recovered well after bypass surgery, and hemispheric infarction occurred 3 hours after intraluminal repair, followed by multiple organ failure (MSOF) and death, which was estimated to be related to the lowering of pressure at the time of release. The remaining four cases had complete thrombosis in the pseudolumen or aneurysmal lumen of the thoracic segment 3 months after surgery, with no endoleaks or ischemic complications at an average follow-up of 9 months. (3) Application of partial fork type SG of aortic arch. This OSG is divided into two parts, the main body and the branch, and is preceded by the same arterial bypass as in countermeasure 2. At the time of completion, the main body and branch of the SG are implanted via the right common carotid and femoral arteries, respectively. Chuter et al. reported the successful repair of an aortic arch aneurysm using this method with satisfactory results. (4) Recently, there have been case reports of successful intracavitary repair of aortic arch aneurysms using scalloped SG and left subclavian artery in situ open-window SG, respectively. What about short proximal abdominal aortic aneurysm neck? The proximal neck of an abdominal aortic aneurysm is as important as the proximal anchor zone, and in the past it was thought that intraluminal repair was not considered for aneurysms <15 mm. Verhoeven et al. reported the use of a windowed SG for endoluminal repair of 18 abdominal aortic aneurysms with a proximal neck <15 mm, with a 100% success rate of the technique Of the 46 target visceral arteries (10 superior mesenteric arteries and 36 renal arteries), all but one of the paramedian arteries were successfully preserved with a mean follow-up of 9.4 months and one type II endoleak. 45 of the preserved visceral arteries were patent. 22 cases were reported by Greerlberg et al. using the bifurcated SG in 20 cases and the tubular type in 2 cases with a 100% technical success rate, involving a total of 58 visceral arteries (mainly The bifurcated SG can also be used for endoluminal repair of thoracoabdominal aortic aneurysms. Is a coarctation aneurysm suitable for endoluminal repair? The main goal of treatment for a clogged aneurysm, which is a major long-term complication of AD, is to stop further aneurysm expansion and prevent rupture. The ideal outcome of treatment should be a complete patenting of the false lumen, complete thrombosis, and normalization or significant improvement of blood flow in the true lumen. However, because (1) chronic AD often extends to the distal part of the aorta, forming multiple breaches near the opening of the visceral artery, even if the primary breach is completely sealed, blood flow can still back up into the false lumen through the distal breach; (2) the endothelial sheet becomes hyperplastic and thickened during the chronic phase, and its compliance decreases, which affects the ideal adhesion of SG to the endothelium; (3) the complete opening of the false lumen may lead to partial ischemia of the aortic branches, so it is difficult to seal the primary breach alone. Therefore, it is difficult to obtain the "optimal" effect by only sealing the primary rupture, and the effect of partial patenting of the false lumen to prevent aortic dilatation, aneurysm formation and rupture is still uncertain. Greenberg et al. advocated that open thoracoabdominal surgery should be performed for patients in good general condition, and for patients who cannot tolerate open thoracic surgery (e.g., with severe pulmonary disease), a combined SG repair of the left common iliac artery, a celiac trunk, superior mesenteric artery, and bilateral renal arteries, combined with a full segment of the thoracoabdominal aorta, but it is more tedious and more invasive. The Department of Vascular Surgery, Zhongshan Hospital, Fudan University, summarized 141 cases of endoluminal repair of type B coarctation aneurysms from 2000 to 2004. More than 90% of the patients had complete thrombosis of the thoracic segment pseudo-lumen 3 months after surgery, and the abdominal segment pseudo-lumen did not expand, and the visceral arteries originating from the pseudo-lumen were still supplied by the pseudo-lumen backflow without ischemic complications. The treatment results were similar to those reported by Nienaber et al. Although there is a lack of long-term follow-up data to assess whether the pseudolumen of the abdominal segment is likely to gradually enlarge and form an aneurysm in the long term or to extend proximally or distally, involving the visceral arteries and leading to adverse outcomes, at least the results of near- and mid-term treatment are encouraging, especially in patients with advanced age, comorbidities, poor tolerance of conventional surgery, and aneurysms >60 mm in diameter, considering the need for treatment, safety, life expectancy, and quality of life. The endoluminal repair is a viable option, and further research and exploration is of practical importance. How to prevent and treat endoleaks? As a major complication, the incidence of endoleaks after endoluminal repair of thoracic main and abdominal aortic aneurysms is about 17.8% and 16%, respectively. The Department of Vascular Surgery, Zhongshan Hospital, Fudan University, summarized 102 cases of endoluminal repair of type B coarctation aneurysms from August 2000 to February 2004, and 19 cases (18.63%) of proximal type I endoleaks were found after surgery. The occurrence of type I is closely related to the short proximal anchorage area/proximal aneurysm neck and the irregular morphology of the area. stanley et al. showed that the incidence of endoleaks in proximal aneurysm neck ≤10 mm was 57% (8/14), and the 141 endoleaks after endoluminal repair of clotted aneurysms in the Department of Vascular Surgery of Zhongshan Hospital were 57% (8/14). The incidence of endoleaks after endovascular repair was 84.21% (16/19) associated with folding of the aortic isthmus. Vallabhaneni et al. analyzed the interim results of 2862 endoluminal AAA repairs on EUROSTAR as of July 2000 and concluded that the persistence of endoleaks was closely associated with late aneurysm rupture and intermediate open abdomen; Bockler et al. summarized 520 cases of endoluminal treatment of subrenal AAA during the 6-year period from August 1994 to May 2000, with 37 cases (7.1%) intermediate surgery The important reason for late conversion to open abdomen was type I endoleaks (16 cases). Therefore, active prevention and control of endoleaks is beneficial to improve the outcome of endoluminal treatment. The main preventive measures include: (1) meticulous preoperative imaging assessment, including the distance available for proximal and distal anchorage, the morphology of the site, and the presence of calcified plaque; (2) accurate preoperative measurement and selection of appropriately sized SGs, which should generally exceed 15-20% (thoracic aorta) or 20-25% (abdominal aorta) of their anchorage site diameter proximally; (3) ensuring adequate and reliable SG (3) ensure adequate and reliable proximal anchoring, in which adequate anchoring distance is crucial and can often compensate for the shortage of proximal anchoring area or proximal aneurysm neck with irregular morphology and obvious calcified plaque, and corresponding measures should be taken for patients with short proximal anchoring distance (specific method as above); (4) design and develop anti-endoleak SG, the vascular surgery department of Zhongshan Hospital has designed SG with expansion material to prevent type I endoleak and asymmetric SG (with oblique mouth proximally) The vascular surgery department of Zhongshan Hospital has designed SGs with expansion material to prevent type I endoleaks and asymmetric SGs (with a beveled proximal end, which can increase the proximal anchoring distance without affecting the opening of the three major branches of the aortic arch), and coagulant-coated SGs to prevent type II endoleaks. The management of endoleaks depends on the fractionation and severity: (1) Type I should be actively managed generally does not advocate conservative treatment, the main methods are balloon dilation, Cuff or Extention implantation and transit surgery. (2) Type II can be followed up when the volume is low, and interventional embolization of the regurgitant artery, transcatheter lumbar puncture aneurysm embolization, laparoscopic artery clamping of the regurgitant artery or intermediate surgery is feasible when it persists or worsens. (3) Type III should be treated as early as possible by implanting Cuff or Extention, inserting another SG inside the original SG, switching to AUI type SG, or reversal surgery. (4) Type IV is self-limiting and can be left untreated if found intraoperatively. If it persists for more than 30 days, attention should be paid to exclude other types of endoleaks. How to prevent the occurrence of paraplegia? Both traditional open surgery and endoluminal treatment of paraplegia are of great concern. 7% to 26% occurrence of traditional surgery and 3% of endoluminal treatment, to some extent it brings emotional pain and economic burden to patients and their families as much as, or even more than, death. Adamkiewicz artery usually emanates from T8 to L1 intercostal artery, and when endoluminal repair is needed to cover the segment and there is no The risk of paraplegia is higher when the intercostal artery remains patent with no obvious thrombosis. More preventive measures have been reported, such as intercostal artery reimplantation, cerebrospinal fluid drainage, and evoked potentials, but the results are not very satisfactory. Is intracavitary repair of asymptomatic AD necessary? The traditional treatment of asymptomatic AD is aggressive antihypertension and close follow-up. However, long-term follow-up results show that 20% of these patients later develop aortic dissection and 30% to 40% die or undergo surgery within seven years due to aortic lesions. Therefore, it is important to actively delay and stop aortic dilation. Early endoluminal SG repair is thought to play an important role in this regard: at the beginning of the disease, when the endoluminal flap is not yet hyperplastic and hypertrophic and has good mobility and compliance, endoluminal repair has a better chance of completely sealing the rupture, opening the prosthetic lumen, and causing complete thrombosis, thus facilitating the transformation of acute AD into an “intermural hematoma” and healing, and preventing distant aneurysm formation. Of course, a prospective randomized controlled study with drug therapy is needed to confirm this.