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▍微創主動脈治療
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主動脈瘤血管內套膜支架目前的發展(三)

經濟和生活水平

費用是目前此項技術的最重要考量，當前的與相關血管內套膜支架的費用，即使在美國也遠超出醫療保障系統所能負擔的。依靠裝置製造商之間的競爭來減少裝置的價格，在目前似乎是非常不太可能。因此血管內套膜支架的費用將仍是此項技術關心的重點。並且，血管內套膜支架之療程將有更高門診追蹤費用存在。但是有一點支持血管內套膜支架遠勝於手術修補乃在於生活品質的提昇。患者以血管內套膜支架治療比手術修補的患者更早回到了基礎線狀態。[ 36 ] 也減少了巨大的外科精神創傷。[ 37]

未來的趨勢

微創性手術在未來是有極大的潛力。目前除了以血管內套膜支架治療腹主動脈瘤是成功的以外，對於ICU 停留和醫院停留時間的明顯減少，也是手術修補無法比擬的。另外，改善裝置裡設計與置放技術，將使此項技術有更廣泛的運用。當我們繼續尋找最佳方案來治療血管疾病，看起來，各式各樣的新技術將變得越來越重要。

 

台灣的發展現況

距Juan ·Parodi 博士於1991年完成人體內第一例後，台北榮總於八年後亦為1999年八月二日，由心臟血管外科施俊哲醫師團隊，成功完成國內第一例腹主動脈瘤內套膜支架植入手術(Vanguard II)，[ 38]並於民國九十年(六例Zenith) 共七例人體試驗手術，及隨後台大醫院亦進行Talent植入人體試驗，共經四年追蹤證實為手術後有效之治療，衛生署終於九十四年七月七日通過為受規範之常規手術（醫院及操作醫師必需取得衛生署核可之執照）。並規定唯有具有操作執照之心臟血管外科醫師能單獨為病患治療，放射科或介入性心臟內科醫師，則必須由具有操作執照之心臟血管外科醫師共同操作下才能執行植入手術。不過目前國際間的趨勢及台北榮總現行皆由「心臟血管外科」主持。

根據2004至2005年歐美兩大重要動脈瘤治療方式，採隨機之臨床研究方式(the Dutch Randomised Endovascular Aneurysm Management (DREAM) trial and the Endovascular Aneurysm Repair Trial-1 (EVAR-1)) ，顯示手術死亡率由4.6-4.7 %至 1.7-1.2%。[ 39,40] 然而長期存活率分別經二年及四年追蹤結果並無顯著差異，所以目前僅建議適用於年老病患或不適合傳統手術者。而因此受惠之病患自九十四年七 月七 日通過為常規手術後，至今九十五年六月全台共植入Zenith血管內套膜支架，共超越五十例及Talent共八例之呈現快速增長之趨勢。

本院內套膜支架植入手術於九十四年十月起正式成為一般的常規手術。

台北榮總腹主動脈瘤內套膜支架微創治療發展史

台北榮總的成績

台北榮總目前總共治療病人數目共40人（至2006年 十二月）

目前接受內套膜支架血管治療者呈現增加的趨勢且約佔腹主動脈瘤數目的45%

結論

　內套膜支架治療法已成為未來治療胸、腹主動脈瘤的一項「有效」、「簡捷」而又「微創」的常規新技術。目前適合且接受內套膜支架血管治療者呈現增加的趨勢且約佔腹主動脈瘤病患數目的一半左右。雖然此新興手術目前尚存三個主要問題：滲漏、位移及長期耐用性不如傳統手術，然而不適合此項手術者既屬於易出現此後遺症之高危險群，而且血管支架材料及技術仍持續進步中，相信不久將來皆可一一克服。

 


　

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