Parent F Noel, Godziachvili Vasso, Meier George H, Parker Frank M, Carter Kathleen, Gayle Robert G, Demasi Richard J, Gregory Roger T
Norfolk Surgical Group, VA 23510, USA.
J Vasc Surg. 2002 Apr;35(4):686-90. doi: 10.1067/mva.2002.118595.
The purpose of this study was to define the incidence and treatment of endograft limb stenosis or occlusion (endograft limb dysfunction [ELD]) in a single center with the ANCURE unsupported bifurcated or aortouniiliac endograft by using intraoperative completion angiography and postoperative color duplex ultrasound scanning (CDU).
Sixty-seven endografts (58 bifurcated, 9 uniiliac) were implanted between February 1996 and July 2000. Intraoperative completion aortography was performed in every patient. Postoperative assessment of the endograft consisted of CDU and computed tomography scanning and kidney, ureter and bladder radiographs within 7 days of implantation, at 3 and 6 months after the operation, and every 6 months thereafter.
At the time of endograft implantation, widely patent normal-appearing endograft limbs were revealed by means of the initial completion angiogram in 58 of 67 patients (group 1). ELD subsequently developed in seven of these 58 patients (13.4%). The results of the completion angiogram were not normal in the remaining nine patients (group 2), leading to the deployment of a self-expanding stent within the endograft limbs. The results of subsequent angiography were normal. No ELD has occurred in any patient in group 2 to date. The primary assisted patency rate at 30 months was 88% +/- 5.2% for group 1 versus 100% +/- 0% for group 2 (P = not significant, Log-rank test). Postoperative ELD occurred in seven patients (10.4%). Endovascular graft thrombosis occurred in three patients (3 endograft limbs). In each case, an endovascular approach was attempted; however, the guidewire would not traverse the occluded endovascular graft limb. Revascularization was accomplished by means of femorofemoral bypass grafting. Endovascular graft stenosis occurred in four patients (4 endograft limbs). Three patients with bifurcated endografts and limb stenosis who had no symptoms diagnosed by means of CDU were successfully treated by means of balloon angioplasty with self-expanding stent implantation, and the endograft limbs remained patent at 3, 5, and 26 months follow-up. The remaining patient who had an aortouniiliac endograft with recurrent severe stenoses underwent endograft explantation and aortobifemoral bypass grafting. The overall incidence of ELD during or after endovascular abdominal aortic aneurysm repair was 23.8% (16 of 67 patients).
Unsupported endografts are at risk for developing ELD. The use of stents for limb support at the time of the initial endograft implantation may prevent subsequent ELD and bears further study. Endograft limb occlusion usually presents with acute severe ischemic symptoms, and the failure of operative thrombectomy necessitates femorofemoral artery bypass grafting. Endograft limb stenosis is identified by means of CDU surveillance in the postoperative period. Prompt treatment with percutaneous transluminal angioplasty/stent yields satisfactory primary assisted patency. Intraoperative intravenous ultrasound scanning, oblique angiograms, pressure gradients, and completion angiography may be necessary to detect and treat ELD.
本研究旨在通过术中完成血管造影和术后彩色双功超声扫描（CDU），确定在单一中心使用ANCURE无支撑分叉型或主动脉单髂动脉内移植物时，内移植物肢体狭窄或闭塞（内移植物肢体功能障碍[ELD]）的发生率及治疗方法。
1996年2月至2000年7月期间植入了67个内移植物（58个分叉型，9个单髂动脉型）。每位患者均进行了术中完成主动脉造影。术后对内移植物的评估包括CDU、计算机断层扫描以及在植入后7天、术后3个月和6个月以及此后每6个月进行的肾脏、输尿管和膀胱X线照片检查。
在内移植物植入时，67例患者中有58例（第1组）通过初始完成血管造影显示内移植物肢体广泛通畅且外观正常。这58例患者中有7例（13.4%）随后发生了ELD。其余9例患者（第2组）的完成血管造影结果不正常，导致在内移植物肢体中植入了自膨式支架。随后的血管造影结果正常。迄今为止，第2组中没有患者发生ELD。第1组30个月时的主要辅助通畅率为88%±5.2%，而第2组为100%±0%（P = 无显著性差异，对数秩检验）。术后ELD发生在7例患者（10.4%）中。血管内移植物血栓形成发生在3例患者（3个血管内移植物肢体）中。在每种情况下，均尝试了血管内途径；然而，导丝无法穿过闭塞的血管内移植物肢体。通过股-股旁路移植术实现了血运重建。血管内移植物狭窄发生在4例患者（4个血管内移植物肢体）中。3例分叉型内移植物且肢体狭窄但通过CDU未诊断出症状的患者通过球囊血管成形术并植入自膨式支架成功治疗，在3个月、5个月和26个月的随访中内移植物肢体保持通畅。其余1例患有复发性严重狭窄的主动脉单髂动脉内移植物患者接受了内移植物取出术和主动脉双股旁路移植术。血管内腹主动脉瘤修复期间或之后ELD的总体发生率为23.8%（67例患者中的16例）。
无支撑内移植物有发生ELD的风险。在初始内移植物植入时使用支架进行肢体支撑可能预防随后的ELD，值得进一步研究。血管内移植物肢体闭塞通常表现为急性严重缺血症状，手术取栓失败需要进行股-股动脉旁路移植术。术后通过CDU监测识别血管内移植物肢体狭窄。经皮腔内血管成形术/支架的及时治疗可产生令人满意的主要辅助通畅率。术中静脉超声扫描、斜位血管造影、压力梯度和完成血管造影对于检测和治疗ELD可能是必要的。
