Greenberg R K, Haulon S, O'Neill S, Lyden S, Ouriel K
Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
Eur J Vasc Endovasc Surg. 2004 May;27(5):484-91. doi: 10.1016/j.ejvs.2004.02.015.
To evaluate outcomes of an endovascular graft incorporating the visceral aortic segment with graft material in the setting of juxtarenal aneurysms.
A prospective analysis of patients undergoing implantation of an endovascular device with graft material proximal to the renal arteries was conducted. All patients were deemed unacceptable candidates for open surgical repair and had proximal neck length=<10 mm, or =<15 mm with a compromising morphology (funnel or thrombus). Fenestrations were customized to accommodate aortic branch anatomy based upon CT and intravascular ultrasound data. Selective visceral ostia were treated with balloon expandable stents following endograft deployment. All patients were evaluated with CT, duplex ultrasound, and abdominal radiograph at discharge, 1, 6, 12 and 24 months.
A total of 32 patients were enrolled in the trial. Short proximal necks (3-10 mm) were present in 22, and 10 had necks 10-15 mm in length with concomitant angulation or thrombus compromising neck quality. Endograft design included bifurcated (30) and aortic tube (2) systems. A total of 83 visceral vessels were incorporated (mean of 2.6 per patient). These most commonly included both renal arteries and the SMA. All prostheses were implanted successfully without the acute loss of any visceral arteries. The mean follow-up was 9.2 months (range 0-24 months). One patient died within 30 days of device implantation and hypogastric bypass following the development of aspiration pneumonia. Three early (<30 days) and three late secondary interventions were performed. The 30-day endoleak rate was 6.5%. The aneurysm sac decreased greater than 5 mm in 58% of patients at 6 months and in 75% of patients at 12 months. One patient, with a persistent type II endoleak had 5 mm of sac growth over 12 months. Six patients had transient or permanent elevation of serum creatinine (>30% from baseline), with one requiring hemodialysis. Of the 83 vessels incorporated, three late stenoses (all successfully treated with an endovascular approach) and two renal occlusions were detected during follow-up. Three patients died of unrelated causes during the follow-up period.
The placement of endovascular prostheses with graft material incorporating the visceral arteries is technically feasible. The incidence of endoleaks is exceptionally low. It remains critical to follow the status of stented visceral vessels, and establish the long-term efficacy of this type of repair.
评估在近肾动脉瘤情况下，采用带有移植物材料的血管内移植物覆盖内脏主动脉段的治疗效果。
对在肾动脉近端植入带有移植物材料的血管内装置的患者进行前瞻性分析。所有患者均被认为不适合接受开放手术修复，其近端颈部长度≤10mm，或长度≤15mm且形态不佳（呈漏斗状或有血栓）。根据CT和血管内超声数据定制开窗，以适应主动脉分支解剖结构。在植入血管内移植物后，对选择性内脏开口处使用球囊扩张支架进行治疗。所有患者在出院时、1个月、6个月、12个月和24个月时均接受CT、双功超声和腹部X线检查。
共有32例患者纳入该试验。22例患者近端颈部较短（3 - 10mm），10例患者颈部长度为10 - 15mm，伴有成角或血栓，影响颈部质量。血管内移植物设计包括分叉型（30例）和主动脉管状（2例）系统。共纳入83支内脏血管（平均每位患者2.6支）。这些血管最常见的包括双侧肾动脉和肠系膜上动脉。所有假体均成功植入，无任何内脏动脉急性丢失。平均随访时间为9.2个月（范围0 - 24个月）。1例患者在装置植入后30天内死亡，因吸入性肺炎发展而行下腹旁路手术。进行了3次早期（<30天）和3次晚期二次干预。30天内漏血发生率为6.5%。6个月时，58%的患者动脉瘤囊缩小超过5mm；12个月时，75%的患者动脉瘤囊缩小超过5mm。1例患者存在持续性II型内漏，动脉瘤囊在12个月内增长了5mm。6例患者血清肌酐短暂或永久性升高（较基线升高>30%），其中1例需要进行血液透析。在随访期间，在纳入的83支血管中，检测到3例晚期狭窄（均通过血管内方法成功治疗）和2例肾动脉闭塞。3例患者在随访期间死于无关原因。
采用带有覆盖内脏动脉的移植物材料的血管内假体进行植入在技术上是可行的。内漏发生率极低。密切关注带支架内脏血管的状况并确定此类修复的长期疗效仍然至关重要。
