主动脉疾病的血管内治疗：是否需要手术环境？

Moore Randy D, Villalba Laurencia, Petrasek Paul F, Samis Gregory, Ball Chad G, Motamedi Mona

Division of Vascular Surgery, Peter Lougheed Centre, University of Calgary, Alberta, Canada.

J Vasc Surg. 2005 Oct;42(4):645-9; discussion 649. doi: 10.1016/j.jvs.2005.06.033.

OBJECTIVE

Interventional radiologists, cardiologists, and vascular surgeons are capable of performing endovascular procedures successfully in their respective environments. Suboptimal anatomy or intraoperative technical problems can be encountered, and endovascular management alone is not always suitable. The objectives of this study were to define the incidence of adjunctive surgical techniques, to discuss the rationale for endovascular reconstruction in a well-developed surgical environment, and to assess the effect of experience on the incidence of adjunctive repair.

METHODS

All primary aortic and aortoiliac elective, urgent, and emergent endovascular procedures performed at the Peter Lougheed Center and entered into a prospective database from May 25, 1999 to June 01, 2005, were reviewed. All adjunctive surgical techniques to enable stent deployment, enhance attachment site, or solve intraoperative difficulties were captured. The study period was divided into two time periods based on learning curve data to assess the effect of experience on the rate of adjunctive repairs.

RESULTS

Four hundred thirty-eight patients underwent elective (80%), urgent (15%), or emergent (5%) endovascular procedures during the study period. These consisted of 101 thoracic and 337 abdominal operations, including the use of 13 fenestrated stents. One hundred thirty-nine patients (31.7%) required 180 open surgical procedures. Complete data were available for the entire patient cohort. The mean follow-up was 793.2 days (SD, 519.1 days). Procedures were necessary for vascular access, arterial dissection/rupture, limb ischemia, and enhancement/elongation of the stent attachment site. The persistent endoleak rate was 5.3%, the late rupture rate was 0.7%, the conversion rate was 1.6%, the 30-day surgical mortality rate was 3.2%, all-cause mortality to date is 7.3%, and the reintervention rate was 4.6%. There was no statistically significant effect of the learning curve on the incidence of surgical adjunctive procedures in either the thoracic group (11/26 [42.3%] for phase 1 vs 17/75 [22.6%] for phase 2) or the abdominal group (14/50 [28.0%] for phase 1 vs 97/287 [33.8%] for phase 2). Overall, 31.5% of patients required adjunctive surgical repair.

CONCLUSIONS

Successful endografting requires endovascular expertise in addition to a well-developed surgical environment to increase applicability and decrease patient risk. Despite advances in endovascular technology, hybrid techniques will continue to be required to achieve good overall success rates.

目的

介入放射科医生、心脏病专家和血管外科医生都能够在各自的工作环境中成功地进行血管内手术。可能会遇到解剖结构不理想或术中技术问题，仅靠血管内治疗并不总是合适的。本研究的目的是确定辅助手术技术的发生率，讨论在成熟的外科环境中进行血管内重建的基本原理，并评估经验对辅助修复发生率的影响。

方法

回顾了1999年5月25日至2005年6月1日在彼得·洛希德中心进行的所有原发性主动脉和主髂动脉择期、急诊和紧急血管内手术，并录入前瞻性数据库。记录所有用于使支架展开、增强附着部位或解决术中困难的辅助手术技术。根据学习曲线数据将研究期分为两个时间段，以评估经验对辅助修复率的影响。

结果

在研究期间，438例患者接受了择期（80%）、急诊（15%）或紧急（5%）血管内手术。其中包括101例胸段手术和337例腹段手术，包括使用了13个开窗支架。139例患者（31.7%）需要进行180次开放手术。整个患者队列都有完整的数据。平均随访时间为793.2天（标准差，519.1天）。手术用于血管通路、动脉夹层/破裂、肢体缺血以及增强/延长支架附着部位。持续性内漏率为5.3%，晚期破裂率为0.7%，转换率为1.6%，30天手术死亡率为3.2%，迄今为止的全因死亡率为7.3%，再次干预率为4.6%。学习曲线对胸段组（第1阶段11/26 [42.3%] vs第2阶段17/75 [22.6%]）或腹段组（第1阶段14/50 [28.0%] vs第2阶段97/287 [33.8%]）辅助手术的发生率均无统计学显著影响。总体而言，31.5%的患者需要辅助手术修复。