Cox Daniel E, Jacobs Donald L, Motaganahalli Raghunandan L, Wittgen Catherine M, Peterson Gary J
Division of Vascular Surgery, St. Louis University School of Medicine, MO 63110, USA.
Vasc Endovascular Surg. 2006 Jan-Feb;40(1):35-40. doi: 10.1177/153857440604000105.
Hostile neck anatomy remains the predominant reason that patients are denied endovascular aneurysm repair (EVAR). We reviewed our experience of EVAR with use of prophylactic adjunctive proximal balloon-expandable stents in patients with hostile neck anatomy and adjunctive proximal balloon-expandable stents in patients with type I endoleaks. Of 140 patients who underwent EVAR between 2000 and 2004, we reviewed data for 19 patients in whom we used proximal balloon-expandable stents. By high-resolution computed tomography scan or angiography, hostile neck anatomy was classified as length <15 mm, neck diameters > or =26 mm, circumferential thrombus at the proximal neck, angulated neck > or =60 degrees, and neck bulge or reverse taper necks. Patients were considered to have hostile anatomy if they met 1 or more of the above-cited criteria. All patients underwent AAA repair with commercially available endograft systems, Zenith (Cook, Bloomington, IN) and AneuRx (Medtronic/AVE, Minneapolis, MN). Balloon-expandable stents utilized included Cordis-Palmaz stents (17/19) and eV3 Max stents (2/19). Stents were deployed in the proximal graft with transrenal extension. AneuRx (18/19) and Zenith (1/19) endografts were used in all of the patients. Of the 19 patients, 15 had prophylactic stent placement for known hostile neck anatomy and 4 patients had stent placement for type I endoleak. Assisted primary technical success was achieved in all patients. Three patients had maldeployment of the endograft or proximal stent requiring additional endovascular interventions at the time of surgery. No endografts were deployed too low requiring stent placement. Procedure-related complications occurred in 2 of 19 patients. These included 1 operative death secondary to pneumonia and 1 patient who developed progressive renal failure. Short-term clinical success was achieved in 17 of 19 patients. Two patients required secondary interventions, 1 due to device migration with secondary conversion to open repair, and an endoleak, which, on angiogram, was a large type II endoleak successfully treated with coiling of the inferior mesenteric artery. One patient was observed to have a type II endoleak with no associated aneurysm enlargement. Short-term results suggest the use of prophylactic adjunctive balloon-expandable stents may decrease the incidence of secondary interventions related to hostile neck anatomy when used as an adjunctive measure with EVAR. Based on our experience, we feel EVAR may be offered to an expanded patient population with hostile neck anatomy with use of prophylactic balloon-expandable stents.
颈部解剖结构复杂不利于手术操作仍是患者被拒绝接受血管内动脉瘤修复术（EVAR）的主要原因。我们回顾了在颈部解剖结构复杂的患者中使用预防性辅助近端球囊扩张支架以及在Ⅰ型内漏患者中使用辅助近端球囊扩张支架进行EVAR的经验。在2000年至2004年间接受EVAR的140例患者中，我们回顾了19例使用近端球囊扩张支架患者的数据。通过高分辨率计算机断层扫描或血管造影，将复杂的颈部解剖结构分为长度<15mm、颈部直径>或=26mm、近端颈部圆周血栓、成角颈部>或=60度以及颈部膨出或反向锥形颈部。如果患者符合上述1项或更多标准，则认为其具有复杂的解剖结构。所有患者均使用市售的腔内移植物系统（Cook公司的Zenith，印第安纳州布卢明顿市；美敦力/AVE公司的AneuRx，明尼阿波利斯市）进行腹主动脉瘤修复。使用的球囊扩张支架包括Cordis-Palmaz支架（17/19）和eV3 Max支架（2/19）。支架通过经肾延伸部署在近端移植物中。所有患者均使用AneuRx（18/19）和Zenith（1/19）腔内移植物。在这19例患者中，15例因已知颈部解剖结构复杂而进行预防性支架置入，4例因Ⅰ型内漏而进行支架置入。所有患者均实现了辅助性主要技术成功。3例患者的腔内移植物或近端支架部署不当，需要在手术时进行额外的血管内干预。没有腔内移植物部署过低而需要置入支架的情况。19例患者中有2例发生了与手术相关的并发症。其中包括1例因肺炎导致的手术死亡和1例出现进行性肾衰竭的患者。19例患者中有17例取得了短期临床成功。2例患者需要进行二次干预，1例是由于装置移位并二次转换为开放修复，另1例是内漏，血管造影显示为大型Ⅱ型内漏，经肠系膜下动脉线圈栓塞成功治疗。观察到1例患者有Ⅱ型内漏，但无相关动脉瘤增大。短期结果表明，当作为EVAR的辅助措施使用时，预防性辅助球囊扩张支架的使用可能会降低与复杂颈部解剖结构相关的二次干预发生率。根据我们的经验，我们认为对于颈部解剖结构复杂的患者群体，使用预防性球囊扩张支架可以扩大EVAR的适用范围。
