Lee Chong, Dougherty Matthew, Calligaro Keith
Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia 19106, USA.
J Vasc Surg. 2006 May;43(5):903-7. doi: 10.1016/j.jvs.2005.12.063. Epub 2006 Mar 31.
Endograft limb extension to the external iliac artery with embolization of an internal iliac artery (IIA) may be necessary in patients with abdominal aortic aneurysms (AAAs) extending to the common iliac artery to prevent endoleak during endovascular aortic aneurysm repair (EVAR). Coil embolization of the IIA can be performed at the same operative setting as EVAR or, alternatively, as a staged procedure. Most interventionalists favor the latter approach to avoid excessive contrast material and prolonged operative time. We investigated the clinical outcome of concomitant vs staged unilateral IIA embolization in the setting of EVAR.
Vascular surgeons at our institution treated 24 patients with infrarenal EVAR and unilateral coil embolization of the IIA from October 1, 2000 to June 30, 2005. All patients had normal renal function. The details of the operative procedure and perioperative complications were compared in patients undergoing concomitant vs staged procedures. Follow up was 1 to 40 months (average, 11 months).
Among the 24, 16 underwent concomitant unilateral IIA embolization in the setting of EVAR and eight patients underwent the staged procedure. Average duration of operative time (298 vs 284 minutes), amount of intravenous contrast (215 mL vs 164 mL), and preoperative (1.12 vs 1.26 mg/dL), and postoperative (1.15 v. 1.31 mg/dl) creatinine levels were similar in the concomitant vs staged group, respectively (P > .05 for all factors). More sensitive markers of renal insufficiency such as creatinine clearance were not measured. In the concomitant group, 25% (4/16) of patients reported significant symptoms of buttock claudication ipsilateral to the embolized IIA, which resolved after a mean of 8.8 months (range, 1 to 15 months) vs no cases (0/8) in the staged group (P = .02048). One patient in the staged group developed ischemic colitis, which was treated conservatively. Coil embolizations that were performed as staged procedures were all done on an outpatient basis. All 24 patients were admitted the day of the EVAR and were discharged the next day, except one patient in the concomitant group was discharged the second day after the procedure, and one patient in the staged group was discharged 7 days after the procedure.
Despite concern of prolonged operative time and the amount of contrast needed to perform concomitant IIA embolization and EVAR, our results showed that in patients with normal renal function, concomitant unilateral IIA embolization in the setting of EVAR was safe and effective and associated with shorter hospitalization compared with staged procedures. The disadvantage of a concomitant procedure is an increased likelihood of transient buttock claudication, but the small number of patients in this series prohibits definite conclusions about this complication. The concomitant procedure may be preferable for infirm patients with normal renal function who would be greatly inconvenienced by two procedures.
对于腹主动脉瘤（AAA）累及髂总动脉的患者，在血管腔内修复术（EVAR）期间，将移植物肢体延伸至髂外动脉并栓塞髂内动脉（IIA）对于预防内漏可能是必要的。IIA的弹簧圈栓塞可以与EVAR在同一手术过程中进行，或者作为分期手术进行。大多数介入医生倾向于后一种方法，以避免过多的造影剂和延长手术时间。我们研究了在EVAR背景下同期与分期单侧IIA栓塞的临床结果。
2000年10月1日至2005年6月30日，我院血管外科医生治疗了24例接受肾下EVAR和单侧IIA弹簧圈栓塞的患者。所有患者肾功能均正常。对同期与分期手术患者的手术操作细节和围手术期并发症进行了比较。随访时间为1至40个月（平均11个月）。
24例患者中，16例在EVAR时同期进行了单侧IIA栓塞，8例患者接受了分期手术。同期组与分期组的平均手术时间（298分钟对284分钟）、静脉造影剂用量（215 mL对164 mL）、术前（1.12 mg/dL对1.26 mg/dL）和术后（1.15 mg/dL对1.31 mg/dL）肌酐水平相似（所有因素P>.05）。未测量肌酐清除率等更敏感的肾功能不全指标。同期组中，25%（4/16）的患者报告栓塞侧IIA同侧臀部出现明显的间歇性跛行症状，平均8.8个月（范围1至15个月）后症状缓解，而分期组无此情况（0/8）（P = 0.02048）。分期组中有1例患者发生缺血性结肠炎，经保守治疗。分期进行的弹簧圈栓塞均在门诊完成。所有24例患者均在EVAR当天入院，除同期组1例患者术后第二天出院，分期组1例患者术后7天出院外，其余患者均于次日出院。
尽管担心同期进行IIA栓塞和EVAR会延长手术时间和增加造影剂用量，但我们的结果表明，对于肾功能正常的患者，EVAR时同期进行单侧IIA栓塞是安全有效的，且与分期手术相比住院时间更短。同期手术的缺点是短暂性臀部间歇性跛行的可能性增加，但本系列患者数量较少，无法就该并发症得出明确结论。对于肾功能正常但身体虚弱的患者，同期手术可能更可取，因为两次手术会给他们带来极大不便。
