Moise Mireille A, Woo Edward Y, Velazquez Omaida C, Fairman Ronald M, Golden Michael A, Mitchell Marc E, Carpenter Jeffrey P
Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-4227, USA.
Vasc Endovascular Surg. 2006 May-Jun;40(3):197-203. doi: 10.1177/153857440604000304.
Despite improvements in endovascular aortic aneurysm repair (EVAR) devices and techniques, significant anatomic constraints still preclude successful EVAR in a large number of patients. The authors sought to identify the current barriers to EVAR and examine their evolution over time. Patients were evaluated for potential endovascular repair by computed tomography angiography (CTA) with or without supplemental conventional arteriograms. The patient population was separated into 2 groups (A and B) based on early and late time periods in the experience with EVAR, corresponding to the availability of various devices. Group A (early) consisted of the Guidant Ancure, Medtronic Talent, and AneuRx devices and comprised patients presenting between April 1997 through June 2000. Group B (late) consisted of the Medtronic AneuRx, Cook Zenith, Edwards Lifepath, Gore Excluder, and Endologix PowerLink devices and comprised patients presenting between July 2000 and December 2003. Patient demographics and anatomic reasons for rejection were recorded in a database for statistical analysis. In total, 547 patients were evaluated (463 men, 84 women). Of these, 346 patients (63%; 312 men, 34 women) were deemed suitable candidates for EVAR and 201 (37%; 151 men, 50 women) were rejected. There was no significant difference in the overall rate of rejection in the early vs the late time period (34% A, 41% B, p = 0.08), but the number of exclusion criteria per patient decreased over time; patients rejected for EVAR had an overall average of 1.6 exclusion criteria (Group A, 1.9; Group B, 1.2). The reasons for rejection did significantly change over time. Specifically, rejection on the basis of inadequate arterial access, presence of extensive iliac artery aneurysms, or an inadequate proximal neck decreased. A disproportionate number of women were excluded throughout the study: Group A, 56% of women compared to 30% of men (p = 0.0003); Group B, 63% of women compared to 36% of men (p = 0.0022). Women were more likely than men to have inadequate arterial access routes. In addition, patients with high operative risk were also more likely to be excluded from EVAR, a finding that persisted over time. Anatomic constraints continue to pose significant challenges to aortic endografting. Progress has been made in that technological advances have conquered some of the previous anatomic challenges, chiefly those of arterial access and treatment of concomitant iliac aneurysm disease. However, the overall rate of rejection for EVAR remains the same. The chief anatomic barriers continue to be the difficult aortic neck and management of branched vascular segments.
尽管血管内主动脉瘤修复（EVAR）设备和技术有所改进，但严重的解剖学限制仍使大量患者无法成功进行EVAR。作者试图确定当前EVAR的障碍，并研究其随时间的演变。通过计算机断层扫描血管造影（CTA）对患者进行潜在的血管内修复评估，必要时辅以传统动脉造影。根据EVAR经验的早期和晚期时间段，将患者群体分为两组（A组和B组），这与各种设备的可用性相对应。A组（早期）包括Guidant Ancure、Medtronic Talent和AneuRx设备，包括1997年4月至2000年6月期间就诊的患者。B组（晚期）包括Medtronic AneuRx、Cook Zenith、Edwards Lifepath、Gore Excluder和Endologix PowerLink设备，包括2000年7月至2003年12月期间就诊的患者。患者人口统计学和拒绝的解剖学原因记录在数据库中进行统计分析。总共评估了547例患者（463例男性，84例女性）。其中，346例患者（63%；312例男性，34例女性）被认为是EVAR的合适候选人，201例（37%；151例男性，50例女性）被拒绝。早期和晚期的总体拒绝率没有显著差异（A组34%，B组41%，p = 0.08），但每位患者的排除标准数量随时间减少；因EVAR被拒绝的患者总体平均有1.6个排除标准（A组1.9个；B组1.2个）。拒绝的原因确实随时间发生了显著变化。具体而言，因动脉入路不足、广泛髂动脉瘤的存在或近端颈部不足而被拒绝的情况减少。在整个研究过程中，被排除的女性比例过高：A组，女性为56%，男性为30%（p = 0.0003）；B组，女性为63%，男性为36%（p = 0.0022）。女性比男性更有可能有不足的动脉入路途径。此外，手术风险高的患者也更有可能被排除在EVAR之外，这一发现随着时间的推移持续存在。解剖学限制仍然对主动脉内植入术构成重大挑战。在技术进步克服了一些以前解剖学挑战方面取得了进展，主要是动脉入路和伴发髂动脉瘤疾病的治疗方面。然而，EVAR的总体拒绝率仍然相同。主要的解剖学障碍仍然是困难的主动脉颈部和分支血管段的处理。
