Rodriguez Julio A, Olsen Dawn M, Shtutman Alena, Lucas Leonardo Aguiar, Wheatley Grayson, Alpern Jeffrey, Ramaiah Venkatesh, Diethrich Edward B
Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute and Arizona Heart Hospital, Phoenix, AZ 85006, USA.
J Vasc Surg. 2007 Sep;46(3):413-20. doi: 10.1016/j.jvs.2007.05.042.
To evaluate our experience of thoracic endoluminal graft (ELG) repair of various thoracic aortic pathologies using a commercially available device approved by the Food and Drug Administration. Our patient population includes patients eligible for open surgical repair and those with prohibitive surgical risk.
From March 1998 to March 2006, endovascular stent repair of the thoracic aorta was performed on 406 patients with 324 patients (median age 72; 200 male) receiving the Gore Excluder endograft. Patient demographics, procedural characteristics, complications, including endoleak, spinal cord ischemia, and mortality, were retrospectively reviewed during follow-up. All patients were followed with chest computer tomography at 6 months and yearly. Statistical analysis was performed utilizing the SPSS Windows 11.0 program. Logistic regression (univariate) analysis used to identify risk factors for paraplegia; analysis of variance (ANOVA) for endoleak distribution; and chi(2) used to analyze variables. Survival analysis was done using SAS version 9.1 (SAS Institute, Cary, NC).
Three hundred twenty-four patients were treated with Gore Excluder graft between March 1998 and March 2006. One hundred fifty-seven patients (48.5%) had atherosclerotic aneurysms, 82 (25.3%) had dissections type B (DTB), 34 (10.5%) had penetrating ulcers (PU), 26 (8.0%) with pseudoaneurysms (PSA), 11 (3.4%) had transections (MVAT), 9 (2.8%) aorto-bronchial fistulas (AoBF), 4 (1.2%) embolization, and 1 (0.3%) aorto-esophageal fistula (AoEF). Preoperative aneurysm sac size in TAA ranged from 5 to 12 centimeters, average size 6.3 cm. Sac shrinkage occurred in 65% (102 of 157) of patients. Average postoperative sac size of 5.4 cm in a mean follow-up of 20.4 months. One hundred cases (31.5%) were nonelective; 49 (15.1%) were ruptures. Overall complication was 22.7%, 14.2% (46) in elective cases and 8.5% (28) in nonelective cases. Paraplegia occurred in five (1.5%) patients and paresis in three (0.9%); two of the latter improved and one resolved completely prior to discharge. Incidence of paraplegia was statistically significant (P value < .05) with retroperitoneal approach, perioperative blood loss greater than 1000 cc, and aortic coverage greater than 40 cm. Early endoleaks included 18 (5.5%) type I, four (1.2%) type II, and two (0.6%) type III. Thirty-day mortality was 5.5% (18 related deaths, including three intraoperative deaths). A log rank test did not find statistical differences in actuarial survival with 30-day related mortality between TAA and other pathologies (P = .29) or between DTB and other pathologies (P = .97). Late mortality was 9.6% with 31 unrelated deaths. Follow-up ranged between 1 month and 70 months, average 17 months.
Endoluminal grafting is a feasible alternative to open surgical repair for thoracic aortic pathologies. After more than 300 cases, 30-day morbidity and mortality compares favorably with open repair. Paraplegia remains low as a complication and increases in incidence with retroperitoneal approach, increased perioperative blood loss, and increased aortic coverage.
使用美国食品药品监督管理局批准的商用设备，评估我们采用胸段腔内移植物（ELG）修复各种胸主动脉病变的经验。我们的患者群体包括适合开放手术修复的患者以及手术风险极高的患者。
1998年3月至2006年3月，对406例患者进行了胸主动脉腔内支架修复，其中324例患者（中位年龄72岁；男性200例）接受了戈尔覆膜支架移植物治疗。回顾性分析患者的人口统计学资料、手术特征、并发症，包括内漏、脊髓缺血和死亡率。所有患者在术后6个月和每年进行胸部计算机断层扫描随访。使用SPSS Windows 11.0程序进行统计分析。采用逻辑回归（单变量）分析确定截瘫的危险因素；采用方差分析（ANOVA）分析内漏分布；采用卡方检验分析变量。使用SAS 9.1版本（SAS Institute，Cary，NC）进行生存分析。
1998年3月至2006年3月期间，324例患者接受了戈尔覆膜支架移植物治疗。157例患者（48.5%）患有动脉粥样硬化性动脉瘤，82例（25.3%）患有B型夹层（DTB），34例（10.5%）患有穿透性溃疡（PU），26例（8.0%）患有假性动脉瘤（PSA），11例（3.4%）患有横断伤（MVAT），9例（2.8%）患有主动脉支气管瘘（AoBF），4例（1.2%）患有栓塞，1例（0.3%）患有主动脉食管瘘（AoEF）。胸段动脉瘤术前瘤囊大小为5至12厘米，平均大小为6.3厘米。65%（157例中的102例）的患者瘤囊缩小。平均随访20.4个月，术后瘤囊平均大小为5.4厘米。100例（31.5%）为非选择性手术；49例（15.1%）为破裂病例。总体并发症发生率为22.7%，择期手术病例为14.2%（46例），非择期手术病例为8.5%（28例）。5例（1.5%）患者发生截瘫，3例（0.9%）患者发生轻瘫；后3例中有2例症状改善，1例在出院前完全恢复。采用腹膜后入路、围手术期失血量超过1000 cc和主动脉覆盖长度超过40 cm时，截瘫发生率具有统计学意义（P值<0.05）。早期内漏包括18例（5.5%）I型、4例（1.2%）II型和2例（0.6%）III型。30天死亡率为5.5%（18例相关死亡，包括3例术中死亡）。对数秩检验未发现胸段动脉瘤与其他病变之间（P = 0.29）或B型夹层与其他病变之间（P = 0.97）在30天相关死亡率的精算生存率上存在统计学差异。晚期死亡率为9.6%，有31例非相关死亡。随访时间为1个月至70个月，平均17个月。
对于胸主动脉病变，腔内移植物植入术是开放手术修复的一种可行替代方法。超过300例手术之后，30天的发病率和死亡率与开放手术相比具有优势。截瘫作为一种并发症发生率仍然较低，且随着腹膜后入路、围手术期失血量增加和主动脉覆盖长度增加而上升。
