Slater Bethany J, Harris E John, Lee Jason T
Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA 94305, USA.
Ann Vasc Surg. 2008 Nov;22(6):716-22. doi: 10.1016/j.avsg.2008.06.001. Epub 2008 Jul 26.
Mortality from ruptured abdominal aortic aneurysms (rAAAs) remains high despite improvements in anesthesia, postoperative intensive care, and surgical techniques. Recent small series and single-center experiences suggest that endovascular aneurysm repair (EVAR) for rAAAs is feasible and may improve short-term survival. However, the applicability of EVAR to all cases of rAAA is unknown. The purpose of this study was to investigate the anatomical suitability of ruptured aneurysms for EVAR as determined by preoperative cross-sectional imaging. A contemporary consecutive series of rAAAs presenting to a tertiary academic center was retrospectively reviewed. Preoperative radiographic imaging was reviewed and assessed for endovascular compatibility based on currently available EVAR devices. Patients with aneurysm morphology demonstrating neck diameter >32 mm, neck length <10 mm, neck angulation >60 degrees, severe iliac tortuosity, or external iliac diameter <6 mm were deemed noncandidates for EVAR. Forty-seven rAAAs were treated over a 10-year period, with 47% of patients presenting with free rupture and 60% of patients transferred from outside hospitals. Five (11%) patients were treated with EVAR, all over the past 2 years, while the remaining 42 patients underwent open repair. Preoperative imaging was available for review in 43 (91%) patients, and morphological measurements indicated that 49% would have been candidates for EVAR with currently available devices. Criteria precluding EVAR in this cohort were inadequate neck length in 73%, unsuitable iliac access in 23%, large neck diameter in 18%, and severe neck angulation in 14%. Overall 30-day mortality was 34%, and 1-year mortality was 42%. Candidates for EVAR were more likely than non-EVAR candidates to be male (95% vs. 68%, p = 0.046) and to have smaller sac diameters (7.0 vs. 8.5 cm, p = 0.02) and longer neck lengths (24.1 vs. 8.6 mm, p < 0.0001); less likely to have a >60 degree angulated neck (10% vs. 45%, p = 0.0002), larger external iliac diameter (8.9 vs. 7.3 mm, p = 0.015), and less blood loss during surgical repair (2.4 vs. 6.0 L, p = 0.02); and more likely to be discharged home (71% vs. 25%, p = 0.05). There were no differences in 30-day, 1-year, or overall mortality between candidates for EVAR and noncandidates. Only 49% of patients with rAAAs in this consecutive series were found to be candidates for EVAR with conventional stent-graft devices. Differences in demographics, aneurysm morphology, and outcomes between candidates and noncandidates undergoing open repair suggest that differential risks apply to ruptured aneurysm patients. Protocols and future reports of EVAR for rAAAs should be tailored to these results. Device and technique modifications are necessary to increase the applicability of EVAR for rAAAs.
尽管在麻醉、术后重症监护和手术技术方面有所改进，但腹主动脉瘤破裂（rAAA）导致的死亡率仍然很高。最近的小样本系列研究和单中心经验表明，对rAAA进行血管内动脉瘤修复（EVAR）是可行的，并且可能提高短期生存率。然而，EVAR在所有rAAA病例中的适用性尚不清楚。本研究的目的是通过术前横断面成像来研究破裂动脉瘤进行EVAR的解剖学适宜性。对一所三级学术中心收治的一系列当代连续性rAAA病例进行了回顾性研究。回顾术前影像学检查，并根据目前可用的EVAR装置评估血管内兼容性。动脉瘤形态显示颈部直径>32mm、颈部长度<10mm、颈部成角>60度、严重髂动脉迂曲或髂外动脉直径<6mm的患者被视为不适合进行EVAR。在10年期间共治疗了47例rAAA，47%的患者表现为游离破裂，60%的患者从外院转入。5例（11%）患者接受了EVAR治疗，均在过去2年，其余42例患者接受了开放修复。43例（91%）患者有术前影像学资料可供回顾，形态学测量表明，使用目前可用的装置，49%的患者适合进行EVAR。该队列中排除EVAR的标准为：73%的患者颈部长度不足，23%的患者髂动脉入路不合适，18%的患者颈部直径大，14%的患者颈部严重成角。总体30天死亡率为34%，1年死亡率为42%。EVAR候选患者比非EVAR候选患者更可能为男性（95%对68%，p = 0.046），瘤体直径更小（7.0对8.5cm，p = 0.02），颈部长度更长（24.1对8.6mm，p < 0.0001）；颈部成角>60度的可能性更小（10%对45%，p = 0.0002），髂外动脉直径更大（8.9对7.3mm，p = 0.015），手术修复期间失血更少（2.4对6.0L，p = 0.02）；更可能出院回家（71%对25%，p = 0.05）。EVAR候选患者和非候选患者在30天、1年或总体死亡率方面没有差异。在这个连续性系列中，只有49%的rAAA患者被发现适合使用传统覆膜支架装置进行EVAR。接受开放修复的候选患者和非候选患者在人口统计学、动脉瘤形态和结局方面的差异表明，破裂动脉瘤患者面临不同的风险。rAAA的EVAR方案和未来报告应根据这些结果进行调整。需要对装置和技术进行改进，以提高EVAR在rAAA中的适用性。
