主动脉套和转换器在血管内移植物迁移中的应用效果的对比分析。
A comparative analysis of the outcomes of aortic cuffs and converters for endovascular graft migration.
机构信息
Section of Vascular Surgery, Division of General Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo, USA.
出版信息
J Vasc Surg. 2010 Jun;51(6):1373-80. doi: 10.1016/j.jvs.2010.01.081.
OBJECTIVE
Proximal attachment failure, often leading to graft migration, is a severe complication of endovascular aneurysm repair (EVAR). Aortic cuffs have been used to treat proximal attachment failure with mixed results. The Zenith Renu AAA Ancillary Graft (Cook Inc, Bloomington, Ind) is available in two configurations: converter and main body extension. Both provide proximal extension with active fixation for the treatment of pre-existing endovascular grafts with failed or failing proximal fixation or seal in patients who are not surgical candidates. We prospectively compared the outcomes of patient treatment with these two device configurations.
METHODS
From September 2005 to May 2008, a prospective, nonrandomized, postmarket registry was conducted to collect data from 151 patients treated at 95 institutions for proximal aortic endovascular graft failure using the Renu graft. Treatment indications included inadequate proximal fixation or seal, for example, migration, and type I and III endoleak. A total of 136 patients (90%) had migration, 111 (74%) had endoleak, and 94 (62%) had endoleaks and graft migration. AneuRx grafts were present in 126 patients (83%), of which 89 (59%) were treated with a converter and 62 (41%) with a main body extension. Outcomes using converters vs main body extensions for endoleak rates, changes in aneurysm size, and ruptures were compared.
RESULTS
Preprocedural demographics between the two groups did not differ significantly. Procedural success rates were 98% for the converter group and 100% for the main body extension group. At a mean follow-up of 12.8 +/- 7.5 months, no type III endoleaks (0%)were identified in the converter group, and five (8%) were identified in the main body extension group. There were no aneurysm ruptures in patients treated with converters (0%) and three ruptures (5%) in patients treated with main body extensions. Each patient with aneurysm rupture had been treated with a Renu main body extension, developed a type III endoleak, and underwent surgical conversion. Two of the three patients died postoperatively.
CONCLUSIONS
Proximal attachment failure and graft migration are potentially lethal complications of EVAR. Proximal graft extension using an aortic cuff is the easiest technique for salvaging an endovascular graft. Unfortunately, it has a predictable failure mode (development of a type III endoleak due to component separation) and is associated with a significantly higher failure rate than with the use of a converter. EVAR salvage with a converter and a femorofemoral bypass is a more complex but superior option for endovascular graft salvage.
目的
血管内动脉瘤修复术（EVAR）后常发生近端连接失败，进而导致移植物迁移，这是一种严重的并发症。使用主动脉环扎带治疗近端连接失败的效果不一。Zenith Renu AAA 辅助移植物（库克公司，印第安纳州布鲁明顿）有两种配置：转换器和主体延伸。两者都为治疗现有血管内移植物的近端固定或密封失败或失效提供近端延长，并为不适合手术的患者提供主动固定。我们前瞻性地比较了这两种装置配置的患者治疗效果。
方法
2005 年 9 月至 2008 年 5 月，进行了一项前瞻性、非随机、上市后登记研究，收集了在 95 家机构使用 Renu 移植物治疗近端主动脉血管内移植物失败的 151 例患者的数据。治疗指征包括近端固定或密封不足，例如迁移和 1 型和 3 型内漏。共有 136 例（90%）患者发生迁移，111 例（74%）患者发生内漏，94 例（62%）患者发生内漏和移植物迁移。126 例患者（83%）存在 AneuRx 移植物，其中 89 例（59%）采用转换器治疗，62 例（41%）采用主体延伸治疗。比较了使用转换器和主体延伸治疗内漏率、动脉瘤大小变化和破裂的结果。
结果
两组患者的术前人口统计学特征无显著差异。转换器组的手术成功率为 98%，主体延伸组为 100%。在平均 12.8±7.5 个月的随访中，转换器组未发现 3 型内漏（0%），主体延伸组发现 5 例（8%）。采用转换器治疗的患者中无一例发生动脉瘤破裂（0%），采用主体延伸治疗的患者中有 3 例发生破裂（5%）。每例发生动脉瘤破裂的患者均接受了 Renu 主体延伸治疗，发生了 3 型内漏，并接受了手术转换。其中 3 例患者术后死亡。
结论
近端连接失败和移植物迁移是 EVAR 的潜在致命并发症。使用主动脉环扎带进行近端移植物延长是挽救血管内移植物最简单的技术。不幸的是，它具有可预测的失效模式（由于组件分离而导致 3 型内漏的发生），并且与使用转换器相比，其失效率明显更高。使用转换器和股股旁路进行 EVAR 挽救是一种更复杂但更优越的血管内移植物挽救选择。
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