腔内修复术后延迟性腹主动脉瘤破裂的治疗选择。
Treatment options for delayed AAA rupture following endovascular repair.
机构信息
Institute for Vascular Health and Disease, Albany Medical College, The Vascular Group, Albany, NY 12208, USA.
出版信息
J Vasc Surg. 2011 Jan;53(1):14-20. doi: 10.1016/j.jvs.2010.07.052. Epub 2010 Sep 26.
PURPOSE
Delayed abdominal aortic aneurysm (AAA) rupture is a well recognized complication of endovascular aneurysm repair (EVAR). We wanted to evaluate the frequency, etiology, and outcomes of delayed AAA rupture following EVAR, and identify treatment options that facilitate improved survival.
METHODS
From 2002 to 2009, 1768 patients underwent elective and emergent EVAR. At a mean follow-up of 29 months, 27 (1.5%) patients presented with delayed AAA rupture and required repair by either open surgical conversion or endovascular means. All data were prospectively collected in a vascular registry, and outcomes analyzed.
RESULTS
Over a mean follow-up of 29 months, the incidence of delayed AAA rupture after elective EVAR was 1.4% (24 of 1615 patients), and after emergent EVAR for ruptured AAA was 2.8% (3 of 106 patients). Of the 27 delayed AAA rupture patients, 20 (74%) were considered "lost to follow-up," and, at presentation, 17 (63%) patients had Type 1 endoleak with stent graft migration, three (11%) had Type 1 endoleak without stent graft migration, five (19%) had Type 2 endoleak, and two (7%) had undetermined etiology for aneurysm rupture. Fifteen (55%) patients underwent open surgical repair via retroperitoneal approach with partial (n = 8; 53%) or complete (n = 7; 47%) stent graft explants and aortoiliac reconstruction, 11 (41%) patients underwent a second EVAR, and one (4%) patient refused treatment and died. Supraceliac aortic clamp was required in three (20%) patients with open surgical conversion, and supraceliac occlusion balloon was required in two (18%) patients with EVAR. There were three (11%) postoperative deaths; two following open surgical conversion and one following EVAR. One additional redo-EVAR patient has undergone successful elective conversion to open surgical repair for persistent type II endoleak and increase in AAA size.
CONCLUSIONS
Delayed AAA rupture following EVAR can be successfully managed in most patients by open surgical conversion or secondary EVAR. The approach to each patient should be individualized; complete stent graft explant is not necessary in most patients; a secondary EVAR for delayed AAA rupture with or without an elective conversion to open surgical repair remains a viable option. Vigilant routine follow-up is needed for all patients after EVAR.
目的
延迟性腹主动脉瘤（AAA）破裂是血管内动脉瘤修复术（EVAR）的一种公认并发症。我们旨在评估 EVAR 后延迟性 AAA 破裂的频率、病因和结果，并确定有助于提高生存率的治疗选择。
方法
2002 年至 2009 年，1768 例患者接受了择期和紧急 EVAR。在平均 29 个月的随访中，27 例（1.5%）患者出现延迟性 AAA 破裂，需要通过开放手术转换或血管内方法进行修复。所有数据均在血管登记处前瞻性收集，并进行了结果分析。
结果
在平均 29 个月的随访中，择期 EVAR 后延迟性 AAA 破裂的发生率为 1.4%（1615 例患者中的 24 例），紧急 EVAR 治疗破裂性 AAA 后的发生率为 2.8%（106 例患者中的 3 例）。在 27 例延迟性 AAA 破裂患者中，20 例（74%）被认为“失访”，就诊时，17 例（63%）患者存在支架移植物迁移的 1 型内漏，3 例（11%）患者存在无支架移植物迁移的 1 型内漏，5 例（19%）患者存在 2 型内漏，2 例（7%）患者的动脉瘤破裂病因不确定。15 例（55%）患者通过经腹膜后途径行开放手术修复，其中 8 例（53%）行部分支架移植物取出，7 例（47%）行完全支架移植物取出和腹主动脉髂动脉重建，11 例（41%）患者行二次 EVAR，1 例（4%）患者拒绝治疗并死亡。在 3 例接受开放手术转换的患者中需要使用腹主动脉上方的主动脉夹，在 2 例接受 EVAR 的患者中需要使用腹主动脉上方的阻断球囊。术后有 3 例（11%）死亡；2 例死于开放手术转换，1 例死于 EVAR。另一位再次行 EVAR 的患者因持续 2 型内漏和 AAA 增大而成功转为择期开放手术修复。
结论
大多数 EVAR 后延迟性 AAA 破裂的患者可以通过开放手术转换或二次 EVAR 成功治疗。应根据每位患者的具体情况进行个体化治疗；大多数患者无需完全取出支架移植物；对于延迟性 AAA 破裂，行二次 EVAR 或联合择期开放手术修复仍然是一种可行的选择。所有 EVAR 后患者均需要进行严密的常规随访。
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