Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, People's Republic of China.
J Endovasc Ther. 2010 Dec;17(6):687-93. doi: 10.1583/10-3084.1.
To analyze a single-center experience of fibrin glue sac embolization to eliminate type I endoleaks after endovascular aneurysm repair (EVAR), assessing the feasibility and effectiveness of the technique in long-term follow-up.
A retrospective study was conducted involving 783 EVAR patients treated between August 2002 and February 2009. Under a standardized protocol, 42 (5.4%) patients (37 men; mean age 73 ± 8 years) underwent intraoperative transcatheter fibrin glue sac embolization to resolve type I endoleak persisting after initial intraoperative maneuvers to close the leak or in necks too short or angulated for cuff placement. Intrasac pressure was measured before and after glue injection. Computed tomographic angiography was performed to assess the outcome after 3, 6, and 12 months and annually thereafter.
In this type I endoleak cohort, 16 (38.1%) patients had proximal necks <10 mm long, and 5 (11.9%) patients had proximal neck angulation >60°; 22 additional devices (8 stents, 14 cuffs) had been placed in the initial attempts to resolve the endoleaks. After fibrin glue injection, 41 (97.6%) of the 42 endoleaks were resolved using a mean 15 ± 10 mL of glue. Intrasac pressure decreased significantly in successfully treated cases. The patient who failed embolotherapy was converted to open surgery (2.4%); he died 2 months later from multiorgan failure. Two (4.8%) patients died in the perioperative period from myocardial infarction. One (2.4%) patient developed right lower extremity ischemia unrelated to the fibrin glue treatment. There were no allergic reactions. Over a median follow-up of 39.9 months (range 10-88), 3 (7.1%) patients died (1 aneurysm-related). Cumulative survival was 90.5% at 1 year, 87.0% at 3 years, and 82.6% at 5 years. The mean maximal aneurysm diameter fell from the baseline 59.5 ± 14.7 mm to 49.0 ± 11.6 mm (p<0.001). Of the 4 patients with increased aneurysm diameter during follow-up, 1 was converted, 2 are being observed due to advanced age, and 1 died of renal failure. No recurrent type I endoleak or glue-related complications were observed in follow-up.
Fibrin glue sac embolization to eliminate type I endoleak after EVAR yielded excellent results in our experience, effectively and durably resolving the leaks. Balloon occlusion of the proximal aorta must be done during glue injection to block proximal flow and facilitate formation of a structured fibrin clot.
分析纤维蛋白胶在血管内动脉瘤修复术（EVAR）后封闭 I 型内漏的单中心经验，评估该技术在长期随访中的可行性和有效性。
对 2002 年 8 月至 2009 年 2 月期间接受治疗的 783 例 EVAR 患者进行回顾性研究。在标准化方案下，42 例（5.4%）患者（37 名男性；平均年龄 73±8 岁）接受术中经导管纤维蛋白胶囊栓塞术，以解决初始术中封闭漏口后或颈部过短或角度过大无法放置套环时持续存在的 I 型内漏。在注射胶前和注射胶后测量囊内压力。术后 3、6、12 个月和此后每年进行计算机断层血管造影术以评估结果。
在这组 I 型内漏患者中，16 例（38.1%）患者近端颈部长度<10mm，5 例（11.9%）患者近端颈部角度>60°；在最初尝试封闭内漏时，还放置了 22 个额外的装置（8 个支架，14 个套环）。在纤维蛋白胶注射后，42 例内漏中有 41 例（97.6%）得到成功封闭，平均使用 15±10mL 胶。在成功治疗的病例中，囊内压力显著下降。栓塞治疗失败的患者转为开放手术（2.4%）；他在术后 2 个月因多器官衰竭死亡。2 例（4.8%）患者在围手术期死于心肌梗死。1 例（2.4%）患者出现与纤维蛋白胶治疗无关的右下肢体缺血。没有过敏反应。在中位随访 39.9 个月（10-88 个月）期间，3 例（7.1%）患者死亡（1 例与动脉瘤相关）。1 年时累积生存率为 90.5%，3 年时为 87.0%，5 年时为 82.6%。最大动脉瘤直径从基线的 59.5±14.7mm 下降到 49.0±11.6mm（p<0.001）。在随访期间，4 例患者的动脉瘤直径增大，其中 1 例已改行开放手术，2 例因年龄较大正在观察，1 例死于肾衰竭。在随访中未发现复发性 I 型内漏或胶相关并发症。
在我们的经验中，纤维蛋白胶囊栓塞术治疗 EVAR 后 I 型内漏效果极佳，能有效持久地封闭内漏。在注射胶时必须进行近端主动脉球囊阻塞，以阻断近端血流并促进形成结构良好的纤维蛋白凝块。
