Arthurs Zachary M, Lyden Sean P, Rajani Ravi R, Eagleton Matthew J, Clair Daniel G
Cleveland Clinic, OH, USA.
Ann Vasc Surg. 2011 Jan;25(1):120-6. doi: 10.1016/j.avsg.2010.08.004.
Perioperative proximal endoleaks during endovascular aneurysm repair potentiate graft migration, aneurysm sac expansion, and stent-graft failure. Adjunctive placement of a Palmaz stent at the proximal landing zone can improve proximal seal and eliminate perigraft flow; however, the long-term sequelae associated with this maneuver are unknown. We sought to evaluate the effect of Palmaz stent placement for type Ia endoleaks on delayed endoleak formation, graft migration, and aneurysm expansion.
A retrospective cohort review of a prospectively maintained database was performed. Between 2000 and 2005, all consecutive patients who had undergone infrarenal endovascular aneurysm repair were evaluated for a type I endoleak that was treated with Palmaz stent placement. Fenestrated, juxtarenal, and investigational devices were excluded from the analysis. Postoperative and follow-up axial imaging were analyzed for the following three primary endpoints: type I endoleak formation, stent-graft migration, and aneurysm sac expansion. In addition, a paired analysis was performed comparing suprarenal aortic diameters, infrarenal aortic neck diameters, aortic neck lengths, and proximal seal zones.
In all, 36 consecutive patients were identified with intraoperative type I endoleaks that were treated with Palmaz stenting. Five patients with ruptured abdominal aortic aneurysms died before discharge; the remaining 31 patients comprised the cohort for analysis. During a median follow-up period of 53 months (interquartile range: 14-91 months), no type I endoleak developed after Palmaz stent placement. Despite patients experiencing shortening of aortic neck length (26%) and loss of the proximal seal zone (35%), no stent-graft migration was seen in this population. Continued aortic degeneration accounted for proximal seal zone loss. At a distance 15 mm below the lowest renal artery, the mean aortic diameter increased by 3.2 mm (95% confidence interval: 0.4-6, p < 0.5), and 63% of patients demonstrated an increase of >10%. Mean aortic sac regression was 5.8 mm (95% confidence interval: 0.5-11.0, p < 0.05). Overall, at the final follow-up evaluation, aortic sac regression was found to have occurred in 55% of patients, aortic sac increased up to 10% in 20% of the patients, and by more than 10% in 25% of the patients.
Proximal neck reinforcement with a Palmaz stent serves as an effective endovascular adjunct to treat intraoperative type I endoleaks, and has a very high technical success rate. Most importantly, it has a clinical effect on delayed type I endoleak formation and stent-graft migration.
血管内动脉瘤修复术中围手术期近端内漏会加剧移植物移位、瘤腔扩张和支架型人工血管失败。在近端锚定区附加放置Palmaz支架可改善近端密封并消除移植物周围血流；然而，这种操作的长期后遗症尚不清楚。我们试图评估放置Palmaz支架治疗Ia型内漏对延迟性内漏形成、移植物移位和动脉瘤扩张的影响。
对前瞻性维护的数据库进行回顾性队列研究。2000年至2005年期间，对所有接受肾下血管内动脉瘤修复术的连续患者进行评估，以确定是否存在通过放置Palmaz支架治疗的I型内漏。分析中排除了开窗型、近肾型和研究性器械。对术后和随访的轴向成像进行分析，以评估以下三个主要终点：I型内漏形成、支架型人工血管移位和瘤腔扩张。此外，进行配对分析，比较肾上主动脉直径、肾下主动脉颈部直径、主动脉颈部长度和近端密封区。
总共确定了36例术中I型内漏且接受Palmaz支架置入治疗的连续患者。5例腹主动脉瘤破裂患者在出院前死亡；其余31例患者组成分析队列。在中位随访期53个月（四分位间距：14 - 91个月）内，放置Palmaz支架后未发生I型内漏。尽管患者的主动脉颈部长度缩短了26%，近端密封区减少了35%，但该人群中未观察到支架型人工血管移位。主动脉持续退变导致近端密封区丧失。在最低肾动脉下方15 mm处，主动脉平均直径增加了3.2 mm（95%置信区间：0.4 - 6，p < 0.5），63%的患者增加超过10%。瘤腔平均缩小5.8 mm（95%置信区间：0.5 - 11.0，p < 0.05）。总体而言，在最终随访评估时，55%的患者瘤腔缩小，20%的患者瘤腔增大达10%，25%的患者瘤腔增大超过10%。
用Palmaz支架加强近端颈部是治疗术中I型内漏的一种有效的血管内辅助手段，技术成功率非常高。最重要的是，它对延迟性I型内漏形成和支架型人工血管移位有临床效果。
