Pintoux David, Chaillou Philippe, Azema Laure, Bizouarn Philippe, Costargent Alain, Patra Philippe, Gouëffic Yann
Service de Chirurgie Vasculaire, Institut du Thorax, CHU de Nantes, Nantes, France.
Ann Vasc Surg. 2011 Nov;25(8):1012-9. doi: 10.1016/j.avsg.2010.08.013.
We evaluated the influence of the proximal fixation systems of stentgrafts on proximal inter-renal or infrarenal aneurysm neck dilatation after endovascular repair of abdominal aortic aneurysms. Anatomic and clinical predictive factors of neck dilatation and stentgraft proximal migration were searched for.
Taking account of a prospective and monocenter register, 58 patients' files, with a complete minimum 3-year follow-up, were analyzed after treatment with stentgrafts with a suprarenal fixation (SRF: 33 Talent) or an infrarenal fixation (IRF: 25 AneuRx). Both groups were compared in terms of inter-renal neck dilatation (D1: diameter between the two renal arteries), infrarenal neck dilatation (D2: 7-mm diameter under the lowest renal artery), and specific complication (proximal migration, endoleak). The diameter measured on the last control computed tomography scan was compared with the postoperative diameter. Neck dilatation was defined by a diameter increase exceeding 3 mm and by the proximal migration due to a caudal displacement of the stentgraft ≥10 mm. Predictive factors of proximal migration or neck dilatation were searched for (anatomy of the neck, aneurysm anatomy, stent graft oversize percentage, demographic factors).
Preoperatively, both groups were comparable in terms of anatomic and demographic characteristics of the aneurysm. Mean follow-up was longer in the AneuRx group (62 ± 17 months vs. 53 ± 13 months, p = 0.045) and the percentage of stent graft oversize was greater in the Talent group (18 ± 6% vs. 13 ± 5%, p < 10(-4)). Freedom from a dilatation exceeding 3 mm in D1 and D2 did not bring any significant difference between the two groups. In each group, the remodeling of the aneurysmal sac (AneuRx median = -4 mm, Talent median = -5 mm, p > 0.05) was only moderately related to proximal neck remodeling. A small angulation of the neck and a smaller neck were the only predictive factors of neck dilatation found respectively in D1 (p = 0.007) and in D2 (p = 0.022). Stent graft proximal migration was more frequent in the AneuRx group (p = 0.031) and was more frequent with large aneurysms (p = 0.029).
In the long term, the absence of proximal stent graft fixation system on the dilatation of the aneurysm proximal neck enhances proximal migration. Conversely, the inter-renal or infrarenal proximal neck dilatation does not depend on the type of proximal fixation but on anatomic factors and on the natural evolution of the aneurysmal disease.
我们评估了腹主动脉瘤血管腔内修复术后，覆膜支架近端固定系统对肾动脉近端或肾下动脉瘤颈部扩张的影响。探寻了颈部扩张和覆膜支架近端移位的解剖学及临床预测因素。
基于一项前瞻性单中心登记研究，分析了58例患者的资料，这些患者接受了肾上固定（SRF：33例使用Talent）或肾下固定（IRF：25例使用AneuRx）的覆膜支架治疗，且至少有3年的完整随访。比较了两组在肾动脉间颈部扩张（D1：双侧肾动脉之间的直径）、肾下颈部扩张（D2：最低肾动脉下方7毫米处的直径）以及特定并发症（近端移位、内漏）方面的情况。将最后一次对照计算机断层扫描测量的直径与术后直径进行比较。颈部扩张定义为直径增加超过3毫米以及由于覆膜支架尾端移位≥10毫米导致的近端移位。探寻近端移位或颈部扩张的预测因素（颈部解剖结构、动脉瘤解剖结构、覆膜支架尺寸过大百分比、人口统计学因素）。
术前，两组在动脉瘤的解剖学和人口统计学特征方面具有可比性。AneuRx组的平均随访时间更长（62±17个月对53±13个月，p = 0.045），Talent组的覆膜支架尺寸过大百分比更高（18±6%对13±5%，p < 10⁻⁴）。D1和D2处直径增加不超过3毫米的情况在两组之间无显著差异。在每组中，动脉瘤囊的重塑（AneuRx组中位数 = -4毫米，Talent组中位数 = -5毫米，p > 0.05）与近端颈部重塑仅呈中度相关。颈部小角度和较小的颈部分别是D1（p = 0.007）和D2（p = 0.022）中发现的颈部扩张的唯一预测因素。AneuRx组中覆膜支架近端移位更频繁（p = 0.031），且在大动脉瘤中更频繁（p = 0.029）。
从长期来看，近端覆膜支架固定系统的缺失会增加动脉瘤近端颈部扩张导致的近端移位。相反，肾动脉近端或肾下近端颈部扩张不取决于近端固定类型，而是取决于解剖学因素和动脉瘤疾病的自然演变。
