Byrne John, Mehta Manish, Dominguez Ivan, Paty Philip S, Roddy Sean P, Feustel Paul, Sternbach Yaron, Darling R Clement
The Vascular Group, The Institute for Vascular Heath and Disease, Albany Medical College, The Center for Vascular Awareness, Inc., Albany, New York 12208, USA.
Ann Vasc Surg. 2013 May;27(4):401-11. doi: 10.1016/j.avsg.2012.10.007. Epub 2013 Mar 26.
Endovascular aneurysm repair (EVAR) is now the standard of care for elective infrarenal and ruptured abdominal aortic aneurysms (AAAs). Difficult proximal necks often require adjuvant measures to seal type 1 endoleaks. We believed this was a predictor of increased 30-day morbidity and mortality and reduced long-term survival.
We reviewed outcomes for all patients entered into our database between 2003 and 2010 who had EVAR for elective or ruptured AAAs. Patient demographics and operative indications were recorded. Operative procedures, including adjuvant procedures, such as Palmaz XL stent deployment, were documented. All postoperative deaths and morbidity were recorded. Long-term survival was calculated using life table analysis. Multivariate analysis was performed to determine significant predictors of early mortality.
Between 2003 and 2010, 1470 patients underwent EVAR for AAA (1378 [93.7%] elective; 92 [6.3%] ruptured or emergent). Elective EVAR patients required Palmaz stent placement in 146 of 1378 (10.6%) cases; in emergent cases, Palmaz stents were required in 16 of 92 (17.4%) cases. This was not significantly different (P=0.06). Thirty-day mortality for elective EVAR was 1.6% (22/1378) compared with 21.7% (20/92) for emergent repair (P<0.0001). Thirty-day mortality among the 146 elective patients undergoing Palmaz stenting was 3.4% compared with 1.4% in the 1232 non-Palmaz stent elective EVAR patients (P=0.085). In emergency cases, the 30-day mortality for the 16 Palmaz patients was 25% compared to 21% for the 76 non-Palmaz stent patients (P=0.76). Among 30-day survivors, there were 428 of 1356 (31.6%) endoleaks identified in the elective patient group and 36 of 72 (50%) in the emergency group (P<0.005). Of the 146 elective patients requiring insertion of a Palmaz stent, 65 (44%) developed endoleaks, significantly more than the 370 of 1232 (30%) in non-Palmaz elective patients (P=0.0004). Among the emergency group, there were also significantly more endoleaks among the 30-day survivors who had a Palmaz stent deployed. In elective EVAR requiring Palmaz XL stents, 14% still had type 1 endoleaks at the end of their procedure; 13% still had type 1 endoleaks in the rupture EVAR Palmaz group. Multivariate analysis of all patients found that while female sex, AAA diameter, and estimated blood loss predicted 30-day mortality, deployment of a Palmaz stent did not. Long-term survival among Palmaz patients was not significantly different from non-Palmaz patients in the elective or emergent setting, although Palmaz patients required more secondary interventions.
During EVAR, deployment of a Palmaz stent is more frequently required in patients with rupture, female sex, and larger sac size. However, Palmaz stent deployment itself is not an independent predictor of increased 30-day mortality in either the elective or emergency setting or of poorer long-term survival. However, they are associated with a greater number of postoperative endoleaks, especially type 1 endoleaks, and predict a greater need for secondary interventions.
血管内动脉瘤修复术（EVAR）现已成为择期肾下型和破裂性腹主动脉瘤（AAA）的标准治疗方法。困难的近端瘤颈通常需要辅助措施来封闭Ⅰ型内漏。我们认为这是30天发病率和死亡率增加以及长期生存率降低的一个预测因素。
我们回顾了2003年至2010年期间录入我们数据库的所有因择期或破裂性AAA接受EVAR治疗的患者的结局。记录患者的人口统计学资料和手术指征。记录手术过程，包括辅助手术，如Palmaz XL支架置入。记录所有术后死亡和发病情况。使用生命表分析计算长期生存率。进行多变量分析以确定早期死亡的显著预测因素。
2003年至2010年期间，1470例患者因AAA接受了EVAR治疗（1378例[93.7%]为择期手术；92例[6.3%]为破裂或急诊手术）。择期EVAR患者中，1378例中有146例（10.6%）需要置入Palmaz支架；在急诊病例中，92例中有16例（17.4%）需要置入Palmaz支架。这一差异无统计学意义（P=0.06）。择期EVAR的30天死亡率为1.6%（22/1378），而急诊修复的死亡率为21.7%（20/92）（P<0.0001）。146例接受Palmaz支架置入的择期患者的30天死亡率为3.4%，而1232例未置入Palmaz支架的择期EVAR患者的死亡率为1.4%（P=0.085）。在急诊病例中，16例接受Palmaz支架置入的患者的30天死亡率为25%，而76例未置入Palmaz支架的患者的死亡率为21%（P=0.76）。在30天幸存者中，择期患者组1356例中有428例（31.6%）发现内漏，急诊组72例中有36例（50%）发现内漏（P<0.005）。在146例需要置入Palmaz支架的择期患者中，65例（44%）发生了内漏，显著多于1232例未置入Palmaz支架的择期患者中的370例（30%）（P=0.0004）。在急诊组中，接受Palmaz支架置入的30天幸存者中的内漏也显著更多。在需要置入Palmaz XL支架的择期EVAR中，14%的患者在手术结束时仍存在Ⅰ型内漏；在破裂性EVAR的Palmaz组中，13%的患者仍存在Ⅰ型内漏对所有患者进行多变量分析发现，虽然女性、AAA直径和估计失血量可预测30天死亡率，但Palmaz支架的置入并不能预测。在择期或急诊情况下，Palmaz支架置入患者的长期生存率与未置入Palmaz支架的患者无显著差异，尽管Palmaz支架置入患者需要更多的二次干预。
在EVAR期间，破裂、女性和瘤体较大的患者更常需要置入Palmaz支架。然而，Palmaz支架置入本身并不是择期或急诊情况下30天死亡率增加或长期生存率较差的独立预测因素。然而，它们与更多的术后内漏相关，尤其是Ⅰ型内漏，并预示着更大的二次干预需求。
