Department of Vascular and Endovascular Surgery, Klinikum Nürnberg, Nürnberg, Germany.
Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands.
J Vasc Surg. 2014 Feb;59(2):307-14. doi: 10.1016/j.jvs.2013.07.118. Epub 2013 Sep 29.
Juxtarenal aneurysms after previous surgical aortic reconstruction constitute a complex clinical scenario. Open redo surgery is technically demanding and usually requires suprarenal or supraceliac clamping. Standard endovascular repair is prohibited due to the lack of a proximal landing zone. We present our experience with fenestrated endovascular aneurysm repair (F-EVAR) in the treatment of juxtarenal aneurysms after previous open surgery.
A prospectively maintained database including all patients with juxtarenal abdominal aortic aneurysm after previous surgical reconstruction that underwent F-EVAR within the period from November 2003 to February 2013 under the instruction of the senior author. Evaluated outcomes included initial technical success and operative mortality and morbidity as well as late survival, target vessel patency, aneurysm diameter regression, renal function, and reintervention.
A total of 35 patients (33 male; mean age, 71.5 ± 6.2 years) were treated. Median interval from the primary surgical reconstruction was 126 months (range, 48-223 months). All patients had proximal anatomies precluding standard endovascular techniques and were considered high risk for open repair due to their comorbidities and redo nature of the operation. In total, 111 vessels were targeted: 77 with small fenestrations, 33 with scallops, and 1 vessel with a downward branch. The operation was completed by totally endovascular means in 34 patients (97.1%). In one patient, a retroperitoneal approach was needed to gain retrograde access to a renal artery. Operative target vessel perfusion success rate was 100%. Operative mortality was 0% and median hospital stay 6 days (range, 2-40 days). Mean follow-up (FU) was 37.5 ± 25 months. Mean aneurysm maximal diameter decreased from 60 ± 4 mm to 47 ± 8 mm (P < .05). No type I endoleak was diagnosed, and no reintervention was required during FU. There were eight late deaths, all unrelated to the aneurysm. Estimated survival rates at 1, 2, and 4 years were 92.0% ± 5.5%, 82.8% ± 7.9% and 76.9% ± 9.3%, respectively. Three target vessel occlusions occurred during FU. One patient suffered a bilateral renal artery occlusion resulting in dialysis. In a second patient, one renal artery occluded without clinical symptoms. No other cases of renal function deterioration were observed.
F-EVAR is a valid treatment option for juxtarenal aneurysms after previous surgical reconstruction. F-EVAR represents a less morbid alternative to redo open surgery, has a high technical success rate, and shows durability in mid-term FU.
肾周动脉瘤在先前的主动脉重建手术后构成了一个复杂的临床情况。开放的再次手术在技术上要求较高，通常需要肾上或肾下单腔夹闭。由于缺乏近端着陆区，标准的血管内修复是禁止的。我们介绍了我们在 2003 年 11 月至 2013 年 2 月期间，在资深作者的指导下，对先前开放手术后肾周动脉瘤进行开窗血管内修复（F-EVAR）治疗的经验。
前瞻性维护数据库，包括所有先前手术重建后患有肾周腹主动脉瘤的患者，这些患者在 2003 年 11 月至 2013 年 2 月期间接受了 F-EVAR 治疗。评估的结果包括初始技术成功率和手术死亡率及发病率，以及晚期存活率、靶血管通畅性、动脉瘤直径消退、肾功能和再干预。
共治疗了 35 例患者（33 例男性；平均年龄 71.5 ± 6.2 岁）。从初次手术重建到中位随访时间为 126 个月（范围 48-223 个月）。所有患者的近端解剖结构均排除了标准的血管内技术，由于其合并症和再次手术的性质，被认为是开放修复的高危因素。总共，有 111 个血管需要治疗：77 个采用小开窗，33 个采用扇贝形，1 个采用下分支。34 例患者（97.1%）完全通过血管内方式完成了手术。在 1 例患者中，需要经腹膜后入路以逆行进入肾动脉。手术目标血管灌注成功率为 100%。手术死亡率为 0%，平均住院时间为 6 天（范围 2-40 天）。平均随访（FU）为 37.5 ± 25 个月。平均动脉瘤最大直径从 60 ± 4mm 减少到 47 ± 8mm（P<.05）。未诊断出 I 型内漏，FU 期间无需再次干预。FU 期间有 8 例晚期死亡，均与动脉瘤无关。1、2、4 年的估计生存率分别为 92.0%±5.5%、82.8%±7.9%和 76.9%±9.3%。FU 期间有 3 例发生靶血管闭塞。1 例患者双侧肾动脉闭塞导致透析。在第 2 例患者中，1 条肾动脉闭塞但无临床症状。未观察到其他肾功能恶化的病例。
F-EVAR 是先前手术重建后肾周动脉瘤的有效治疗选择。F-EVAR 是再次开放手术的一种危害较小的替代方法，具有较高的技术成功率，在中期 FU 中显示出耐久性。
