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血管内主动脉瘤修复失败后的晚期开放转换。

Late open conversion after failed endovascular aortic aneurysm repair.

机构信息

First Department of Surgery, Vascular Division, "Laikon" Hospital, Athens University Medical School, Athens, Greece; Second Department of Propedeutic Surgery, Vascular Division, "Laikon" Hospital, Athens University Medical School, Athens, Greece.

Second Department of Propedeutic Surgery, Vascular Division, "Laikon" Hospital, Athens University Medical School, Athens, Greece.

出版信息

J Vasc Surg. 2014 Feb;59(2):291-7. doi: 10.1016/j.jvs.2013.07.106. Epub 2013 Oct 16.

Abstract

OBJECTIVE

Endovascular aortic aneurysm repair (EVAR) is widely used for the treatment of abdominal aortic aneurysms. Complications secondary to EVAR are also treated with endovascular techniques. When this is not applicable, open surgical repair is mandatory. This study aims to present our experience in open surgical repair after failed EVAR.

METHODS

Within the period from 2004 through 2013, 18 patients (17 men; mean age, 73.9 years) were operated on because of EVAR failure due to persistent type II endoleak (n = 10), type I or III endoleak (n = 3), mixed-type endoleaks (n = 2), stent graft thrombosis (n = 2), and aortoenteric fistulae (n = 1). Stent grafts used for EVAR were Zenith (n = 8), Talent (n = 4), Excluder (n = 4), and Anaconda (n = 2).

RESULTS

Mean time interval between EVAR and open conversion was 36 months (range, 2-120 months). Fifteen (83.3%) operations were elective, and three (16.7%) were urgent due to aneurysm rupture (n = 2) and aortoenteric fistula (n = 1). Six (33.3%) patients with type II endoleak were treated with simple ligation of the culprit vessels, without aortic clamping and stent graft explantation. In six (33.3%) patients, the stent graft was partially removed except from the segment attached to the proximal neck, while in five (27.8%) patients, complete removal of the stent graft was necessary. Finally, in one patient, with type III endoleak, a hybrid endovascular and open repair was performed. Clamping of the aorta was necessary in 12 (66.7%) patients (infrarenal, n = 10 or suprarenal, n = 2). Overall operative mortality was 5.6%. Postoperative complications included one abdominal wall defect requiring surgical revision and paroxysmal atrial fibrillation both in the same patient, and one case of pulmonary infection, requiring prolonged intubation and intensive care unit stay for 6 days.

CONCLUSIONS

Late open conversion after failed EVAR remains challenging. Avoidance of aortic cross-clamping and if possible, partial or total preservation of the stent graft may improve outcomes in terms of operative mortality and morbidity. Elective operations seem to be associated with better outcomes, prompting thus for close follow-up of EVAR patients and early decision for conversion if other options are doubtful.

摘要

目的

血管内主动脉瘤修复术(EVAR)被广泛应用于治疗腹主动脉瘤。EVAR 术后的并发症也可以采用血管内技术进行治疗。如果不适用这些技术,则需要进行开放性手术修复。本研究旨在介绍我们在 EVAR 失败后的开放性手术修复经验。

方法

在 2004 年至 2013 年期间,由于持续的 II 型内漏(n = 10)、I 型或 III 型内漏(n = 3)、混合型内漏(n = 2)、支架移植物血栓形成(n = 2)和主动脉肠瘘(n = 1),18 名患者(17 名男性;平均年龄 73.9 岁)接受了手术治疗。EVAR 中使用的支架移植物包括 Zenith(n = 8)、Talent(n = 4)、Excluder(n = 4)和 Anaconda(n = 2)。

结果

EVAR 与开放转换之间的平均时间间隔为 36 个月(范围为 2-120 个月)。15 例(83.3%)手术为择期手术,3 例(16.7%)因动脉瘤破裂(n = 2)和主动脉肠瘘(n = 1)而紧急进行。6 例(33.3%)II 型内漏患者采用单纯结扎致病血管,不进行主动脉夹闭和支架移植物取出。在 6 例(33.3%)患者中,除了与近端颈部相连的部分外,部分切除支架移植物,而在 5 例(27.8%)患者中,需要完全切除支架移植物。最后,1 例 III 型内漏患者采用血管内和开放杂交修复。12 例(66.7%)患者需要夹闭主动脉(肾下,n = 10 或肾上,n = 2)。总的手术死亡率为 5.6%。术后并发症包括 1 例腹壁缺损需手术修复,1 例患者同时出现阵发性心房颤动,1 例患者发生肺部感染,需要长时间气管插管和重症监护病房治疗 6 天。

结论

EVAR 失败后的晚期开放性转换仍然具有挑战性。避免主动脉夹闭,如果可能的话,部分或完全保留支架移植物可能会降低手术死亡率和发病率。择期手术似乎与更好的结果相关,因此需要对 EVAR 患者进行密切随访,并在其他选择不确定时尽早决定进行转换。

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