Turney Eric J, Steenberge Sean P, Lyden Sean P, Eagleton Matthew J, Srivastava Sunita D, Sarac Timur P, Kelso Rebecca L, Clair Daniel G
Department of Vascular Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.
Department of Vascular Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.
J Vasc Surg. 2014 Apr;59(4):886-93. doi: 10.1016/j.jvs.2013.10.079. Epub 2013 Dec 28.
With more than a decade of use of endovascular aneurysm repair (EVAR), we expect to see a rise in the number of failing endografts. We review a single-center experience with EVAR explants to identify patterns of presentation and understand operative outcomes that may alter clinical management.
A retrospective analysis of EVARs requiring late explants, >1 month after implant, was performed. Patient demographics, type of graft, duration of implant, reason for removal, operative technique, length of stay, complications, and in-hospital and late mortality were reviewed.
During 1999 to 2012, 100 patients (91% men) required EVAR explant, of which 61 were placed at another institution. The average age was 75 years (range, 50-93 years). The median length of time since implantation was 41 months (range, 1-144 months). Explanted grafts included 25 AneuRx (Medtronic, Minneapolis, Minn), 25 Excluder (W. L. Gore & Associates, Flagstaff, Ariz), 17 Zenith (Cook Medical, Bloomington, Ind), 15 Talent (Medtronic), 10 Ancure (Guidant, Indianapolis, Ind), 4 Powerlink (Endologix, Irvine, Calif), 1 Endurant (Medtronic), 1 Quantum LP (Cordis, Miami Lakes, Fla), 1 Aorta Uni Iliac Rupture Graft (Cook Medical, Bloomington, Ind), and 1 homemade tube graft. Overall 30-day mortality was 17%, with an elective case mortality of 9.9%, nonelective case mortality of 37%, and 56% mortality for ruptures. Endoleak was the most common indication for explant, with one or more endoleaks present in 82% (type I, 40%; II, 30%; III, 22%; endotension, 6%; multiple, 16%). Other reasons for explant included infection (13%), acute thrombosis (4%), and claudication (1%). In the first 12 months, 23 patients required explants, with type I endoleak (48%) and infection (35%) the most frequent indication. Conversely, 22 patients required explants after 5 years, with type I (36%) and type III (32%) endoleak responsible for most indications.
The rate of EVAR late explants has increased during the past decade at our institution. Survival is higher when the explant is done electively compared with emergent repair. Difficulty in obtaining a seal at the initial EVAR often leads to failure ≤1 year, whereas progression of aneurysmal disease is the primary reason for failure >5 years.
随着血管内动脉瘤修复术（EVAR）应用超过十年，我们预计失败的血管内移植物数量会增加。我们回顾了单中心EVAR取出术的经验，以确定其表现模式并了解可能改变临床管理的手术结果。
对植入后>1个月需要晚期取出的EVAR进行回顾性分析。回顾了患者的人口统计学资料、移植物类型、植入时间、取出原因、手术技术、住院时间、并发症以及住院期间和晚期死亡率。
1999年至2012年期间，100例患者（91%为男性）需要进行EVAR取出术，其中61例是在其他机构植入的。平均年龄为75岁（范围50 - 93岁）。植入后的中位时间为41个月（范围1 - 144个月）。取出的移植物包括25个AneuRx（美敦力公司，明尼阿波利斯，明尼苏达州）、25个Excluder（W.L.戈尔公司，弗拉格斯塔夫，亚利桑那州）、17个Zenith（库克医疗公司，布卢明顿，印第安纳州）、15个Talent（美敦力公司）、10个Ancure（Guidant公司，印第安纳波利斯，印第安纳州）、4个Powerlink（Endologix公司，尔湾，加利福尼亚州）、1个Endurant（美敦力公司）、1个Quantum LP（科迪斯公司，迈阿密湖，佛罗里达州）、1个主动脉单髂动脉破裂移植物（库克医疗公司，布卢明顿，印第安纳州）和1个自制的管状移植物。总体30天死亡率为17%，择期手术病例死亡率为9.9%，非择期手术病例死亡率为37%，破裂病例死亡率为56%。内漏是取出术最常见的指征，82%的患者存在一个或多个内漏（I型，40%；II型，30%；III型，22%；内张力，6%；多种类型，16%）。其他取出原因包括感染（13%）、急性血栓形成（4%）和跛行（1%）。在最初的12个月内，23例患者需要取出移植物，最常见的指征是I型内漏（48%）和感染（35%）。相反，22例患者在5年后需要取出移植物，I型（36%）和III型（32%）内漏是最主要的指征。
在过去十年中，我们机构的EVAR晚期取出率有所增加。与急诊修复相比，择期取出术的生存率更高。初次EVAR时难以获得密封通常导致≤1年的失败，而动脉瘤疾病的进展是>5年失败的主要原因。
