Katsargyris A, Oikonomou K, Spinelli D, Houthoofd S, Verhoeven E L G
Department of Vascular and Endovascular Surgery Klinikum Nürnberg, Nürnberg, Germany -
J Cardiovasc Surg (Torino). 2014 Apr;55(2 Suppl 1):95-103.
Aim of the study was to review our experience with fenestrated and branched stent-grafts to treat juxtarenal (JAA) and thoracoabdominal (TAAA) aortic aneurysms after previous open or endovascular aortic surgery.
A prospectively maintained database including all consecutive patients with JAA or TAAA treated with fenestrated/branched stent-grafts after previous open or endovascular aortic surgery within the period March 2002-November 2013 was analyzed. Evaluated outcomes included initial technical success, operative mortality and morbidity and late procedure-related events with regard to survival, target vessel patency, and re-intervention.
A total of 122 patients (110 male, 12 female; mean age mean age 70±9.5 years) were treated. Median time interval from previous aortic surgery to current fenestrated/branched stent-grafting was 80 months (range 3-261 months). Seventy-seven (63.1%) patients had previous open infrarenal aortic surgery, 33 (27%) had previous endovascular abdominal aortic aneurysm repair (EVAR), nine (7.4%) had previous open thoracic aortic surgery, and three (2.5%) had previous endovascular thoracic aortic repair (TEVAR). Indication for current treatment was a JAA in 65 (53.3%) patients and a TAAA in 57 (46.7%) patients. Technical success was achieved in 115 (94.3%) patients. Seven patients were considered as technical failure (open conversion; N.=1, target vessel loss; N.=6). Operative target vessel perfusion success rate with endovascular means was 98.5% (391/397). Intraoperative technical difficulties due to pre-existing stent-graft/surgical graft were encountered in 28 (23%) patients (access, N.=12; target vessel catheterisation, N.=16). Thirty-day operative mortality was 4.1% (5/122), with zero mortality in 65 JAA, and 8.8% (5/57) in TAAA, respectively. Cause of death was multiple organ failure (N.=3), acute gastrointestinal bleeding (N.=1), and subdural hematoma (N.=1). Major complications occurred in 20 (16.4%) patients. Median hospital stay was 7 days (range 3-50 days), and mean ICU stay 1.5±3.2 days. Mean follow-up was 22.5±21 months. All-cause late mortality was encountered in 23 patients, including one aneurysm-related mortality. Estimated survival was 91.2±3%, 83.3±4.2% and 81.1±4.6% at one, two and three years, respectively. During follow-up, eight target vessels occluded. Estimated target vessel patency was 97.2±1.1%, and 96.3±1.2% at one and three years, respectively. Reintervention during follow-up was required in 13 (10.6%) cases accounting for an estimated freedom from reintervention of 91.6±3.1%, and 82.1±5.4% at one and three years, respectively.
Fenestrated and branched stent-grafting represents a feasible option for the repair of JAA and TAAA after prior endovascular or open aortic surgery. Despite increased technical difficulties it is associated with high technical success rate and is advantageous in terms of mortality and morbidity compared to redo open aortic surgery.
本研究的目的是回顾我们使用开窗和分支型覆膜支架治疗肾旁（JAA）和胸腹主动脉（TAAA）瘤的经验，这些患者此前接受过开放性或血管腔内主动脉手术。
分析一个前瞻性维护的数据库，该数据库纳入了2002年3月至2013年11月期间所有在接受开放性或血管腔内主动脉手术后接受开窗/分支型覆膜支架治疗的连续性JAA或TAAA患者。评估的结果包括初始技术成功率、手术死亡率和发病率以及与生存、靶血管通畅率和再次干预相关的晚期手术相关事件。
共治疗了122例患者（男性110例，女性12例；平均年龄70±9.5岁5岁）。从上一次主动脉手术到此次开窗/分支型覆膜支架植入的中位时间间隔为80个月（范围3 - 261个月）。77例（63.1%）患者曾接受过开放性肾下主动脉手术，33例（27%）曾接受过血管腔内腹主动脉瘤修复术（EVAR），9例（7.4%）曾接受过开放性胸主动脉手术，3例（2.5%）曾接受过血管腔内胸主动脉修复术（TEVAR）。当前治疗的指征为JAA 65例（53.3%），TAAA 57例（46.7%）。115例（94.3%）患者获得技术成功。7例患者被视为技术失败（转为开放手术；1例，靶血管丢失；6例）。血管腔内手段的手术靶血管灌注成功率为98.5%（391/397）。28例（23%）患者因先前存在的覆膜支架/手术移植物而遇到术中技术困难（通路问题，12例；靶血管插管问题，16例）。30天手术死亡率为4.1%（5/122），其中65例JAA患者死亡率为零，TAAA患者死亡率为8.8%（5/57）。死亡原因分别为多器官功能衰竭（3例）、急性胃肠道出血（1例）和硬膜下血肿（1例）。20例（16.4%）患者发生主要并发症。中位住院时间为7天（范围3 - 50天），平均ICU住院时间为1.5±3.2天。平均随访时间为22.5±21个月。23例患者出现全因晚期死亡，其中包括1例与动脉瘤相关的死亡。1年、2年和3年的估计生存率分别为91.2±3%、83.3±4.2%和81.1±4.6%。随访期间，8条靶血管闭塞。1年和3年的估计靶血管通畅率分别为97.2±1.1%和96.3±1.2%。随访期间有13例（10.6%）患者需要再次干预，1年和3年的估计无再次干预生存率分别为91.6±3.1%和82.1±5.4%。
开窗和分支型覆膜支架植入术是先前接受血管腔内或开放性主动脉手术后修复JAA和TAAA的一种可行选择。尽管技术难度增加，但它具有较高的技术成功率，并且与再次开放性主动脉手术相比，在死亡率和发病率方面具有优势。
