Blair R, Collins A, Harkin D W
Belfast Vascular Centre, Royal Victoria Hospital, Belfast, BT12 6BA, UK.
Ir J Med Sci. 2015 Dec;184(4):871-5. doi: 10.1007/s11845-014-1210-4. Epub 2014 Oct 17.
Endovascular repair (EVAR) for large abdominal aortic aneurysm (AAA) in anatomically suitable patients is associated with low early mortality and morbidity. However, EVAR is associated with a significant risk of late complication and a high cumulative re-intervention rate. Many large experienced centres have offered complex EVAR to challenging aortic anatomies such as abdominal aorto-iliac aneurysm (AAIA). We hypothesised that complex EVAR, for AAIA, would be associated with an increased risk of late graft-related complications.
The design was a Retrospective Clinical Cohort Study. From a prospective computerised database we identified consecutive patients undergoing EVAR in a single institution between 2008 and 2009. We retrieved analysis clinical data and digital Computed Tomographic Angiography (CTA) scans carried out pre-, early post-, and late post-EVAR. We compared patients undergoing complex EVAR for AAIA with those undergoing conventional standard EVAR for AAA.
We identified 93 consecutive patients undergoing EVAR, 13 patients were excluded (3 eEVAR, 1 TEVAR, 9 data could not be retrieved) leaving 80 patients for analysis, 63 male and 17 female, average age 74.5 years (range 57-86), average follow-up 38 months (range 27-50), primary EVAR success was 100% and there was no mortality. Complex EVAR, EVAR plus internal iliac artery embolisation (+IIAE) and extension of the ipsilateral graft limb to the external iliac artery, for AAIA were carried out in 19/80 patients. After standard EVAR, late post-EVAR AAA sac diameter was significantly reduced in EVAR (63.24 ± 9.76 vs 54.26 ± 13.70, p < 0.001) but not after complex EVAR+IIAE (58.89 ± 16.39 vs 52.35 ± 12.75, p = 0.62). Endoleak these were significantly more common in the complex EVAR+IIAE, 5/19 (26.32%), as compared to the standard EVAR, 11/61 (18.03%), p < 0.01. Interestingly, inferior mesenteric artery (IMA) Patency was much commoner after complex EVAR+IIAE (15/19, 78.95%) compared EVAR (29/61, 47.54%), p < 0.01.
EVAR can be carried out with low early mortality but has a significant risk of late complication, the commonest of which is endoleak. Complex EVAR for abdominal aorto-iliac aneurysm can be carried out with comparable results to conventional EVAR. However, high rates of persistent endoleak and inferior mesenteric artery patency, and lack of aneurysm sac shrinkage, would suggest they may be at increased risk of late complications and may benefit from enhanced and extended radiological surveillance.
对于解剖结构合适的大型腹主动脉瘤（AAA）患者，血管内修复术（EVAR）具有较低的早期死亡率和发病率。然而，EVAR与晚期并发症的显著风险以及较高的累积再次干预率相关。许多经验丰富的大型中心已将复杂的EVAR应用于具有挑战性的主动脉解剖结构，如腹主动脉-髂动脉瘤（AAIA）。我们假设，针对AAIA的复杂EVAR会增加晚期移植物相关并发症的风险。
本研究为回顾性临床队列研究。从一个前瞻性计算机数据库中，我们确定了2008年至2009年在单一机构接受EVAR的连续患者。我们检索并分析了EVAR术前、术后早期和晚期的临床数据以及数字计算机断层血管造影（CTA）扫描结果。我们将接受AAIA复杂EVAR的患者与接受AAA传统标准EVAR的患者进行了比较。
我们确定了93例连续接受EVAR的患者，排除了13例（3例腔内血管内修复术（eEVAR）、1例胸主动脉腔内修复术（TEVAR）、9例无法检索到数据）后，剩余80例患者进行分析，其中男性63例，女性17例，平均年龄74.5岁（范围57 -86岁），平均随访38个月（范围27 -50个月），初次EVAR成功率为100%，且无死亡病例。80例患者中有19例接受了针对AAIA的复杂EVAR，即EVAR联合髂内动脉栓塞（+IIAE）并将同侧移植物肢体延伸至髂外动脉。标准EVAR术后，EVAR组术后晚期AAA瘤腔直径显著减小（63.24±9.76 vs 54.26±13.70，p<0.001），但复杂EVAR+IIAE组未减小（58.89±16.39 vs 52.35±12.75，p = 0.62）。与标准EVAR组11/61（18.03%）相比，内漏在复杂EVAR+IIAE组中明显更常见，为5/19（26.32%），p<0.01。有趣的是，与EVAR组（29/61，47.54%）相比，复杂EVAR+IIAE组肠系膜下动脉（IMA）通畅情况更为常见（15/19，78.95%），p<0.01。
EVAR可在早期死亡率较低的情况下进行，但存在显著的晚期并发症风险，其中最常见的是内漏。腹主动脉-髂动脉瘤的复杂EVAR与传统EVAR的效果相当。然而，持续内漏和肠系膜下动脉通畅率较高，且瘤腔无缩小，这表明它们可能有更高的晚期并发症风险，可能受益于加强和延长的放射学监测。
