Kray Jared, Kirk Spencer, Franko Jan, Chew David K
Department of Surgery, Mercy Medical Center and Iowa Heart Center, Des Moines, Iowa.
Department of Surgery, Mercy Medical Center and Iowa Heart Center, Des Moines, Iowa.
J Vasc Surg. 2015 Apr;61(4):869-74. doi: 10.1016/j.jvs.2014.11.003. Epub 2015 Jan 15.
Endovascular repair (EVAR) of infrarenal aortic aneurysms (AAA) is increasingly used in patients with suitable aortic morphology conforming to device-specific instructions for use. Despite improvements in graft design, type II endoleak (EL-2) from the inferior mesenteric artery (EL-IMA) or the lumbar artery (EL-LA) remains the Achilles' heel of EVAR. The objective of this study was to evaluate the natural history of the AAA sac after EVAR. We hypothesized that persistent EL-2 would be associated with inferior AAA sac volume regression.
A retrospective analysis was performed on all nonruptured AAA treated by elective EVAR using Food and Drug Administration-approved endografts from January 2005 to December 2008 in our facility. Review of medical records and preoperative and follow-up computed tomography angiograms at 1, 6, and 12 months was performed. Patients with type I, III, and IV endoleaks were excluded, as were those lost to all follow-up. AAA size and volume were analyzed using TeraRecon software (Aquarius Intuition, Foster City, Calif). Change in AAA sac volume was compared in patients with and without EL-2, and with an occluded vs patent IMA.
The study cohort comprised 191 patients (161 men, 30 women) with a mean age of 74 years. The mean preoperative AAA diameter was 5.5 cm (range, 4-11 cm), and mean volume was 137.45 cm(3). EL-2 was present in 24% at completion of EVAR and in 9% at a mean follow-up of 6 months (range 4-8 months). Completion angiography at 1 month showed 63% of EL-2 had resolved. Those with EL-2 present at 1 month had statistically inferior sac regression compared with those who did not (23% reduction vs 2% increase at 1 year; P = .002). Preoperatively, the IMA was occluded by coils or was chronically occluded in 82 patients vs 109 patients who had a patent IMA. At the 6-month follow-up, patients with an occluded IMA had an EL-2 rate of 2.4% vs 14.7% in those with a patent IMA (P = .005 by t-test). Sac volume regression was 21.8% in those with an occluded IMA vs 13.2% in those with a patent IMA (P = .004 by t-test). Regression in AAA sac volume was highly significant in patients with occluded IMA, at 30% vs 16% at 1 year (P = .0018 by two-sided t-test).
The presence of persistent EL-2 after EVAR results in inferior AAA sac regression. A preoperatively patent IMA is associated with increased rates of EL-2 and inferior AAA sac regression. Consideration should be given to preoperative occlusion of a patent IMA before EVAR.
对于符合特定器械使用说明的合适主动脉形态的患者，肾下腹主动脉瘤（AAA）的血管腔内修复术（EVAR）应用越来越广泛。尽管移植物设计有所改进，但来自肠系膜下动脉（EL-IMA）或腰动脉（EL-LA）的Ⅱ型内漏（EL-2）仍是EVAR的致命弱点。本研究的目的是评估EVAR术后AAA瘤腔的自然病程。我们假设持续性EL-2与较差的AAA瘤腔体积缩小相关。
对2005年1月至2008年12月在我院采用美国食品药品监督管理局批准的腔内移植物进行择期EVAR治疗的所有非破裂性AAA患者进行回顾性分析。查阅病历以及术前和术后1、6和12个月的计算机断层扫描血管造影。排除Ⅰ型、Ⅲ型和Ⅳ型内漏患者以及失访患者。使用TeraRecon软件（Aquarius Intuition，加利福尼亚州福斯特城）分析AAA大小和体积。比较有和没有EL-2的患者以及肠系膜下动脉闭塞与通畅的患者之间AAA瘤腔体积的变化。
研究队列包括191例患者（161例男性，30例女性），平均年龄74岁。术前AAA平均直径为5.5 cm（范围4 - 11 cm），平均体积为137.45 cm³。EVAR完成时24%的患者存在EL-2，平均随访6个月（范围4 - 8个月）时9%的患者存在EL-2。1个月时的造影显示63%的EL-2已消失。1个月时存在EL-2的患者与不存在EL-2的患者相比，瘤腔缩小在统计学上较差（1年时缩小23% vs增加2%；P = 0.002）。术前，82例患者的肠系膜下动脉被弹簧圈闭塞或长期闭塞，而109例患者的肠系膜下动脉通畅。在6个月随访时肠系膜下动脉闭塞的患者EL-2发生率为2.4%，而肠系膜下动脉通畅的患者为14.7%（t检验P = 0.005）。肠系膜下动脉闭塞的患者瘤腔体积缩小21.8%，而肠系膜下动脉通畅的患者为13.2%（t检验P = 0.004）。肠系膜下动脉闭塞的患者AAA瘤腔体积缩小在1年时非常显著，为30% vs 1年时的16%（双侧t检验P = 0.0018）。
EVAR术后持续性EL-2的存在导致较差的AAA瘤腔缩小。术前肠系膜下动脉通畅与EL-2发生率增加和较差的AAA瘤腔缩小相关。在EVAR术前应考虑对通畅的肠系膜下动脉进行闭塞。
