Vascular and Endovascular Surgery Clinic, Padova University, Padova, Italy.
Vascular and Endovascular Surgery Clinic, Padova University, Padova, Italy.
Eur J Vasc Endovasc Surg. 2015 Aug;50(2):175-80. doi: 10.1016/j.ejvs.2015.03.027. Epub 2015 Apr 25.
Conversion of a previous endovascular aneurysm repair (EVAR) with suprarenal fixation is a challenging situation even in the elective setting. The outcomes of a technique based on preservation of the first proximal covered stent of the endograft, used as a "neo-neck" for proximal anastomosis, are presented.
From 2001 to 2014, nine patients underwent elective conversion of a previous suprarenally fixed EVAR. After supraceliac clamping, the aneurysm sac was opened and the endograft identified; the fabric was cut beyond the first covered stent together with its native aortic wall in order to create a "neo-neck." An aortic balloon was inflated into the visceral aorta to avoid back bleeding. A Dacron bifurcated tube graft (Intergard, Maquet) was then sutured to the neo-neck mimicking endobanding, passing the stitches into the aortic wall and the first covered stent.
The mean age was 68 years (range, 52-84 years). The stent grafts removed were four Zenith (Cook Medical), three Endurant (Medtronic), and two E-vita (Jotec). The indication for conversion was type 1A (n = 2), type 2 (n = 2), and type 3 (n = 1) endoleak, complete endograft thrombosis (n = 2), and abdominal pain with sac enlargement with no radiological sign of endoleak (n = 2). Blood loss was 1,428 mL (range 500-3,000 mL); the visceral ischemic time to perform the proximal anastomosis was 23.5 min ± 2.3 min). The post-operative complication rate was 11% (n = 1/9) related to a case of sac wall bleeding requiring re-intervention; mortality at 30 days was 0%. At 22 months (range, 8-41) the computed tomography angiogram demonstrated no signs of leaks or anastomotic pseudoaneurysm.
Preservation of the proximal covered stent of an endograft with suprarenal fixation used as an infrarenal "neo-neck" with incorporation of the aorta to the suture line during elective surgical explantation simplifies the procedure, and can be achieved with very low early morbidity and mortality; furthermore, it seems to be durable over mid-term follow up.
即使在择期情况下，带有肾上固定的先前血管内动脉瘤修复（EVAR）的转换也是一项具有挑战性的情况。本文介绍了一种基于保留移植物的第一个近端覆盖支架的技术的结果，该支架用作近端吻合的“新颈部”。
2001 年至 2014 年，9 例患者接受了先前肾上固定 EVAR 的择期转换。在腹腔上夹闭后，打开动脉瘤囊并识别移植物；将织物与第一个覆盖支架及其固有主动脉壁一起切割超过，以创建“新颈部”。向内脏主动脉充气一个主动脉球囊以避免反流血。然后将一个 Dacron 分叉管 graft（Intergard，Maquet）缝合到新颈部，模仿 endobanding，将缝线穿过主动脉壁和第一个覆盖支架。
平均年龄为 68 岁（范围 52-84 岁）。移除的支架移植物为四个 Zenith（Cook Medical），三个 Endurant（Medtronic）和两个 E-vita（Jotec）。转换的适应症为 1A 型（n=2），2 型（n=2）和 3 型（n=1）内漏，完全移植物血栓形成（n=2）和腹痛伴囊增大但无内漏放射学迹象（n=2）。失血量为 1428 毫升（范围 500-3000 毫升）；进行近端吻合的内脏缺血时间为 23.5 分钟±2.3 分钟。术后并发症发生率为 11%（n=9/9），与一例需要再次介入治疗的囊壁出血有关；30 天死亡率为 0%。在 22 个月（范围 8-41）时，计算机断层血管造影显示无泄漏或吻合口假性动脉瘤的迹象。
保留肾上固定的移植物的近端覆盖支架，用作肾下“新颈部”，在择期手术取出时将主动脉纳入缝线，可简化手术过程，并且可以实现非常低的早期发病率和死亡率；此外，在中期随访中似乎是持久的。
