Ammar Chad P, Larion Sebastian, Ahanchi Sadaf S, Lavingia Kedar S, Dexter David J, Panneton Jean M
Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va.
Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va.
J Vasc Surg. 2016 Oct;64(4):912-920.e1. doi: 10.1016/j.jvs.2016.03.451. Epub 2016 Aug 8.
An anatomic severity grading (ASG) score for primary descending thoracic aortic aneurysms (DTAs) was developed. The objective of this study was to determine if an ASG score cutoff value for DTAs is predictive of procedural complexity, aortic-related reinterventions, and mortality in patients who undergo thoracic endovascular aortic repair (TEVAR).
A retrospective review from 2008 to 2013 of patient records was conducted of all consecutive patients who underwent TEVAR for a primary DTA. A comprehensive scoring system of preoperative DTA morphology on the basis of computed tomography angiography images was established to identify and classify anatomic features that might influence outcome after TEVAR. ASG score calculations were achieved using preoperative computed tomography angiography images. Primary outcomes included primary technical success, aortic-related reinterventions, aneurysm-related mortality, and all-cause mortality. Secondary outcomes included procedural complexity (unplanned adjunctive procedures, number of endografts implanted, contrast volume, and procedure time), endoleak formation, endoleak requiring reintervention, stroke and paraplegia, and conversion to open repair.
Of 469 patients with a diagnosis of a thoracic aortic aneurysm, 62 patients (13%) underwent TEVAR and had adequate preoperative imaging (mean age, 71 years). Applying the ASG score, we identified 39 patients (63%) with a score ≥24 (high-score group) and 23 patients (37%) with a score <24 (low-score group). Mean follow-up was 15.3 months (range, 4 days to 3.7 years; standard deviation, 1 year) for both groups. Freedom from all-cause mortality was significantly different in the high-score (87% at 1 year, 79% at 2 years, and 57% at 3 years) vs the low-score group (100% at 1, 2, and 3-years; log-rank test, P < .021). There was no significant difference between mortality in the high-score (97% at 1 year, 87% at 2 years, and 69% at 3 years) compared with the low-score group (100% at 1, 2, and 3 years; log-rank test, P = .162). Freedom from aortic-related reinterventions was significantly lower in the high-score (82% at 1 year, 68% at 2 years, and 35% at 3 years) compared with the low-score group (100% at 1, 2, and 3 years; log-rank test, P = .002). Operative difficulty in the form of intraoperative adjunct procedures, number of endografts implanted, and procedural time had significant differences between groups (18% vs 0%, P = .038; 79% vs 39%, P = .004; 120 vs 79 minutes, P = .005, respectively). No significant difference in 30-day combined stroke and paraplegia (16%) was present between groups, and no patient had a conversion to open repair during the follow-up period.
Preoperative ASG score for primary DTAs predicted procedure complexity and aortic-related reinterventions after TEVAR.
已制定了原发性降主动脉瘤（DTA）的解剖严重程度分级（ASG）评分。本研究的目的是确定DTA的ASG评分临界值是否可预测接受胸主动脉腔内修复术（TEVAR）患者的手术复杂性、主动脉相关再次干预及死亡率。
对2008年至2013年期间所有因原发性DTA接受TEVAR的连续患者的病历进行回顾性研究。基于计算机断层血管造影图像建立了术前DTA形态的综合评分系统，以识别和分类可能影响TEVAR术后结局的解剖特征。使用术前计算机断层血管造影图像进行ASG评分计算。主要结局包括初次技术成功、主动脉相关再次干预、动脉瘤相关死亡率和全因死亡率。次要结局包括手术复杂性（非计划辅助手术、植入的腔内移植物数量、对比剂用量和手术时间）、内漏形成、需要再次干预的内漏、中风和截瘫以及转为开放手术修复。
在469例诊断为胸主动脉瘤的患者中，62例（13%）接受了TEVAR且术前影像资料完整（平均年龄71岁）。应用ASG评分，我们识别出39例（63%）评分≥24的患者（高分组合）和23例（37%）评分<24的患者（低分组合）。两组的平均随访时间为15.3个月（范围4天至3.7年；标准差1年）。高分组合的全因死亡率无事件生存率与低分组合有显著差异（1年时为87%，2年时为79%，3年时为57%）对比低分组合（1年、2年和3年时均为100%；对数秩检验，P<0.021）。高分组合的死亡率（1年时为97%，2年时为87%，3年时为69%）与低分组合（1年、2年和3年时均为100%；对数秩检验，P=0.162）相比无显著差异。高分组合的主动脉相关再次干预无事件生存率显著低于低分组合（1年时为82%，2年时为68%，3年时为35%）对比低分组合（1年、2年和3年时均为100%；对数秩检验，P=0.002）。术中辅助手术形式的手术难度、植入的腔内移植物数量和手术时间在两组之间有显著差异（分别为18%对0%，P=0.038；79%对39%，P=0.004；120对79分钟，P=0.005）。两组之间30天合并中风和截瘫发生率（16%）无显著差异，且随访期间无患者转为开放手术修复。
原发性DTA的术前ASG评分可预测TEVAR术后的手术复杂性和主动脉相关再次干预情况。
