Moulakakis Konstantinos G, Klonaris Christos, Kakisis John, Antonopoulos Constantine N, Lazaris Andreas, Sfyroeras George S, Mantas George, Vasdekis Spyridon N, Brountzos Elias N, Geroulakos George
Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
Division of Vascular Surgery, First Department of Surgery, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
Ann Vasc Surg. 2017 Feb;39:56-66. doi: 10.1016/j.avsg.2016.08.029. Epub 2016 Nov 27.
The management of type II endoleak causing sac enlargement continues to be a topic of debate. The purpose of this study was to examine and compare the outcomes between open surgical technique with sacotomy and suturing of the feeding vessels to interventional embolization in patients with aneurysm sac expansion after endovascular aneurysm repair (EVAR).
Inclusion criteria for intervention in patients with prior EVAR and type II endoleak were asymptomatic expanding aneurysm sac > 5 mm between 2 consecutive follow-up computed tomography angiography scans and symptomatic aneurysm sac expansion. Age, sex, comorbidities, clinical presentation, commercial type of endograft of prior EVAR, aneurysm sac increase, type of treatment, morbidity, mortality, and follow-up were also recorded.
A total of 694 consecutive patients were operated with EVAR during the study period. Among them, 29 patients (4.2%) were presented with a type II endoleak that required reintervention. Ten patients (34.5%) were treated with embolization. We recorded a 50% technical success in the group of primary translumbar embolization and 67% in the group of intra-arterial embolization. Twenty-two patients were treated with laparotomy and open ligation of the culprit arteries causing the type II endoleak. Among them, 3 patients (13.6%) had been initially treated with unsuccessful embolization. Periprocedural intervention complications for the embolization group (10%, 1/10) included 1 psoas hematoma. On the contrary, complications after primary open ligation were 13.6% (3/22) and included 1 proximal dislocation treated with endograft explantation, 1 distal dislocation, and 1 limb ligation with femoral-femoral bypass which resulted in colonic ischemia and death (4.5%).
Open surgical repair with sacotomy and suturing of the feeding vessels appeared to have better outcome regarding the exclusion of the aneurysm but was associated with a higher incidence of severe complications and one related death. If these results are confirmed in larger series, endovascular approach should be the preferred treatment option.
导致瘤腔增大的Ⅱ型内漏的处理仍是一个存在争议的话题。本研究的目的是检查并比较在血管内动脉瘤修复术（EVAR）后出现动脉瘤瘤腔扩大的患者中，采用切开瘤腔并缝合供血血管的开放手术技术与介入栓塞术的治疗效果。
对既往接受过EVAR且存在Ⅱ型内漏的患者进行干预的纳入标准为：在连续两次随访的计算机断层扫描血管造影（CTA）扫描之间，无症状的动脉瘤瘤腔扩大超过5 mm，以及有症状的动脉瘤瘤腔扩大。还记录了患者的年龄、性别、合并症、临床表现、既往EVAR的血管内支架商业类型、动脉瘤瘤腔增大情况、治疗类型、发病率、死亡率及随访情况。
在研究期间，共有694例连续患者接受了EVAR手术。其中，29例患者（4.2%）出现了需要再次干预的Ⅱ型内漏。10例患者（34.5%）接受了栓塞治疗。我们记录到，在初次经腰动脉栓塞组的技术成功率为50%，动脉内栓塞组为67%。22例患者接受了剖腹手术并对导致Ⅱ型内漏的责任动脉进行开放结扎。其中，3例患者（13.6%）最初接受的栓塞治疗未成功。栓塞组的围手术期干预并发症发生率为10%（1/10），包括1例腰大肌血肿。相反，初次开放结扎后的并发症发生率为13.6%（3/22），包括1例近端移位，通过取出血管内支架进行治疗；1例远端移位；以及1例肢体结扎并进行股-股旁路移植术，导致结肠缺血和死亡（4.5%）。
切开瘤腔并缝合供血血管的开放手术修复在排除动脉瘤方面似乎有更好的效果，但与严重并发症的较高发生率及1例相关死亡有关。如果这些结果在更大规模的系列研究中得到证实，血管内治疗方法应成为首选的治疗选择。
