Ullery Brant W, Tran Kenneth, Itoga Nathan K, Dalman Ronald L, Lee Jason T
Providence Heart and Vascular Institute, Portland, Ore.
Division of Vascular Surgery, Stanford University Medical Center, Stanford, Calif.
J Vasc Surg. 2017 Apr;65(4):981-990. doi: 10.1016/j.jvs.2016.10.085. Epub 2017 Feb 8.
Alternative endovascular strategies using parallel or snorkel/chimney (chimney endovascular aneurysm repair [ch-EVAR]) techniques have been developed to address the lack of widespread availability and manufacturing limitations with branched/fenestrated aortic devices for the treatment of complex abdominal aortic aneurysms. Despite high technical success and midterm patency of snorkel stent configurations, concerns remain regarding the perceived increased incidence of early gutter-related type Ia endoleaks. We aimed to evaluate the incidence and natural history of gutter-related type Ia endoleaks following ch-EVAR.
Review of medical records and available imaging studies, including completion angiography and serial computed tomographic angiography, was performed for all patients undergoing ch-EVAR at our institution between September 2009 and January 2015. Only procedures involving ≥1 renal artery with or without visceral snorkel stents were included. Primary outcomes of the study were presence and persistence or resolution of early gutter-related type Ia endoleak. Secondary outcomes included aneurysm sac shrinkage and need for secondary intervention related to the presence of type Ia gutter endoleak.
Sixty patients (mean age, 75.8 ± 7.6 years; male, 70.0%) underwent ch-EVAR with a total of 111 snorkel stents (97 renal [33 bilateral renal], 12 superior mesenteric artery, 2 celiac). A mean of 1.9 ± 0.6 snorkel stents were placed per patient. Early gutter-related type Ia endoleaks were noted on 30.0% (n = 18) of initial postoperative imaging studies. Follow-up imaging revealed spontaneous resolution of these gutter endoleaks in 44.3%, 65.2%, and 88.4% of patients at 6, 12, and 18 months postprocedure, respectively. Long-term anticoagulation, degree of oversizing, stent type and diameter, and other clinical/anatomic variables were not significantly associated with presence of gutter endoleaks. Two patients (3.3%) required secondary intervention related to persistent gutter endoleak. At a mean radiologic follow-up of 20.9 months, no difference in mean aneurysm sac size change was observed between those with or without early type Ia gutter endoleak (-6.1 ± 10.0 mm vs -4.9 ± 11.5 mm; P = .23).
Gutter-related type Ia endoleaks represent a relatively frequent early occurrence after ch-EVAR, but appears to resolve spontaneously in the majority of cases during early to midterm follow-up. Given that few ch-EVAR patients require reintervention related to gutter endoleaks and the presence of such endoleak did not correlate to increased risk for aneurysm sac growth, its natural history may be more benign than originally expected.
已开发出使用平行或烟囱/烟囱型（烟囱式血管腔内动脉瘤修复术[ch-EVAR]）技术的替代性血管腔内策略，以解决用于治疗复杂腹主动脉瘤的分支/开窗主动脉装置广泛可用性不足和制造限制的问题。尽管烟囱式支架构型在技术上成功率高且中期通畅，但对于早期与通道相关的Ia型内漏发生率增加的担忧仍然存在。我们旨在评估ch-EVAR术后与通道相关的Ia型内漏的发生率和自然病程。
对2009年9月至2015年1月在我们机构接受ch-EVAR的所有患者的病历和可用影像学研究进行回顾，包括完成血管造影和系列计算机断层血管造影。仅纳入涉及≥1条肾动脉且有或无内脏烟囱式支架的手术。该研究的主要结局是早期与通道相关的Ia型内漏的存在以及持续或消退情况。次要结局包括瘤囊缩小以及因Ia型通道内漏而需要进行二次干预。
60例患者（平均年龄75.8±7.6岁；男性占70.0%）接受了ch-EVAR，共使用了111个烟囱式支架（97个用于肾动脉[其中33个为双侧肾动脉]，12个用于肠系膜上动脉，2个用于腹腔干）。每位患者平均放置1.9±0.6个烟囱式支架。在术后初始影像学研究中，30.0%（n = 18）的患者发现早期与通道相关的Ia型内漏。随访影像学显示，这些通道内漏分别在术后6、12和18个月时，44.3%、65.2%和88.4% 的患者中自发消退。长期抗凝、超大尺寸程度、支架类型和直径以及其他临床/解剖学变量与通道内漏的存在无显著相关性。两名患者（3.3%）因持续性通道内漏需要进行二次干预。在平均20.9个月的影像学随访中，有或无早期Ia型通道内漏的患者之间，平均瘤囊大小变化无差异（-6.1±10.0 mm对-4.9±11.5 mm；P = 0.23）。
与通道相关的Ia型内漏是ch-EVAR术后相对常见的早期情况，但在早期至中期随访期间，大多数病例似乎会自发消退。鉴于很少有ch-EVAR患者因通道内漏需要再次干预，且这种内漏的存在与瘤囊生长风险增加无关，其自然病程可能比最初预期的更良性。
