Schanzer Andres, Simons Jessica P, Flahive Julie, Durgin Jonathan, Aiello Francesco A, Doucet Danielle, Steppacher Robert, Messina Louis M
University of Massachusetts Medical School, Worcester, Mass.
University of Massachusetts Medical School, Worcester, Mass.
J Vasc Surg. 2017 Sep;66(3):687-694. doi: 10.1016/j.jvs.2016.12.111. Epub 2017 Mar 1.
More than 80% of infrarenal aortic aneurysms are treated by endovascular repair. However, adoption of fenestrated and branched endovascular repair for complex aortic aneurysms has been limited, despite high morbidity and mortality associated with open repair. There are few published reports of consecutive outcomes, inclusive of all fenestrated and branched endovascular repairs, starting from the inception of a complex aortic aneurysm program. Therefore, we examined a single center's consecutive experience of fenestrated and branched endovascular repair of complex aortic aneurysms.
This is a single-center, prospective, observational cohort study evaluating 30-day and 1-year outcomes in all consecutive patients who underwent fenestrated and branched endovascular repair of complex aortic aneurysms (definition: requiring one or more fenestrations or branches). Data were collected prospectively through an Institutional Review Board-approved registry and a physician-sponsored investigational device exemption clinical trial (G130210).
We performed 100 consecutive complex endovascular aortic aneurysm repairs (November 2010 to March 2016) using 58 (58%) commercially manufactured custom-made devices and 42 (42%) physician-modified devices to treat 4 (4%) common iliac, 42 (42%) juxtarenal, 18 (18%) pararenal, and 36 (36%) thoracoabdominal aneurysms (type I, n = 1; type II, n = 4; type III, n = 12; type IV, n = 18; arch, n = 1). The repairs included 309 fenestrations, branches, and scallops (average of 3.1 branch arteries/case). All patients had 30-day follow-up for 30-day event rates: three (3%) deaths; six (6%) target artery occlusions; five (5%) progressions to dialysis; eight (8%) access complications; one (1%) paraparesis; one (1%) bowel ischemia; and no instances of myocardial infarction, paralysis, or stroke. Of 10 type I or type III endoleaks, 8 resolved (7 with secondary intervention, 1 without intervention). Mean follow-up time was 563 days (interquartile range, 156-862), with three (3%) patients lost to follow-up. On 1-year Kaplan-Meier analysis, survival was 87%, freedom from type I or type III endoleak was 97%, target vessel patency was 92%, and freedom from aortic rupture was 100%. Average lengths of intensive care unit stay and inpatient stay were 1.4 days (standard deviation, 3.3) and 3.6 days (standard deviation, 3.6), respectively.
These results show that complex aortic aneurysms can now be treated with minimally invasive fenestrated and branched endovascular repair. Endovascular technologies will likely continue to play an increasingly important role in the management of patients with complex aortic aneurysm disease.
超过80%的肾下腹主动脉瘤通过血管腔内修复术治疗。然而，尽管开放修复术伴有高发病率和死亡率，但带开窗和分支的血管腔内修复术在复杂主动脉瘤治疗中的应用一直有限。从复杂主动脉瘤治疗项目启动以来，很少有已发表的关于包括所有带开窗和分支的血管腔内修复术的连续治疗结果的报告。因此，我们研究了一个中心对复杂主动脉瘤进行带开窗和分支的血管腔内修复术的连续经验。
这是一项单中心、前瞻性、观察性队列研究，评估所有连续接受复杂主动脉瘤带开窗和分支血管腔内修复术（定义：需要一个或多个开窗或分支）患者的30天和1年治疗结果。数据通过机构审查委员会批准的登记系统和医生发起的研究性器械豁免临床试验（G130210）前瞻性收集。
我们连续进行了100例复杂的血管腔内主动脉瘤修复术（2010年11月至2016年3月），使用58个（58%）商业制造的定制器械和42个（42%）医生改良器械，治疗4例（4%）髂总动脉瘤、42例（42%）近肾动脉瘤、18例（18%）肾旁动脉瘤和36例（36%）胸腹主动脉瘤（I型，n = 1；II型，n = 4；III型，n = 12；IV型，n = 18；弓部，n = 1）。修复包括309个开窗、分支和扇贝形结构（平均每例3.1支分支动脉）。所有患者均进行了30天随访以获取30天事件发生率：3例（3%）死亡；6例（6%）靶动脉闭塞；5例（5%）进展为透析；8例（8%）通路并发症；1例（1%）下肢轻瘫；1例（1%）肠缺血；无心肌梗死、瘫痪或中风病例。10例I型或III型内漏中，8例得到解决（7例进行了二次干预，1例未干预）。平均随访时间为563天（四分位间距，156 - 862天），3例（3%）患者失访。在1年的Kaplan - Meier分析中，生存率为87%，无I型或III型内漏率为97%，靶血管通畅率为92%，无主动脉破裂率为100%。重症监护病房平均住院时间和住院平均时间分别为1.4天（标准差，3.3）和3.6天（标准差，3.6）。
这些结果表明，复杂主动脉瘤现在可以通过微创带开窗和分支的血管腔内修复术进行治疗。血管腔内技术可能会在复杂主动脉瘤疾病患者的治疗中继续发挥越来越重要的作用。
