Tassiopoulos Apostolos K, Monastiriotis Spyridon, Jordan William D, Muhs Bart E, Ouriel Kenneth, De Vries Jean Paul
Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY.
Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY.
J Vasc Surg. 2017 Jul;66(1):45-52. doi: 10.1016/j.jvs.2016.12.117. Epub 2017 Mar 6.
Dilatation of the aorta within the proximal neck after endovascular aneurysm repair (EVAR) can be associated with late endoleaks and migration. This study was designed to identify predictors of early neck dilation in patients undergoing EVAR with Heli-FX EndoAnchors (Medtronic, Santa Rosa, Calif) measured perioperatively to 1 year at different longitudinal levels of neck length.
The study group of Aneurysm Treatment Using the Heli-FX Aortic Securement System (ANCHOR) comprises 257 consecutive patients prospectively enrolled between April 2012 and September 2014 undergoing EVAR with Heli-FX EndoAnchor implantation at 38 investigational sites. Only patients undergoing EndoAnchor implantation at the time of the initial EVAR were included (primary treatment arm). Aortic diameter was measured at the suprarenal level and at three levels within the proximal neck. Neck dilatation was assessed in 209 patients with adequate computed tomography imaging at baseline and 1 month and in 62 patients at 1 month and 1 year (mean, 11.9 ± 4.0 months). Multivariable analyses were performed to identify independent predictors of perioperative (baseline to 1 month) and early postoperative (1 month to 1 year) aortic dilation at each level; analyses included 6 candidate variables, 6 clinical, and 14 anatomic run in eight models (one at each of the four aortic levels for both time frames).
The mean aortic neck dilation at 1 month was 0.2 ± 1.7 mm, 0.7 ± 2.2 mm, and 0.9 ± 3.6 mm at 0 mm, 5 mm, and 10 mm below the lowest renal artery, and 0.0 ± 1.5 mm at the suprarenal level. From 1 month to 1 year, neck dilatation was 0.5 ± 1.6 mm, 0.4 ± 1.5 mm, 0.2 ± 1.8 mm, and -0.3 ± 1.1 mm at the same four levels, respectively. Dilatation of ≥3 mm at level 5 mm distal to the lowest renal artery was observed in 26 patients (12.5%) from preoperative to 1 month and in 5 patients (8.1%) between 1 month and 1 year. Multivariable regression identified several variables predictive of perioperative (preoperative to 1 month) neck dilatation: baseline neck diameter, mural calcium (protective), and endografts with a suprarenal stent. Neck dilatation between 1 month and 1 year was associated with baseline neck diameter, neck length (protective), neck angulation, device oversizing, number of EndoAnchors implanted (protective), and endografts with a suprarenal stent.
Aortic diameter and graft oversizing appear to be independent risk factors for early aortic neck dilatation. EndoAnchors have a protective effect on neck dilatation at their usual level of deployment.
血管内动脉瘤修复术（EVAR）后近端颈部主动脉扩张可能与晚期内漏和移植物移位有关。本研究旨在确定接受使用Heli-FX EndoAnchors（美敦力公司，加利福尼亚州圣罗莎）进行EVAR治疗的患者早期颈部扩张的预测因素，在围手术期至1年期间在不同颈部长度的纵向水平进行测量。
使用Heli-FX主动脉固定系统（ANCHOR）治疗动脉瘤的研究组包括257例连续患者，这些患者于2012年4月至2014年9月前瞻性入组，在38个研究地点接受了Heli-FX EndoAnchor植入的EVAR治疗。仅纳入在初次EVAR时接受EndoAnchor植入的患者（主要治疗组）。在肾上水平和近端颈部的三个水平测量主动脉直径。对209例在基线和1个月时有足够计算机断层扫描成像的患者以及62例在1个月和1年时（平均11.9±4.0个月）的患者评估颈部扩张情况。进行多变量分析以确定每个水平围手术期（基线至1个月）和术后早期（1个月至1年）主动脉扩张的独立预测因素；分析包括6个候选变量、6个临床变量和14个解剖变量，共8个模型（两个时间框架内四个主动脉水平各一个）。
在最低肾动脉下方0mm、5mm和10mm处，1个月时主动脉颈部平均扩张分别为0.2±1.7mm、0.7±2.2mm和0.9±3.6mm，在肾上水平为0.0±1.5mm。从1个月到1年，在相同的四个水平处，颈部扩张分别为0.5±1.6mm、0.4±1.5mm、0.2±1.8mm和 -0.3±1.1mm。在最低肾动脉远端5mm处，从术前到1个月有26例患者（12.5%）扩张≥3mm，在1个月至1年之间有5例患者（8.1%）。多变量回归确定了几个围手术期（术前至1个月）颈部扩张的预测变量：基线颈部直径、壁内钙化（有保护作用）以及带有肾上支架的血管内移植物。1个月至1年之间的颈部扩张与基线颈部直径、颈部长度（有保护作用）、颈部角度、移植物尺寸过大、植入的EndoAnchors数量（有保护作用）以及带有肾上支架的血管内移植物有关。
主动脉直径和移植物尺寸过大似乎是早期主动脉颈部扩张的独立危险因素。EndoAnchors在其通常的部署水平对颈部扩张有保护作用。
