胸腹主动脉瘤全腔内修复术中开窗及分支型血管内支架植入术后脊髓缺血的临床结局
Clinical Outcomes of Spinal Cord Ischemia after Fenestrated and Branched Endovascular Stent Grafting during Total Endovascular Aortic Repair for Thoracoabdominal Aortic Aneurysms.
作者信息
Baba Takeshi, Ohki Takao, Kanaoka Yuji, Maeda Koji, Ohta Hiroki, Fukushima Soichirou, Toya Naoki, Hara Masayuki
机构信息
Department of Surgery, Division of Vascular Surgery, Jikei University School of Medicine, Tokyo, Japan.
Department of Surgery, Division of Vascular Surgery, Jikei University School of Medicine, Tokyo, Japan.
出版信息
Ann Vasc Surg. 2017 Oct;44:146-157. doi: 10.1016/j.avsg.2017.04.025. Epub 2017 May 5.
BACKGROUND
In this single-center study, we assessed the clinical outcomes of fenestrated endovascular aortic repair (f-EVAR) and branched EVAR on morbidity and mortality during total endovascular aortic repair for thoracoabdominal aortic aneurysms (TAAAs).
METHODS
Between July 2006 and June 2015, elective f-EVAR and multibranched EVAR (t-Branch) for TAAAs were performed in 99 patients at our institution (Crawford classification types I [7], II [13], III [6], IV [55], and V [18]). We retrospectively analyzed 44 patients, excluding those with Crawford type IV TAAAs, and compared 30 patients treated with f-EVAR and 14 treated with t-Branch. Multivariate analysis was performed to determine the factors associated with perioperative spinal cord ischemia (SCI).
RESULTS
Technical success was 96.7% with f-EVAR and 100% with t-Branch, and the 30-day mortality rate was 3.3% with f-EVAR and 7.1% with t-Branch (P = 0.646). The incidences of perioperative SCI were higher with t-Branch (n = 5, 35.7%) than those with f-EVAR (n = 2, 6.7%; P = 0.04). Endoleaks were more prevalent with f-EVAR (n = 9, 30.0%) than with t-Branch (n = 1, 7.1%; P = 0.046). Rates of freedom from aneurysm-related death after 1 year for f-EVAR and t-Branch were 96.7 and 92.9%, respectively, and those after 3 years were 88.8 and 92.9% (P = 0.982), respectively. The risk of SCI remarkably increased in the presence of risk factors such as procedure (t-Branch), maximum short axis of ≥65 mm, coverage length of ≥360 mm, internal iliac artery occlusion, and ≥ 5 sacrificed intercostal arteries.
CONCLUSIONS
Our initial to mid-term results of f-EVAR and t-Branch were good with low rates of perioperative mortality and high rates of freedom from aneurysm-related death. SCI incidence with t-Branch was significantly high; it is important to develop additional SCI prevention methods for patients with high-risk factors.
背景
在这项单中心研究中，我们评估了开窗式血管腔内主动脉修复术（f-EVAR）和分支型血管腔内主动脉修复术在胸腹主动脉瘤（TAAA）全血管腔内主动脉修复术中对发病率和死亡率的临床疗效。
方法
2006年7月至2015年6月期间，我们机构对99例TAAA患者（Crawford分型I型[7例]、II型[13例]、III型[6例]、IV型[55例]和V型[18例]）进行了选择性f-EVAR和多分支血管腔内主动脉修复术（t-Branch）。我们回顾性分析了44例患者，排除Crawford IV型TAAA患者，并比较了30例行f-EVAR治疗的患者和14例行t-Branch治疗的患者。进行多因素分析以确定与围手术期脊髓缺血（SCI）相关的因素。
结果
f-EVAR的技术成功率为96.7%，t-Branch为100%；f-EVAR的30天死亡率为3.3% , t-Branch为7.1%（P = 0.646）。t-Branch围手术期SCI的发生率（n = 5，35.7%）高于f-EVAR（n = 2，6.7%；P = 0.04）。f-EVAR的内漏发生率（n = 9，30.0%）高于t-Branch（n = 1，7.1%；P = 0.046）。f-EVAR和t-Branch术后1年动脉瘤相关死亡的无事件生存率分别为96.7%和92.9%，术后3年分别为88.8%和92.9%（P = 0.982）。在存在手术方式（t-Branch）、最大短轴≥65 mm、覆盖长度≥360 mm、髂内动脉闭塞以及≥5根肋间动脉牺牲等危险因素时，SCI风险显著增加。
结论
我们对f-EVAR和t-Branch的初期至中期结果良好，围手术期死亡率低，动脉瘤相关死亡的无事件生存率高。t-Branch的SCI发生率显著较高；为高危因素患者开发额外的SCI预防方法很重要。
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