Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY.
Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY.
J Vasc Surg. 2018 May;67(5):1345-1352. doi: 10.1016/j.jvs.2017.08.098. Epub 2017 Nov 20.
Open surgical repair remains the "gold standard" treatment for chronic type B aortic dissection (cTBD) with aneurysm. Thoracic endovascular aortic repair (TEVAR) has gained popularity in recent years for the treatment of thoracic aortic diseases, including cTBD. We assessed the effectiveness of TEVAR in the treatment of cTBD using the Vascular Quality Initiative (VQI) database.
The VQI registry identified 4713 patients treated with TEVAR from July 2010 to November 2015, including 125 repairs for cTBD. We analyzed TEVAR outcomes in this cohort per the Society for Vascular Surgery reporting standards for TEVAR.
Median age was 65.0 years (interquartile range [IQR], 56.0-72.0 years), and 85 (68.0%) were male. Median aneurysm diameter was 5.5 cm (IQR, 4.8-6.3 cm). Sixty-two (49.6%) patients were asymptomatic on presentation, 57 (45.6%) were symptomatic, and 6 (4.8%) presented with rupture. Median length of stay was 8.0 days (IQR, 4.0-11.0 days). Fluoroscopy time was 17.3 minutes (IQR, 10.5-25.6 minutes). The distal landing zone was aortic zone 4 in 27 (21.6%) and aortic zone 5 and distal in 98 (78.4%) patients. Successful device delivery occurred in 123 (98.4%) patients. Conversion to open repair occurred in one (0.8%) patient. A type IA endoleak was present in 2 (1.6%), type IB endoleak in 2 (1.6%), and type II endoleak in 2 (1.6%) patients. Perioperative complications included stroke in 1 (0.8%), respiratory complications in 6 (4.8%), and spinal cord ischemia symptoms present at discharge in 3 (2.4%) patients. In-hospital mortality occurred in three (2.4%) patients. Reintervention was required in two (1.6%) patients for false lumen perfusion and in two (1.6%) patients for extension of the dissection. Follow-up was available for 43 patients at a median time of 239 days (IQR, 38-377 days). Median change in sac diameter was -0.2 cm (IQR, -0.5 to 0.1 cm). Sac shrinkage of 0.5 cm was noted in 12 (27.9%), with sac growth >0.5 cm in four (9.3%) patients. Extent of stent graft coverage did not affect sac shrinkage (P = .65). Patients with aneurysms ≥5.5 cm compared with <5.5 cm were more likely to demonstrate shrinkage (-0.6 cm vs 0.0 cm; 95% confidence interval, 0.3-11.7; P = .04).
TEVAR for cTBD may be performed with acceptable rates of morbidity and mortality. Changes in sac diameter in the midterm are promising. Long-term data are needed to determine whether this approach is durable.
开放手术修复仍然是慢性 B 型主动脉夹层（cTBD）合并动脉瘤的“金标准”治疗方法。近年来，胸主动脉腔内修复术（TEVAR）在治疗包括 cTBD 在内的胸主动脉疾病方面越来越受欢迎。我们使用血管质量倡议（VQI）数据库评估了 TEVAR 在治疗 cTBD 中的效果。
VQI 登记处确定了 2010 年 7 月至 2015 年 11 月期间接受 TEVAR 治疗的 4713 例患者，其中包括 125 例 cTBD 修复术。我们按照血管外科学会 TEVAR 报告标准分析了该队列中的 TEVAR 结果。
中位年龄为 65.0 岁（四分位距 [IQR]，56.0-72.0 岁），85 例（68.0%）为男性。中位动脉瘤直径为 5.5 cm（IQR，4.8-6.3 cm）。62 例（49.6%）患者就诊时无症状，57 例（45.6%）有症状，6 例（4.8%）有破裂。中位住院时间为 8.0 天（IQR，4.0-11.0 天）。透视时间为 17.3 分钟（IQR，10.5-25.6 分钟）。远端着陆区在 27 例（21.6%）患者中为主动脉区 4 区，在 98 例（78.4%）患者中为主动脉区 5 区和远端区。123 例（98.4%）患者成功进行了器械输送。1 例（0.8%）患者转为开放修复。2 例（1.6%）患者存在 1 型内漏，2 例（1.6%）患者存在 1B 型内漏，2 例（1.6%）患者存在 2 型内漏。围手术期并发症包括 1 例（0.8%）卒中，6 例（4.8%）呼吸并发症，3 例（2.4%）出院时脊髓缺血症状。3 例（2.4%）患者院内死亡。2 例（1.6%）患者因假腔灌注需要再次干预，2 例（1.6%）患者因夹层延伸需要再次干预。43 例患者获得中位时间为 239 天（IQR，38-377 天）的随访。中位瘤径变化为-0.2 cm（IQR，-0.5 至 0.1 cm）。12 例（27.9%）患者瘤径缩小≥0.5 cm，4 例（9.3%）患者瘤径增大>0.5 cm。支架移植物覆盖范围的大小不影响瘤径缩小（P=.65）。与<5.5 cm 的动脉瘤相比，≥5.5 cm 的动脉瘤更可能出现瘤径缩小（-0.6 cm 比 0.0 cm；95%置信区间，0.3-11.7；P=.04）。
TEVAR 治疗 cTBD 的发病率和死亡率可能可以接受。中期瘤径的变化是有希望的。需要长期数据来确定这种方法是否持久。
