Zhu J C, Dai X C, Luo Y D, Fan H L, Feng Z, Zhang Y W, Hu F G
Department of Vascular Surgery, General Hospital of Tianjin Medical University, Tianjin 300052, China.
Zhonghua Yi Xue Za Zhi. 2018 Mar 27;98(12):921-925. doi: 10.3760/cma.j.issn.0376-2491.2018.12.009.
To evaluate the early results of fenestrated endovascular aortic repair (FEVAR) using physician-modified stent grafts (PMSGs) for the treatment of patients with thoracoabdominal pathologies. Nineteen consecutive patients who underwent FEVAR using PMSGs between April 2012 and September 2017 were retrospectively reviewed. The modality of FEVAR technique was assessed, perioperative clinical data was recorded and the early results were evaluated. Indications were thoracoabdominal aortic pathologies, including juxtarenal abdominal aortic aneurysm (JAAA) (=12), chronic thoracoabdominal aortic dissection with aneurysmal dilatation (=3), thoracoabdominal aortic aneurysm (TAAA) (=1), infrarenal AAA with an accessory renal artery in the segment of the aneurysmal neck (=2) and type Ⅰ endoleak after EVAR for AAA(=1). Nineteen fenestrated stent grafts were deployed , including custom-made Cook Zenith fenestrated stent graft(=1), home-made Cook Zenith TX2 fenestrated stent graft(=6), home-made Cook Zenith TFFB fenestrated stent graft(=9), home-made Cook Zenith Cuff fenestrated stent graft(=2), home-made Gore C3 fenestrated stent graft(=1). Mean duration for stent graft modification was 110 (90-140) min. Mean operative time was 268.0 (59.0-334.0) min, and fluoroscopy time was 66.0 (15.0-175.0) min. There were a total of 50 target vessels, of which 45 (95%) were stented. Bare metal stents were used in 28 vessels, and covered stents were used in 17 vessels. Technical success rate was 100%. No intraoperative target vessel loss was observed. Perioperative mortality was 5.3% (1/19). Endoleaks were persisted even after ballooning in five patients. A small type Ⅰ proximal endoleak and type Ⅲ endoleak were found in 2 and 1 patients, respectively. Type Ⅲ endoleak combined with type Ⅱ endoleak were observed in 2 patients. All the endoleaks were accepted and needed watching. In two patients, iliofemoral artery problems were resolved after local endarterectomy and stenting. Two patients presented renal deterioration postoperatively and recovered after the conservative therapy. Median length of stay was 6.6 (2.0-12.0)d. No early reintervention (<30 days) was performed. The mean duration of follow-up was 11.2 (2.0-41.0) months. One patient died 6 months after FEVAR due to advanced renal carcinoma. All target vessels remained patent except for one accessory artery occlusion. FEVAR using PMSGs may be a viable alternative for high-risk patients with thoracoabdominal pathologies.
评估使用医生改良型覆膜支架（PMSG）进行开窗式血管腔内主动脉修复术（FEVAR）治疗胸腹主动脉病变患者的早期疗效。回顾性分析2012年4月至2017年9月期间连续19例行PMSG-FEVAR治疗的患者。评估FEVAR技术方式，记录围手术期临床数据并评估早期疗效。适应证为胸腹主动脉病变，包括肾周腹主动脉瘤（JAAA）（=12例）、慢性胸腹主动脉夹层伴动脉瘤样扩张（=3例）、胸腹主动脉瘤（TAAA）（=1例）、肾下型腹主动脉瘤伴瘤颈处副肾动脉（=2例）以及腹主动脉瘤腔内修复术后Ⅰ型内漏（=1例）。共植入19枚开窗式覆膜支架，包括定制的Cook Zenith开窗式覆膜支架（=1枚）、自制的Cook Zenith TX2开窗式覆膜支架（=6枚）、自制的Cook Zenith TFFB开窗式覆膜支架（=9枚）、自制的Cook Zenith Cuff开窗式覆膜支架（=2枚）、自制的Gore C3开窗式覆膜支架（=1枚）。覆膜支架改良的平均时间为110（90 - 140）分钟。平均手术时间为268.0（59.0 - 334.0）分钟，透视时间为66.0（15.0 - 175.0）分钟。共有50条靶血管，其中45条（95%）成功植入支架。28条血管使用裸金属支架，17条血管使用覆膜支架。技术成功率为100%。未观察到术中靶血管丢失。围手术期死亡率为5.3%（1/19）。5例患者球囊扩张后仍存在内漏。分别在2例和1例患者中发现小的Ⅰ型近端内漏和Ⅲ型内漏。2例患者观察到Ⅲ型内漏合并Ⅱ型内漏。所有内漏均予以观察。2例患者经局部动脉内膜切除术和支架置入术后解决了髂股动脉问题。2例患者术后出现肾功能恶化，经保守治疗后恢复。中位住院时间为6.6（2.0 - 12.0）天。未进行早期再次干预（<30天）。平均随访时间为11.2（2.0 - 41.0）个月。1例患者在FEVAR术后6个月因晚期肾癌死亡。除1条副肾动脉闭塞外，所有靶血管均保持通畅。对于患有胸腹主动脉病变的高危患者，使用PMSG进行FEVAR可能是一种可行的替代方案。
