Division of Vascular Surgery, "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy.
Division of Vascular Surgery, "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy.
J Vasc Surg. 2018 May;67(5):1360-1371. doi: 10.1016/j.jvs.2017.09.024.
The objective of this study was to investigate the outcomes of patients with visceral aortic patch (VAP) aneurysms after open repair of thoracoabdominal aortic aneurysm (TAAA) treated with three different approaches: open, hybrid, and endovascular repair.
Between 1993 and 2016, there were 29 cases treated for VAP aneurysm after initial TAAA open repair (median time interval, 6.2 years; interquartile range, 4-8 years). Three different treatment modalities were employed: redo open repair (O group) in 14 cases (48.3%), hybrid repair (H group) in 10 cases (34.5%), and endovascular custom-made fenestrated endograft repair (E group) in 5 cases (17.2%). Early (30-day) and midterm results were recorded. The primary end point was a composite major adverse event score: any 30-day death plus any grade ≥2 postoperative complications plus any surgical revision classified according to the Society for Vascular Surgery/American Association for Vascular Surgery reporting standards. Patients were evaluated with computed tomography scans in the outpatient clinic at 3, 6, and 12 months and annually thereafter.
The composite major adverse event score significantly differed among groups (O group, 79%; H group, 60%; E group, 0%; P = .009). Two cases (6.9%) of temporary delayed spinal cord ischemia (grade 1) were observed in both the E and H groups. The treatment modality employed was differently associated with blood loss ≥1000 mL (O group, 79%; H group, 40%; E group, 0%; P = .007), number of packed red blood cells transfused ≥3 units (O group, 100%; H group, 90%; E group, 40%; P = .003), intensive care unit stay >1 day (O group, 71%; H group, 70%; E group, 0%; P = .014), and length of hospital stay ≥7 days (O group, 79%; H group, 80%, E group, 20%; P = .034). At short term (6 months), we observed one endovascular reintervention in the E group and one fatal visceral graft thrombosis in the H group. At a median follow-up of 30 months (interquartile range, 15-75 months), we observed another aneurysm-related death in the H group due to graft infection and four unrelated deaths (one case in the H group and two cases in the O group).
This retrospective study confirms that repair of VAP aneurysms that develop after open repair of TAAAs can be performed with open, hybrid, and endovascular techniques. Current practice favors endovascular repair if possible, but a conclusion that it is superior to any other technique requires validation in a larger sample or a randomized trial.
本研究旨在探讨内脏主动脉补片（VAP）动脉瘤患者在接受开胸腹主动脉瘤（TAAA）开放修复后采用三种不同方法（开放、杂交和血管内修复）的治疗结果。
1993 年至 2016 年，有 29 例患者在初次 TAAA 开放修复后接受 VAP 动脉瘤治疗（中位时间间隔 6.2 年；四分位距 4-8 年）。采用三种不同的治疗方式：14 例（48.3%）行再次开放修复（O 组），10 例（34.5%）行杂交修复（H 组），5 例（17.2%）行定制的血管内开窗支架修复（E 组）。记录早期（30 天）和中期结果。主要终点为复合主要不良事件评分：任何 30 天死亡加任何≥2 级术后并发症加任何根据血管外科学会/血管外科学会报告标准进行的手术修正。患者在门诊通过计算机断层扫描进行评估，随访时间为 3、6 和 12 个月，此后每年随访一次。
复合主要不良事件评分在各组间差异有统计学意义（O 组 79%，H 组 60%，E 组 0%，P=0.009）。E 组和 H 组各有 2 例（6.9%）发生暂时性延迟性脊髓缺血（1 级）。所采用的治疗方式与出血量≥1000ml（O 组 79%，H 组 40%，E 组 0%，P=0.007）、输注红细胞≥3 单位（O 组 100%，H 组 90%，E 组 40%，P=0.003）、入住重症监护病房>1 天（O 组 71%，H 组 70%，E 组 0%，P=0.014）和住院时间≥7 天（O 组 79%，H 组 80%，E 组 20%，P=0.034）有关。在短期（6 个月），我们观察到 E 组有 1 例血管内再干预，H 组有 1 例致命内脏移植物血栓形成。在中位随访 30 个月（四分位距 15-75 个月）期间，我们观察到 H 组因移植物感染和 4 例非相关死亡（H 组 1 例，O 组 2 例）导致另 1 例与动脉瘤相关的死亡。
本回顾性研究证实，TAAA 开放修复后发生的 VAP 动脉瘤可采用开放、杂交和血管内技术进行修复。目前的实践倾向于尽可能采用血管内修复，但要得出它优于任何其他技术的结论，还需要在更大的样本量或随机试验中进行验证。
