Gallitto Enrico, Faggioli Gianluca, Mascoli Chiara, Pini Rodolfo, Ancetti Stefano, Vacirca Andrea, Stella Andrea, Gargiulo Mauro
Vascular Surgery, Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy.
Vascular Surgery, Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy.
J Vasc Surg. 2018 Dec;68(6):1667-1675. doi: 10.1016/j.jvs.2018.02.051. Epub 2018 May 24.
Thoracoabdominal aortic aneurysms (TAAAs) after previous aortic open surgical repair (OSR) are challenging clinical scenarios. Redo-OSR is technically demanding, and standard endovascular repair is unavailable due to visceral vessel involvement. Fenestrated and branched endografts (FB-EVAR) are effective options to treat TAAAs in high surgical risk patients but dedicated studies on the FB-EVAR outcomes in patients with TAAAs with previous OSR are not available. The aim of the study was to evaluate the impact of previous OSR on TAAAs FB-EVAR outcomes.
Between 2010 and 2016, all TAAAs undergoing FB-EVAR were prospectively evaluated, retrospectively categorized in two groups, and then compared: group A-primary TAAAs and group B-TAAAs after previous OSR (abdominal, thoracic, or thoracoabdominal aneurysm). Early end points were technical success (absence of type I-III endoleak, target visceral vessel loss, conversion to OSR, intraoperative mortality), spinal cord ischemia (SCI), and 30-day mortality. Follow-up end points were survival, target visceral vessel patency, and freedom from reinterventions.
Sixty-two patients (male: 74%; age: 72 ± 7 years) with 1 (1%) extent I, 14 (23%) extent II, 24 (39%) extent III, and 23 (37%) extent IV TAAA underwent FB-EVAR. The mean TAAA diameter and total target visceral vessels were 65 ± 13 mm and 226, respectively. Ninety branches and 136 fenestrations were planned. Thirty cases (48%) were clustered in group A and 32 (52%) in group B. Patients in group A and group B had similar preoperative clinical and morphologic characteristics, except for female sex (group A: 40% vs group B: 13%; P = .02). Technical success was 92% (group A: 90% vs group B: 94%; P = .6), SCI 5% (group A: 10% vs group B: 0%; P = .1) and 30-day mortality 5% (group A: 10% vs group B: 0%; P = .1). The mean follow-up was 17 ± 11 months with a total survival of 86%, 80%, and 60% at 6, 12, and 24 months, respectively and no differences in the two groups (group A: 83%, 83%, and 67% vs group B: 88%, 78%, and 55% respectively; P = .96). There was no late TAAA-related mortality. Target visceral vessel patency was 91%, 91%, and 91% at 6, 12, and 24 months, respectively (group A: 87%, 87%, and 87% vs group B: 95%, 95%, and 95%; P = .25). Freedom from reinterventions was 90%, 87%, and 87%, at 6, 12, and 24 months, respectively, and it was significantly lower in group A compared with group B (group A: 83%, 76%, and 76% vs group B: 96%, 96%, and 96% respectively; P = .002).
Previous open surgery repair does not significantly affect the early outcomes of FB-EVAR in TAAA, with encouraging results in terms of technical success, SCI, mortality, and lower reinterventions rate at midterm follow-up.
既往接受过主动脉开放手术修复（OSR）后的胸腹主动脉瘤（TAAA）是具有挑战性的临床情况。再次行OSR技术要求高，且由于内脏血管受累无法进行标准的血管腔内修复。开窗和分支型腔内移植物（FB-EVAR）是治疗手术风险高的TAAA患者的有效选择，但关于既往接受过OSR的TAAA患者行FB-EVAR治疗效果的专门研究尚缺乏。本研究的目的是评估既往OSR对TAAA患者行FB-EVAR治疗效果的影响。
2010年至2016年期间，对所有接受FB-EVAR治疗的TAAA患者进行前瞻性评估，回顾性分为两组并进行比较：A组为原发性TAAA，B组为既往接受过OSR（腹主动脉瘤、胸主动脉瘤或胸腹主动脉瘤）后的TAAA。早期终点为技术成功（无I-III型内漏、目标内脏血管丢失、转为OSR、术中死亡）、脊髓缺血（SCI）和30天死亡率。随访终点为生存率、目标内脏血管通畅率和无需再次干预。
62例患者（男性：74%；年龄：72±7岁）接受了FB-EVAR治疗，其中I型TAAA 1例（1%），II型14例（23%），III型24例（39%），IV型23例（37%）。TAAA平均直径和目标内脏血管总数分别为65±13mm和226。计划植入90个分支和136个开窗。30例（48%）归入A组，32例（52%）归入B组。A组和B组患者术前临床和形态学特征相似，但女性比例不同（A组：40% vs B组：13%；P = .02）。技术成功率为92%（A组：90% vs B组：94%；P = .6），SCI发生率为5%（A组：10% vs B组：0%；P = .1），30天死亡率为5%（A组：10% vs B组：0%；P = .1）。平均随访时间为17±11个月，6、12和24个月时的总生存率分别为86%、80%和60%，两组间无差异（A组分别为83%、83%和67%，B组分别为88%、78%和55%；P = .96）。无晚期TAAA相关死亡。目标内脏血管通畅率在6、12和24个月时分别为91%、91%和91%（A组：87%、87%和87% vs B组：95%、95%和95%；P = .25）。无需再次干预率在6、12和24个月时分别为90%、87%和87%，A组显著低于B组（A组分别为83%、76%和76%，B组分别为96%、96%和96%；P = .002）。
既往开放手术修复对TAAA患者行FB-EVAR的早期效果无显著影响，在技术成功、SCI、死亡率及中期随访时较低的再次干预率方面取得了令人鼓舞的结果。
