Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan.
J Vasc Surg. 2019 Jan;69(1):15-23. doi: 10.1016/j.jvs.2018.03.425. Epub 2018 Jun 15.
Thoracic endovascular aortic repair (TEVAR) with supra-aortic debranching has recently been introduced as a treatment option for aortic arch disease. Although less invasive than open repair, TEVAR is associated with a risk of perioperative embolic stroke due to dislodgment of atherosclerotic plaque debris, especially in individuals with atheromatous degeneration of the aortic lumen. It is difficult to determine atheroma vulnerability, and there is no current method for predicting the risk of atheroembolism. This study aimed to evaluate the usefulness of our method of quantifying the shagginess of the aorta in predicting the short- and long-term outcomes of TEVAR involving the aortic arch.
The study included 77 patients (63 men and 14 women; median age, 78 years) who underwent elective TEVAR for aortic arch disease between 2009 and 2013. The proximal landing of the stent graft was in zone 0 in 22 patients, zone 1 in 23 patients, and zone 2 in 32 patients. The shagginess score of each patient was calculated from preoperative contrast-enhanced computed tomography images of the aorta using a workstation. The relationships between preoperative factors, including the shagginess score, and the development of perioperative stroke and late survival were analyzed retrospectively.
Perioperative ischemic stroke occurred in nine patients, and no patient died within 30 days postoperatively. Univariate analyses demonstrated that the shagginess score was significantly higher in patients who developed postoperative cerebral infarction than in those who did not (P = .04). The median follow-up period was 1570 days, and the 5-year cumulative survival rate was 69.2%. Cox proportional hazards analyses showed that comorbid hypercholesterolemia was significantly associated with all-cause mortality (hazard ratio [HR], 3.22; 95% confidence interval [CI], 1.24-8.32; P = .02). As for cardiovascular mortality, the shagginess score was a significant predictive factor (HR, 1.84; 95% CI, 1.04-3.28; P = .04), whereas statin use was significantly protective (HR, 0.11; 95% CI, 0.02-0.66; P = .02).
The shagginess score may be a useful predictive index of perioperative ischemic stroke as well as a prognostic factor of long-term outcomes after TEVAR with aortic arch involvement.
胸主动脉腔内修复术（TEVAR）联合主动脉弓去分支术最近已被引入作为主动脉弓疾病的一种治疗选择。尽管与开放修复相比，TEVAR 的创伤性较小，但由于动脉粥样硬化斑块碎片的脱落，仍存在围手术期栓塞性卒中的风险，尤其是在主动脉管腔存在粥样硬化变性的患者中。确定动脉粥样硬化易损性较为困难，目前尚无预测动脉粥样硬化栓塞风险的方法。本研究旨在评估我们量化主动脉毛糙度的方法在预测涉及主动脉弓的 TEVAR 短期和长期结果方面的作用。
本研究纳入了 77 名（男 63 名，女 14 名；中位年龄，78 岁）于 2009 年至 2013 年期间因主动脉弓疾病接受择期 TEVAR 的患者。支架移植物的近端锚定区位于 0 区 22 例，1 区 23 例，2 区 32 例。使用工作站从主动脉术前增强 CT 图像计算每位患者的毛糙度评分。回顾性分析术前因素（包括毛糙度评分）与围手术期卒中及晚期生存之间的关系。
9 例患者发生围手术期缺血性卒中，术后 30 天内无患者死亡。单因素分析显示，发生术后脑梗死的患者毛糙度评分明显高于未发生脑梗死的患者（P=0.04）。中位随访时间为 1570 天，5 年累积生存率为 69.2%。Cox 比例风险分析显示，合并高胆固醇血症与全因死亡率显著相关（风险比 [HR]，3.22；95%置信区间 [CI]，1.24-8.32；P=0.02）。对于心血管死亡率，毛糙度评分是一个显著的预测因素（HR，1.84；95% CI，1.04-3.28；P=0.04），而他汀类药物的使用具有显著的保护作用（HR，0.11；95% CI，0.02-0.66；P=0.02）。
毛糙度评分可能是预测 TEVAR 围手术期缺血性卒中的有用指标，也是涉及主动脉弓的 TEVAR 后长期结果的预后因素。
