Gaudric Julien, Tresson Philippe, Derycke Lucie, Tezenas Du Montcel Sophie, Couture Thibault, Davaine Jean-Michel, Kashi Mahine, Lawton James, Chiche Laurent, Koskas Fabien
Department of Vascular Surgery, Pitié-Salpêtrière Hospital, UPMC Paris 06, Paris, France.
Department of Vascular Surgery, Pitié-Salpêtrière Hospital, UPMC Paris 06, Paris, France.
J Vasc Surg. 2018 Dec;68(6):1736-1743. doi: 10.1016/j.jvs.2018.03.416. Epub 2018 Jun 21.
The objective of this study was to assess outcomes of a hybrid technique for treatment of abdominal aortic aneurysm (AAA) associated with iliac aneurysm without distal neck by combining an AAA endovascular repair approach with open surgery for preservation of the internal iliac artery (IIA).
The files of 51 patients operated on between 1998 and 2017 in a single vascular surgery department were retrospectively analyzed. Inclusion criteria were patients with AAA associated with uni-iliac or bi-iliac aneurysm without suitable distal sealing zone. Surgery consisted of deployment of an aortouni-iliac stent graft combined with an extra-anatomic crossover prosthetic bypass. With use of a limited retroperitoneal approach, the contralateral proximal common iliac aneurysm was surgically excluded and the IIA revascularized by direct ilioiliac anastomosis or terminal common iliac suture, preserving the iliac bifurcation.
The patients' mean age was 74 years (58-88 years), and 92% were men. The mean follow-up was 5.8 years (0.1-18 years). Twenty-nine patients (57%) had one or more high-risk criteria for open surgery. Nineteen patients (37.3%) had aortouni-iliac aneurysms, 19 (37.3%) aortobi-iliac aneurysms, 5 (10%) isolated iliac aneurysms, and 8 (15.7%) bi-iliac aneurysms without aortic location. Four patients (7.8%) also had IIA aneurysms. Surgery was successful in all cases. Two patients (4%) died during the 30 days after surgery. One surgically preserved IIA occluded within the first month, resulting in buttock claudication. The 5-year IIA primary patency rate was 96%. Type I proximal endoleaks occurred in two patients, requiring additional surgery 3 years and 13 years after the initial surgery, respectively.
This hybrid technique, consisting of AAA endovascular exclusion combined with open IIA revascularization, is safe and effective for preservation of pelvic vascularization. It is associated with long-term patency and low morbidity rates. We have been using this technique since before the advent of branched dedicated devices, allowing preservation of the IIA with good results. This technique should continue to be proposed, especially in patients not eligible for endovascular iliac branch repair because of anatomic contraindications, to avoid pelvic ischemia if the IIA has to be sacrificed.
本研究的目的是评估一种杂交技术治疗无远端颈部的腹主动脉瘤（AAA）合并髂动脉瘤的疗效，该技术通过将AAA血管腔内修复方法与开放手术相结合以保留髂内动脉（IIA）。
回顾性分析1998年至2017年在单一血管外科接受手术的51例患者的病历。纳入标准为患有AAA合并单侧或双侧髂动脉瘤且无合适远端密封区的患者。手术包括植入主动脉-单侧髂动脉支架移植物并结合解剖外交叉人工血管旁路移植术。采用有限的腹膜后入路，手术排除对侧近端髂总动脉瘤，并通过直接髂-髂吻合或髂总动脉末端缝合使IIA再血管化，保留髂动脉分叉。
患者的平均年龄为74岁（58 - 88岁），92%为男性。平均随访时间为5.8年（0.1 - 18年）。29例患者（57%）有一项或多项开放手术的高危标准。19例患者（37.3%）患有主动脉-单侧髂动脉瘤，19例（37.3%）患有主动脉-双侧髂动脉瘤，5例（10%）为孤立性髂动脉瘤，8例（15.7%）为无主动脉部位的双侧髂动脉瘤。4例患者（7.8%）还患有IIA动脉瘤。所有病例手术均成功。2例患者（4%）在术后30天内死亡。1例手术保留的IIA在第一个月内闭塞，导致臀部间歇性跛行。IIA的5年原发性通畅率为96%。2例患者发生I型近端内漏，分别在初次手术后3年和13年需要再次手术。
这种由AAA血管腔内排除联合开放IIA再血管化组成的杂交技术对于保留盆腔血管化是安全有效的。它具有长期通畅率和低发病率。在分支专用装置出现之前我们就一直在使用这种技术，能够很好地保留IIA。这种技术应继续被推荐，特别是对于因解剖学禁忌而不符合血管腔内髂动脉分支修复条件的患者，以避免在必须牺牲IIA时发生盆腔缺血。
