Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center of Hamburg, Hamburg, Germany; Department of Surgery, Division of Vascular Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong.
Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center of Hamburg, Hamburg, Germany.
J Vasc Surg. 2019 Feb;69(2):334-340. doi: 10.1016/j.jvs.2018.04.052. Epub 2018 Jun 23.
Manufacturers often recommend the iliac arteries as the distal landing zone in fenestrated or branched endovascular aortic repair (FB-EVAR) for thoracoabdominal aneurysm. It is not uncommon to choose distal landing at the infrarenal aorta for preservation of lumbar arteries or the inferior mesenteric artery (IMA); however, the safety and durability of this procedure have not been verified in the literature.
Consecutive patients who underwent FB-EVAR with distal landing at the infrarenal aorta were reviewed retrospectively. The primary outcome measured any type IB endoleak over time. Secondary outcomes measured perioperative complications of paraplegia and bowel ischemia, preservation of lumbar artery and IMA, and degeneration of infrarenal aorta (diameter of infrarenal aorta at landing zone) and common iliac arteries (maximum diameters) over time.
Between August 2011 and August 2017, 40 patients (40% male with a mean age of 72 ± 8 years) affected by types I (37.5%), II (25.0%), III (20.0%), and V (17.5%) thoracoabdominal aneurysms were included. The mean aneurysm diameter was 6.4 ± 1.5 cm. There was no immediate or delayed type IB endoleak with mean follow-up period of 15 ± 18 months (range, 0-72 months). Postoperative complications included six (15%) spinal cord ischemia (five temporary and one permanent) and no mesenteric ischemia. There were three deaths (7.5%) within 30 days. Follow-up with computed tomography arteriography showed that 37 patients (92.5%) had at least one lumbar artery preserved. Out of the 31 preoperatively patent IMA, 23 (74.2%) were preserved. There was one incidental finding of new focal dissection distal to the stent graft end. Mean infrarenal aorta diameters were 24.8, 27.7, 27.7, and 29.4 mm immediately preoperatively, and at 1 and 2 years postoperatively, respectively. The mean maximal right common iliac diameters were stable and measured 15.8, 15.9, and 14.8 mm preoperatively, immediately postoperatively, and 1 year postoperatively, respectively. Mean maximal left common iliac diameters were also stable and measured 15.7, 15.9, and 14.7 mm preoperatively, immediately postoperatively, and at 1 year postoperatively, respectively.
Our early experience showed that distal landing at the infrarenal aorta was secure in FB-EVAR with no type IB endoleak, although the observation of gradual infrarenal aortic degeneration mandates regular surveillance.
制造商通常建议在胸主动脉瘤的开窗或分支腔内血管修复术（FB-EVAR）中使用髂动脉作为远端着陆区。为了保留腰动脉或肠系膜下动脉（IMA），选择在肾下主动脉进行远端着陆并不少见；然而，该手术的安全性和耐久性尚未在文献中得到验证。
回顾性分析了 2011 年 8 月至 2017 年 8 月期间接受 FB-EVAR 并在肾下主动脉进行远端着陆的连续患者。主要结局指标是随时间推移的任何类型的 1B 型内漏。次要结局指标包括截瘫和肠缺血的围手术期并发症、腰动脉和 IMA 的保留情况、肾下主动脉（着陆区的肾下主动脉直径）和髂总动脉（最大直径）随时间的退化情况。
共纳入 40 例患者（男性占 40%，平均年龄 72±8 岁），其中 37.5%为 I 型、25.0%为 II 型、20.0%为 III 型和 17.5%为 V 型胸主动脉瘤。平均动脉瘤直径为 6.4±1.5cm。平均随访 15±18 个月（0-72 个月），无即时或延迟的 1B 型内漏。术后并发症包括 6 例（15%）脊髓缺血（5 例为暂时性，1 例为永久性）和无肠系膜缺血。30 天内死亡 3 例（7.5%）。计算机断层血管造影术随访显示，37 例（92.5%）至少有 1 支腰动脉保留。在 31 支术前通畅的 IMA 中，23 支（74.2%）得到保留。支架移植物末端远端发现 1 例偶发性新的局灶性夹层。术前、术后 1 年和 2 年的肾下主动脉直径分别为 24.8、27.7、27.7 和 29.4mm。术前、术后即刻和术后 1 年右侧髂总动脉最大直径分别稳定在 15.8、15.9 和 14.8mm。术前、术后即刻和术后 1 年左侧髂总动脉最大直径也稳定在 15.7、15.9 和 14.7mm。
我们的早期经验表明，在 FB-EVAR 中，肾下主动脉的远端着陆是安全的，没有 1B 型内漏，但逐渐发生的肾下主动脉退化需要定期监测。
