Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Bejing, China.
Department of Interventional Radiology, Beijing Anzhen Hospital of Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing China.
Ann Thorac Surg. 2019 Mar;107(3):718-724. doi: 10.1016/j.athoracsur.2018.09.043. Epub 2018 Nov 4.
Experience is limited with distal stent graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) of type B dissection (TBAD). We report the management strategy and outcomes in such patients.
Clinical data were analyzed for 95 patients (age, 53.2 ± 10.9 years; 82 men) who presented with distal SINE after TEVAR for TBAD.
Follow-up was 100% for 7.2 ± 3 years after primary TEVAR. Distal SINE occurred at a mean of 2.7 ± 2.4 years. Re-TEVAR was performed for 78, with routine stent grafts in 64 and a more tapered graft in 14. Three patients were managed surgically and 14 medically. Two patients died after re-TEVAR. During follow-up at 5.8 ± 2.9 years, late death occurred in 19 patients, 7 with medical therapy and 12 with re-TEVAR. Distal SINE recurred in 11 at 3.5 ± 1.7 years after re-TEVAR. Reintervention significantly improved survival up to 8 years compared with medical therapy (88.3% vs 63.5%, p = 0.001). In 64 patients with routine stent grafts, mortality was 24%, distal SINE recurred in 20%, and recurrence-free survival was 56% at 6 years. Neither death nor recurrence of SINE occurred in 14 patients with a more tapered stent graft. Predictors for distal SINE after primary TEVAR were stent graft length (hazard ratio, 0.984; p = 0.037) and chronic phase (hazard ratio, 1.725; p = 0.049).
In TBAD patients with distal SINE after TEVAR, reintervention with re-TEVAR could improve long-term survival significantly. Recurrence of distal SINE was high after re-TEVAR using routine stent grafts. More tapered stent grafts may be helpful in preventing the recurrence of distal SINE.
胸主动脉腔内修复术（TEVAR）治疗 B 型夹层（TBAD）后发生远端支架移植物内新入口（SINE）的经验有限。我们报告了此类患者的治疗策略和结果。
分析了 95 例 TEVAR 治疗 TBAD 后发生远端 SINE 的患者的临床资料（年龄 53.2±10.9 岁；82 例男性）。
TEVAR 后 7.2±3 年的随访率为 100%。远端 SINE 的平均发生时间为 2.7±2.4 年。78 例行再次 TEVAR，其中 64 例行常规支架移植物，14 例行更锥形的支架移植物。3 例患者行手术治疗，14 例患者行药物治疗。2 例患者在再次 TEVAR 后死亡。在 5.8±2.9 年的随访中，19 例患者死亡，其中 7 例接受药物治疗，12 例接受再次 TEVAR。再次 TEVAR 后 3.5±1.7 年，11 例患者发生远端 SINE 复发。与药物治疗相比，再次干预显著提高了 8 年的生存率（88.3% vs. 63.5%，p=0.001）。在 64 例行常规支架移植物的患者中，死亡率为 24%，20%发生远端 SINE 复发，6 年无复发生存率为 56%。14 例行更锥形支架移植物的患者中无死亡或 SINE 复发。初次 TEVAR 后发生远端 SINE 的预测因素包括支架移植物长度（风险比，0.984；p=0.037）和慢性期（风险比，1.725；p=0.049）。
TBAD 患者 TEVAR 后发生远端 SINE，再次 TEVAR 可显著提高长期生存率。再次 TEVAR 后常规支架移植物的远端 SINE 复发率较高。更锥形的支架移植物可能有助于防止远端 SINE 的复发。
