Department of Vascular Medicine, German Aortic Center, University Heart Center, Hamburg, Germany.
Department of Cardiovascular Surgery, German Aortic Center, University Heart Center, Hamburg, Germany.
J Vasc Surg. 2019 Apr;69(4):977-985.e1. doi: 10.1016/j.jvs.2018.07.076. Epub 2018 Nov 23.
Whereas open repair is the "gold standard" for most aortic arch diseases, a subgroup of patients might benefit from an endovascular approach. The introduction of branched stent grafts with dedicated design to address the challenges of the ascending aorta and the aortic arch has opened an entirely new area of treatment for these patients. We investigated the early outcomes of branched thoracic endovascular aortic repair (b-TEVAR) in various types of disease of the aortic arch.
A retrospective analysis was conducted of prospectively collected data from a single center of all consecutive patients treated with b-TEVAR. The indication for elective endovascular repair was consented in an interdisciplinary case conference. All patients were treated with a custom-made inner branched arch endograft with two internal branches (Cook Medical, Bloomington, Ind) and left-sided carotid-subclavian bypass. Study end points were technical success, 30-day mortality, and complications as well as late complications and reinterventions.
Between 2012 and 2017, there were 54 patients (38 male; median age, 71 years) treated with diseases of the aortic arch. Indications for therapy involved degenerative aortic arch or proximal descending aortic aneurysms requiring arch repair (n = 24), dissection with or without false lumen aneurysms (n = 26), and penetrating aortic ulcers (n = 4). Forty-three cases (80%) were performed electively and 11 urgently for contained ruptures (n = 3) or symptomatic aneurysms (n = 8) with endografts already available for the patient or with grafts of other patients with similar anatomy. Technical success was achieved in 53 cases (98%). The 30-day mortality and major stroke incidence were 5.5% (3/54) and 5.5% (3/54), respectively; in-hospital mortality was 7.4% (n = 4), and minor strokes (including asymptomatic new cerebral lesions) occurred in 5.5% (n = 3). There were two cases of transient spinal cord ischemia with complete recovery and one of paraplegia. No retrograde type A dissections or cardiac injuries were observed. Three early stent graft-related reinterventions were necessary to correct proximal endograft kinking with type IA endoleak in one patient, a bridging stent graft stenosis in another patient, and false lumen persistent perfusion from dissected supra-aortic vessels in the last patient. Mean in-hospital stay was 14 ± 8 days. During a mean follow-up of 12 ± 9 months, three nonaorta-related deaths and one aorta-related death distal to the arch repair were observed.
Treatment of aortic arch diseases with b-TEVAR is feasible and safe with acceptable mortality and stroke rates.
尽管开放修复是大多数主动脉弓疾病的“金标准”，但一部分患者可能受益于血管内治疗方法。具有专用设计的分支支架移植物的引入解决了升主动脉和主动脉弓的挑战，为这些患者开辟了全新的治疗领域。我们研究了分支胸主动脉腔内修复术（b-TEVAR）在各种类型的主动脉弓疾病中的早期结果。
对来自单个中心的所有连续接受 b-TEVAR 治疗的患者的前瞻性收集数据进行回顾性分析。在跨学科病例会议上同意进行择期血管内修复的适应证。所有患者均采用定制的带两个内分支的腔内分支弓支架移植物（库克医疗，布卢明顿，印第安纳州）和左侧颈动脉锁骨下旁路进行治疗。研究终点为技术成功率、30 天死亡率和并发症以及晚期并发症和再介入。
2012 年至 2017 年，共有 54 名（38 名男性；中位年龄 71 岁）患者接受了主动脉弓疾病的治疗。治疗适应证包括需要弓部修复的退行性主动脉弓或近端降主动脉瘤（n=24）、夹层伴或不伴假腔动脉瘤（n=26）和穿透性主动脉溃疡（n=4）。43 例（80%）为择期手术，11 例为紧急手术，其中 3 例为破裂性破裂（n=3），8 例为症状性动脉瘤（n=8），患者已有内支架或具有类似解剖结构的其他患者的支架。53 例（98%）达到技术成功。30 天死亡率和主要卒中发生率分别为 5.5%（3/54）和 5.5%（3/54）；住院死亡率为 7.4%（n=4），小卒中（包括无症状性新脑病变）发生率为 5.5%（n=3）。有 2 例短暂性脊髓缺血，完全恢复，1 例截瘫。无逆行型 A 型夹层或心脏损伤。3 例早期支架移植物相关再介入需要纠正 1 例患者近端内移植物扭结合并 I 型内漏、1 例患者桥接支架移植物狭窄和最后 1 例患者夹层升主动脉血管持续灌注的假腔。平均住院时间为 14±8 天。在平均 12±9 个月的随访中，观察到 3 例非主动脉相关死亡和 1 例弓部修复后远端主动脉相关死亡。
b-TEVAR 治疗主动脉弓疾病是可行和安全的，死亡率和卒中率可接受。
