Section of Vascular and Endovascular Surgery, Yale School of Medicine, New Haven, Conn; Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
J Vasc Surg. 2019 Mar;69(3):671-679.e1. doi: 10.1016/j.jvs.2018.06.209. Epub 2018 Oct 24.
The objective of this study was to evaluate outcomes of endovascular treatment of aortic coarctation in adults.
Clinical data and imaging studies of 93 consecutive patients treated at nine institutions from 1999 to 2015 were reviewed. We included newly diagnosed aortic coarctation (NCO), recurrent coarctation, and aneurysmal/pseudoaneurysmal degeneration (ANE) after prior open surgical repair (OSR) of coarctation. Primary end points were morbidity and mortality. Secondary end points were stent patency and freedom from reintervention.
There were 54 (58%) male and 39 (42%) female patients with a mean age of 44 ± 17 years. Thirty-two patients had NCO (mean age, 48 ± 16 years) and 61 had endovascular reinterventions after prior OSR during childhood (mean, 30 ± 17 years after initial repair), including 50 patients (54%) with recurrent coarctation and 11 (12%) with ANE. Clinical presentation included asymptomatic in 31 patients (33%), difficult to control hypertension in 42 (45%), and lower extremity claudication in 20 (22%). Endovascular treatment was performed using balloon-expandable covered stents in 47 (51%) patients, stent grafts in 36 (39%) patients, balloon-expandable uncovered stents in 9 (10%) patients, and primary angioplasty in 1 (1%) patient. Mean lesion length and diameter were 64.5 ± 50.6 mm and 19.5 ± 6.7 mm, respectively. Mean systolic pressure gradient decreased from 24.0 ± 17.5 mm Hg to 4.4 ± 7.4 mm Hg after treatment (P < .001). Complications occurred in nine (10%) patients, including aortic dissections in three (3%) patients and intraoperative ruptures in two patients; type IA endoleak, renal embolus, spinal headache, and access site hemorrhage occurred in one patient each. The aortic dissections and ruptures were treated successfully by deploying an additional covered stent proximal to the site of dissection or rupture. Two patients died within 30 days of the index procedure. After a mean follow-up of 3.2 ± 3.1 years, nearly all patients (98%) were clinically improved and all stents were patent. Reintervention was needed in 10 (11%) patients. Freedom from reintervention at 5 years was 85%. Two additional patients died during follow-up of coarctation-related causes, including rupture of an infected graft and visceral ischemia. Patient survival at 5 years was 89%.
Endovascular repair is effective with an acceptable safety profile in the treatment of NCO and postsurgical complications of coarctation after initial OSR. Aortic rupture is an infrequent (2%) but devastating complication with high mortality. Balloon-expandable covered stents are preferred for NCO, whereas stent grafts are used for ANE. The rate of reinterventions is acceptable, with high procedural and long-term clinical success.
本研究旨在评估血管内治疗成人主动脉缩窄的结果。
回顾了 1999 年至 2015 年 9 家机构的 93 例连续患者的临床数据和影像学研究。我们纳入了新诊断的主动脉缩窄（NCO）、复发性缩窄以及先前开放手术修复（OSR）后发生的动脉瘤/假性动脉瘤（ANE）。主要终点是发病率和死亡率。次要终点是支架通畅率和免于再次介入。
54 例（58%）为男性，39 例（42%）为女性，平均年龄为 44±17 岁。32 例为 NCO（平均年龄为 48±16 岁），61 例为儿童期 OSR 后再次血管内介入治疗（初次修复后平均 30±17 年），包括 50 例（54%）复发性缩窄和 11 例（12%）ANE。临床表现包括无症状 31 例（33%），难以控制的高血压 42 例（45%），下肢跛行 20 例（22%）。血管内治疗采用球囊扩张覆膜支架 47 例（51%），支架移植物 36 例（39%），球囊扩张非覆膜支架 9 例（10%），单纯球囊扩张 1 例（1%）。平均病变长度和直径分别为 64.5±50.6mm 和 19.5±6.7mm。治疗后平均收缩压梯度从 24.0±17.5mmHg 降至 4.4±7.4mmHg（P<0.001）。9 例（10%）患者发生并发症，包括 3 例（3%）主动脉夹层和 2 例术中破裂；1 例发生 1 型内漏、肾栓塞、脊髓头痛和入路出血。通过在夹层或破裂部位近端放置额外的覆膜支架，成功治疗了 3 例（3%）主动脉夹层和 2 例（2%）术中破裂。2 例患者在指数手术后 30 天内死亡。平均随访 3.2±3.1 年后，几乎所有患者（98%）的临床状况均得到改善，所有支架均通畅。10 例（11%）患者需要再次介入治疗。5 年免于再次介入的比例为 85%。另外 2 例患者死于与缩窄相关的原因，包括感染性移植物破裂和内脏缺血。5 年患者生存率为 89%。
血管内修复在治疗 NCO 和 OSR 后缩窄的外科并发症方面是有效的，且具有可接受的安全性。主动脉破裂是一种罕见（2%）但具有高死亡率的破坏性并发症。球囊扩张覆膜支架适用于 NCO，而支架移植物用于 ANE。再次介入的发生率可以接受，具有较高的手术和长期临床成功率。
