Kouvelos George N, Antoniou George, Spanos Konstantinos, Giannoukas Athanasios, Matsagkas Miltiadis
Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece -
Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK.
J Cardiovasc Surg (Torino). 2019 Apr;60(2):167-174. doi: 10.23736/S0021-9509.19.10869-5. Epub 2019 Jan 18.
The aim was to investigate the impact of wide proximal aortic diameter on outcome after standard endovascular repair (sEVAR) of infrarenal abdominal aortic aneurysms.
A systematic search of the literature was undertaken using the PUBMED, EMBASE, and Cochrane databases for articles comparing outcome after sEVAR in patients with large versus small diameter aortic neck. The prognostic factor of interest was large diameter proximal aortic neck and the results were reported as odds ratio (OR) or mean difference (MD) and 95% confidence interval (CI). A time-to-event data meta-analysis for late outcomes was performed using the inverse-variance method and reported the results as summary hazard ratio (HR) and 95% CI.
We identified 6 observational studies reporting on a total of 6602 patients (1616 with large and 4986 with small diameter neck). Patients with large proximal aortic neck were older (MD 0.87, 95% CI: 0.35-1.39; P=0.001). The prevalence of male gender (OR=1.63, 95% CI: 1.34-1.98; P<0.001), coronary artery disease (OR=1.20, 95% CI: 1.06-1.36; P=0.004), chronic obstructive pulmonary disease (OR=1.18, 95% CI: 1.03-1.36; P=0.02) and chronic kidney disease (OR=1.43, 95% CI: 1.23-1.66; P<0.001) was higher in the wide neck group. Patients with large diameter proximal neck had shorter proximal neck (MD=-1.91, 95% CI: -2.04 to -1.77; P<0.001) and a larger aneurysm diameter compared to those with small diameter neck (MD=3.40, 95% CI: 2.71-4.10; P<0.001). Patients with small diameter proximal neck had significantly higher freedom from aneurysm-related reintervention (HR=2.06, 95% CI: 1.23-3.45; P=0.006), freedom from type Ia endoleak (HR=6.69, 95% CI: 4.39-10.20; P<0.001), freedom from sac expansion (HR=10.07, 95% CI: 1.80-56.53; P=0.009), freedom from aneurysm rupture (HR 5.10, 95% CI: 1.40-18.58; P=0.01), and survival (HR=1.55, 95% CI: 1.08-2.24; P=0.02).
Patients with a wide proximal aortic neck undergoing standard EVAR were found to have worse outcome, as indicated by a lower freedom from aneurysm-related reintervention, type Ia endoleak, sac expansion and aneurysm rupture, and a higher overall survival. This anatomic characteristic should be considered in decision making. In such patients, closer imaging surveillance after EVAR in the long term may be required to identify early and treat timely the complications.
目的是研究肾下腹主动脉瘤标准血管腔内修复术（sEVAR）后近端主动脉直径增宽对预后的影响。
使用PUBMED、EMBASE和Cochrane数据库对文献进行系统检索，以查找比较大直径与小直径主动脉颈部患者sEVAR术后预后的文章。感兴趣的预后因素是近端主动脉颈部直径较大，结果以比值比（OR）或平均差（MD）及95%置信区间（CI）报告。使用逆方差法对晚期结局进行事件发生时间数据的荟萃分析，并将结果报告为汇总风险比（HR）和95%CI。
我们确定了6项观察性研究，共报告6602例患者（1616例近端颈部直径大，4986例近端颈部直径小）。近端主动脉颈部直径大的患者年龄更大（MD 0.87，95%CI：0.35 - 1.39；P = 0.001）。宽颈部组男性（OR = 1.63，95%CI：1.34 - 1.98；P < 0.001）、冠状动脉疾病（OR = 1.20，95%CI：1.06 - 1.36；P = 0.004）、慢性阻塞性肺疾病（OR = 1.18，95%CI：1.03 - 1.36；P = 0.02）和慢性肾脏病（OR = 1.43，95%CI：1.23 - 1.66；P < 0.001）的患病率更高。与近端颈部直径小的患者相比，近端颈部直径大的患者近端颈部较短（MD = -1.91，95%CI： - 2.04至 - 1.77；P < 0.001），动脉瘤直径更大（MD = 3.40，95%CI：2.71 - 4.10；P < 0.001）。近端颈部直径小的患者在免于动脉瘤相关再干预（HR = 2.06，95%CI：1.23 - 3.45；P = 0.006）、免于Ia型内漏（HR = 6.69，95%CI：4.39 - 10.20；P < 0.001）、免于瘤体扩张（HR = 10.07，95%CI：1.80 - 56.53；P = 0.009）、免于动脉瘤破裂（HR 5.10，95%CI：1.40 - 18.58；P = 0.01）和生存（HR = 1.55, 95%CI：1.08 - 2.24；P = 0.02）方面显著更高。
接受标准血管腔内修复术的近端主动脉颈部直径增宽的患者预后较差，表现为免于动脉瘤相关再干预、Ia型内漏、瘤体扩张和动脉瘤破裂的比例较低，总体生存率较高。在决策时应考虑这一解剖特征。对于此类患者，可能需要在血管腔内修复术后进行长期更密切的影像学监测，以早期识别并及时治疗并发症。
