Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass.
Division of Vascular Surgery and Endovascular Interventions, NewYork-Presbyterian/Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY.
J Vasc Surg. 2019 Aug;70(2):369-380. doi: 10.1016/j.jvs.2018.11.021. Epub 2019 Feb 2.
Endovascular repair of complex abdominal aortic aneurysms has become increasingly common, but reports have mostly been limited to single centers and single devices.
We studied all endovascular repairs of complex abdominal aortic aneurysms (zone 6 or caudal) from 2014 to 2018 in the Vascular Quality Initiative. This included all commercially available fenestrated endovascular aneurysm repair (FEVAR), chimney/snorkel repairs, and physician-modified endografts (PMEGs), exclusive of investigational device exemptions and clinical trial devices. We used inverse probability-weighted multilevel logistic regression to compare rates of perioperative outcomes including death, acute kidney injury (AKI), and major adverse cardiac events (MACEs; the composite of death/stroke/myocardial infarction) and Cox regression for long-term mortality.
During the study period, surgeons performed 1396 complex endovascular repairs: 1308 (94%) elective, 63 (4.5%) for symptomatic aneurysms, and 25 (1.8%) for rupture. The number of centers performing complex endovascular repairs expanded steadily from 39 in 2014 to 81 in 2017. There were 880 FEVAR (63%), 256 PMEG (18%), and 260 chimney/snorkel repairs (19%). In elective cases, 3214 visceral vessels were incorporated and revascularized; 120 repairs (9%) involved one vessel, 481 (38%) repairs involved two vessels, 560 (44%) involved three vessels, and 113 (9%) involved four vessels. The mean number of arteries incorporated was 2.5 ± 0.8, with PMEGs involving the most arteries (3.3 ± 0.8 for PMEG vs 2.5 ± 0.6 for FEVAR and 1.9 ± 0.9 for chimney/snorkel; P < .001). PMEGs were used to treat more extensive aneurysms, and more incorporated the celiac and superior mesenteric arteries. There was no change in aneurysm extent, but the length of proximal seal extended over time. Chimney/snorkel cases employed more arm or neck access, had longer procedure times, and used more contrast material. Rates of perioperative death (3.4% for FEVAR vs 2.7% for PMEG vs 6.1% for chimney/snorkel; P = .13) and AKI (17% vs 18% vs 19%; P = .42) were similar, but chimney/snorkel was associated with higher rates of stroke (0.8% vs 0.9% vs 3.3%; P = .03) and MACEs (6.1% vs 5.4% vs 11.7%; P = .02). After adjustment, rates of perioperative death, AKI, and overall complications remained similar, but chimney/snorkel was associated with significantly higher odds of stroke (odds ratio [OR], 7.3 [1.5-36.4]; P = .015), myocardial infarction (OR, 18.7 [2.6-136.8]; P = .004), and MACEs (OR, 11.1 [2.1-58.9]; P = .005). Overall survival after elective repair was 91% at 1 year and 88% at 3 years, with no difference between repair types in crude or adjusted analysis.
The Vascular Quality Initiative provides a unique opportunity to study the real-world application and outcomes of complex endovascular aneurysm repair. Perioperative morbidity appears to be higher after chimney/snorkel repair, but further study is needed to confirm these findings and to establish the durability of these novel technologies.
复杂型腹主动脉瘤的血管内修复已越来越普遍，但大多数报告仅限于单一中心和单一设备。
我们研究了 2014 年至 2018 年血管质量倡议中所有复杂型腹主动脉瘤（6 区或尾部）的血管内修复。这包括所有市售的腔内分支型血管修复术（fenestrated endovascular aneurysm repair，FEVAR）、烟囱/套管修复术和医生改良的移植物（physician-modified endografts，PMEG），不包括研究性器械豁免和临床试验器械。我们使用逆概率加权多水平逻辑回归比较围手术期结局（包括死亡、急性肾损伤（acute kidney injury，AKI）和主要不良心脏事件（major adverse cardiac events，MACE；死亡/中风/心肌梗死的组合））的发生率，并使用 Cox 回归进行长期死亡率分析。
在研究期间，外科医生进行了 1396 例复杂型血管内修复术：1308 例（94%）为择期手术，63 例（4.5%）为症状性动脉瘤，25 例（1.8%）为破裂。开展复杂型血管内修复术的中心数量从 2014 年的 39 家稳步增加到 2017 年的 81 家。其中 FEVAR 880 例（63%）、PMEG 256 例（18%）、烟囱/套管修复术 260 例（19%）。在择期手术中，共纳入和重建了 3214 条内脏血管；120 例（9%）涉及一条血管，481 例（38%）涉及两条血管，560 例（44%）涉及三条血管，113 例（9%）涉及四条血管。平均纳入动脉数为 2.5±0.8，其中 PMEG 涉及的动脉最多（PMEG 为 3.3±0.8，FEVAR 为 2.5±0.6，烟囱/套管修复术为 1.9±0.9；P<0.001）。PMEG 用于治疗更广泛的动脉瘤，更多地包含了腹腔干和肠系膜上动脉。动脉瘤范围没有变化，但近端密封的长度随着时间的推移而延长。烟囱/套管修复术病例采用更多的臂或颈部入路，手术时间更长，使用更多的造影剂。围手术期死亡率（FEVAR 为 3.4%，PMEG 为 2.7%，烟囱/套管修复术为 6.1%；P=0.13）和 AKI（17%比 18%比 19%；P=0.42）相似，但烟囱/套管修复术与更高的中风（0.8%比 0.9%比 3.3%；P=0.03）和 MACE（6.1%比 5.4%比 11.7%；P=0.02）发生率相关。调整后，围手术期死亡率、AKI 和总体并发症发生率仍相似，但烟囱/套管修复术与更高的中风（优势比[OR]，7.3[1.5-36.4]；P=0.015）、心肌梗死（OR，18.7[2.6-136.8]；P=0.004）和 MACE（OR，11.1[2.1-58.9]；P=0.005）发生率相关。择期修复后的 1 年和 3 年总生存率分别为 91%和 88%，不同修复类型在未调整和调整分析中均无差异。
血管质量倡议为研究复杂型血管内动脉瘤修复的真实世界应用和结果提供了一个独特的机会。烟囱/套管修复术后围手术期发病率似乎更高，但需要进一步研究来证实这些发现，并确定这些新技术的耐久性。
