Division of Vascular Surgery, Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC.
Vascular Surgery, University of North Carolina, Raleigh, NC.
J Vasc Surg. 2019 Sep;70(3):691-701. doi: 10.1016/j.jvs.2018.11.043. Epub 2019 Mar 2.
This study compared complications in patients undergoing fenestrated-branched endovascular aneurysm repair (F-BEVAR) without and with stenting of the superior mesenteric artery (SMA) or celiac artery (CA), with particular attention to the length of coverage above the CA.
A retrospective review was performed of a prospectively maintained database of patients treated with F-BEVAR for thoracoabdominal aortic aneurysms between July 2012 and May 2017. Data included demographics, risk factors, comorbidities, preoperative aneurysm characteristics, procedural data, and outcomes. Patients were grouped as follows: group 1, no SMA or CA stent; group 2, SMA or CA stent and <5 cm of coverage above the CA; and group 3, SMA or CA stent and ≥5 cm of coverage above the CA. Complications measured included death, myocardial infarction, respiratory failure, stroke or transient ischemic attack, paraplegia, acute kidney injury, mesenteric ischemia, and vascular complications. Individual and composite complications were compared between groups.
There were 223 patients who had data analyzed (group 1, 53 [24%]; group 2, 101 [45%]; and group 3, 69 [31%]). Mean age was 72 years (76% male). There was no difference in patients' characteristics between groups, except for hypertension (less common in group 2) and history of previous aortic surgery (more common in group 3). Group 2 (15%) and group 3 (90%) had higher spinal drain use than group 1 (2%; P < .0001). Mean operative time was longer in groups 2 and 3 compared with group 1 (group 1, 224 minutes; group 2, 253 minutes; and group 3, 313 minutes; P < .0001). Group 1 had more intraoperative complications, without difference in the technical success and mortality rates. Failure to deliver a bridging stent occurred in only 3 of 695 vessels (0.4%) intended, without difference between groups (P = .79). The incidence of major complications (individually and composite analysis) was similar between groups. On 30-day computed tomography angiography, there was no difference in type I or type III endoleaks (2%, 3%, and 6%) and branch patency (98%, 99%, and 99%) for groups 1, 2, and 3, respectively. At 3 years of follow-up, there was no difference in survival, stent patency, and branch instability. Group 3 had a higher reintervention rate compared with groups 1 and 2 (P < .0001); however, there was no difference between groups 1 and 2 (P = .31).
Patients who needed SMA or CA incorporation with stents during F-BEVAR for aortic repair had more complex procedures, as assessed by operative time, brachial access, number of vessels incorporated, and spinal drain use. However, the extension of the repair did not affect the outcomes, demonstrated by similar mortality and morbidity rates between groups.
本研究比较了在不进行和进行肠系膜上动脉（SMA）或腹腔动脉（CA）支架置入的情况下接受开窗分支型腔内血管修复术（F-BEVAR）的患者的并发症，尤其关注 CA 上方覆盖的长度。
对 2012 年 7 月至 2017 年 5 月间接受 F-BEVAR 治疗胸腹主动脉瘤的前瞻性维护数据库中的患者进行回顾性分析。数据包括人口统计学、危险因素、合并症、术前动脉瘤特征、手术数据和结局。患者分为以下三组：组 1，无 SMA 或 CA 支架；组 2，SMA 或 CA 支架且 CA 上方覆盖长度<5cm；组 3，SMA 或 CA 支架且 CA 上方覆盖长度≥5cm。测量的并发症包括死亡、心肌梗死、呼吸衰竭、卒中和短暂性脑缺血发作、截瘫、急性肾损伤、肠系膜缺血和血管并发症。比较各组之间的个体和复合并发症。
共有 223 例患者的数据进行了分析（组 1：53 例[24%]；组 2：101 例[45%]；组 3：69 例[31%]）。平均年龄为 72 岁（76%为男性）。各组患者特征除高血压（组 2 中较少见）和既往主动脉手术史（组 3 中较多见）外，无差异。组 2（15%）和组 3（90%）比组 1（2%）使用更多的脊髓引流管（P<.0001）。与组 1（224 分钟）相比，组 2 和组 3 的手术时间更长（组 1：224 分钟；组 2：253 分钟；组 3：313 分钟；P<.0001）。组 1 术中并发症更多，但技术成功率和死亡率无差异。计划的 695 个血管中仅 3 个（0.4%）未能输送桥接支架，各组之间无差异（P=.79）。主要并发症（个体和综合分析）的发生率在各组之间相似。30 天 CT 血管造影显示，各组间 I 型和 III 型内漏（2%、3%和 6%）和分支通畅率（98%、99%和 99%）无差异。3 年随访时，各组间生存率、支架通畅率和分支不稳定无差异。与组 1 和组 2 相比，组 3 的再干预率更高（P<.0001）；但组 1 和组 2 之间无差异（P=.31）。
在主动脉修复的 F-BEVAR 中需要 SMA 或 CA 支架置入的患者手术更复杂，评估指标包括手术时间、肱动脉入路、纳入的血管数量和脊髓引流管使用。然而，修复的扩展并未影响结局，各组之间死亡率和发病率相似。
