Complex Aortic Team, Birmingham Heartlands Hospital, The Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
Complex Aortic Team, Birmingham Heartlands Hospital, The Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
Eur J Vasc Endovasc Surg. 2019 May;57(5):639-648. doi: 10.1016/j.ejvs.2018.12.012. Epub 2019 Apr 17.
To report the outcome of elective fenestrated and branch (FEVAR-BEVAR) endovascular aortic repair with supracoeliac (SC) sealing zones and the impact of staged repair without prophylactic cerebrospinal fluid (CSF) drainage on the incidence of spinal cord ischaemia (SCI).
Two hundred and seventy consecutive patients (217 men; mean [SD] age, 72.8 ± 6.3 years; median (IQR) diameter 65 mm [62-75 mm]) with juxtarenal (JRAAA) (n = 69) or thoraco-abdominal aortic aneurysms (TAAAs) (n = 201) underwent elective FEVAR (n = 192) or BEVAR (n = 78) with renovisceral stent grafting, proximal SC (Zones 1-5; <40 mm [n = 83]; ≥40 mm [n = 187]) and distal infrarenal aorto-iliac sealing zone (Zones 9-11) between December 2008 and September 2017. A spinal cord protection protocol (SCPP) including staging without prophylactic CSF drainage was introduced in September 2012.
A total of 1026 renovisceral vessels (mean 3.8 ± 0.5 per patient) were targeted for preservation. One patient (0.4%) died in the institution within 30 days and 31 (11.4%) developed 36 major non-fatal complications including unplanned permanent dialysis (n = 1, 0.4%) and non-ambulatory SCI (n = 6, 2.2%). In patients with <40 mm SC coverage, none were staged or had prophylactic CSF drains and none developed SCI. In patients with ≥40 mm SC coverage, SCI occurred in 3.3% (pre-SCPP: 4/20 [20%; none staged, 13 prophylactic CSF drains] vs. post-SCPP: 2/167 [1.2%; 89 staged, no prophylactic CSF drains]; p = .001 [OR = 19.9]). Estimated survival (±SE) at one, two and three years was 92.6% ± 1.6%, 86.5% ± 2.4%, and 73.8% ± 3.5%, respectively, with no significant difference comparing extent of aneurysm or SC coverage. Forty-three (15.9%) patients required late re-intervention. Estimated freedom from re-intervention at one, two and three years was 91.9% ± 1.8%, 85.1% ± 2.5%, and 79.5% ± 3.2%, respectively.
Elective endovascular thoraco-abdominal aortic repair with SC sealing zones can be performed with low peri-operative risk and good medium-term outcomes. Selective staging without prophylactic CSF drainage contributed to a significant reduction in the incidence of SCI.
报告采用经腹腔内脏动脉支架开窗（FEVAR-BEVAR）并在腹腔干（SC）覆盖区行腔内修复术的治疗结果，以及分期而非预防性腰穿引流对脊髓缺血（SCI）发生率的影响。
2008 年 12 月至 2017 年 9 月，270 例（217 例男性；平均[标准差]年龄 72.8±6.3 岁；中位[四分位间距]直径 65 mm[62-75 mm]）肾下腹主动脉瘤（JRAAA）（n=69）或胸腹主动脉瘤（TAAA）（n=201）患者接受了选择性 FEVAR（n=192）或 BEVAR（n=78）治疗，术中采用了内脏支架开窗、SC 近端（1-5 区；<40 mm[n=83]；≥40 mm[n=187]）和远端肾下腹主动脉-髂动脉密封区（9-11 区）覆膜支架。2012 年 9 月引入了脊髓保护方案（SCPP），包括分期而非预防性腰穿引流。
共定位了 1026 个内脏血管（平均每个患者 3.8±0.5 个）。1 例（0.4%）患者在院内 30 天内死亡，31 例（11.4%）发生了 36 例重大非致命并发症，包括计划性永久透析（n=1，0.4%）和非活动能力 SCI（n=6，2.2%）。在 SC 覆盖<40 mm 的患者中，无患者分期或预防性腰穿引流，也无 SCI 发生。在 SC 覆盖≥40 mm 的患者中，3.3%发生 SCI（术前 SCPP：4/20 [20%]；无分期，13 例预防性腰穿引流 vs. 术后 SCPP：2/167 [1.2%]；89 例分期，无预防性腰穿引流；p=0.001[比值比=19.9]）。1、2、3 年估计生存率（±标准误）分别为 92.6%±1.6%、86.5%±2.4%和 73.8%±3.5%，与动脉瘤范围或 SC 覆盖范围无显著差异。43 例（15.9%）患者需要晚期再次介入治疗。1、2、3 年无再次介入治疗的估计生存率分别为 91.9%±1.8%、85.1%±2.5%和 79.5%±3.2%。
采用经腹腔内脏动脉支架开窗并在 SC 覆盖区行腔内修复术治疗胸腹主动脉瘤，围手术期风险较低，中期结果良好。选择性分期而非预防性腰穿引流显著降低了 SCI 的发生率。
