Reyes Valdivia Andrés, Beropoulis Efthymios, Pitoulias Georgios, Pratesi Giovanni, Alvarez Marcos Francisco, Barbante Matteo, Gandarias Claudio, Torsello Giovanni, Bisdas Theodosios, Donas Konstantinos
Department of Vascular and Endovascular Surgery, Ramón y Cajalś University Hospital, Madrid, Spain.
Department of Vascular Surgery, St Franziskus Hospital Münster, Clinic for Vascular and Endovascular Surgery, Münster University Hospital, Münster, Germany.
Ann Vasc Surg. 2019 Oct;60:61-69. doi: 10.1016/j.avsg.2019.01.017. Epub 2019 Apr 24.
The durability of endovascular aortic aneurysms repair (EVAR) is highly related to several anatomical constraints. The term "hostile neck" describes several anatomical features that usually make EVAR treatment technically demanding despite having higher risk of failure. The aim of the study was to describe a multicenter experience with EVAR and an adjunctive use of EndoAnchors in hostile neck anatomies.
Data were prospectively collected from 4 academic vascular centers including 46 patients with a hostile neck treated by standard EVAR with the adjunctive use of EndoAnchors. Twenty-two of them (47.8%, group A) had an intraoperative type Ia endoleak, and 24 (52.2%) patients were treated in a preventive manner (group B). Primary endpoints were technical and procedural success. Secondary endpoints were regression of the aneurysm sac, freedom from type Ia endoleak, and reinterventions.
Neck length and diameter showed no statistical difference in preoperative measures, 9.1 ± 6.9 mm and 8.6 ± 2.8 mm and 25.4 ± 4.7 mm and 27.3 ± 4.7 mm, in group A and B, respectively. Aneurysm sac diameter decreased from 58.2 ± 8 mm and 57.9 ± 9.8 mm to 55.7 ± 8.5 mm and 53.8 ± 10.4 mm in group A and B; respectively, at the last computed tomography scan. Technical and procedural success was 97.8% and 100%, respectively, for group B. Group A showed persistence of type Ia endoleak at completion angiogram in 9 (40.9%) patients. Five of them showed early spontaneous sealing at the first (30 days) computed tomography angiography (CTA), and in the remaining 4, a delayed spontaneous sealing was diagnosed at 12-month CTA. No neck-related secondary procedures were performed. Overall survival was 91%.
Our study shows that additional use of EndoAnchors can successfully improve the sealing of abdominal endografts in case of intraoperative type Ia endoleaks in hostile neck anatomies, representing a safe and effective endovascular alternative in our armamentarium. However, meticulous radiological follow-up is necessary because complete resolution of all observed intraoperative type Ia endoleaks was not observed until the 12-month CTA follow-up.
血管内主动脉瘤修复术（EVAR）的耐久性与多种解剖学限制密切相关。“不良颈部”这一术语描述了几种解剖学特征，这些特征通常使EVAR治疗在技术上具有挑战性，尽管失败风险较高。本研究的目的是描述在不良颈部解剖结构中EVAR及EndoAnchors辅助使用的多中心经验。
前瞻性收集来自4个学术血管中心的数据，包括46例采用标准EVAR并辅助使用EndoAnchors治疗的不良颈部患者。其中22例（47.8%，A组）术中出现I型内漏，24例（52.2%）患者接受预防性治疗（B组）。主要终点是技术和手术成功。次要终点是瘤囊缩小、无I型内漏以及再次干预。
A组和B组术前颈部长度和直径在测量上无统计学差异，分别为9.1±6.9mm和8.6±2.8mm，以及25.4±4.7mm和27.3±4.7mm。在最后一次计算机断层扫描时，A组和B组的瘤囊直径分别从58.2±8mm和57.9±9.8mm降至55.7±8.5mm和53.8±10.4mm。B组的技术和手术成功率分别为97.8%和100%。A组在完成血管造影时有9例（40.9%）患者存在I型内漏持续存在。其中5例在首次（30天）计算机断层血管造影（CTA）时显示早期自发封闭，其余4例在12个月CTA时诊断为延迟自发封闭。未进行与颈部相关的二次手术。总体生存率为91%。
我们的研究表明，在不良颈部解剖结构中，术中出现I型内漏时，额外使用EndoAnchors可成功改善腹部内移植物的密封效果，是我们现有技术中一种安全有效的血管内替代方法。然而，需要进行细致的影像学随访，因为直到12个月CTA随访时才观察到所有术中观察到的I型内漏完全消失。
