Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Tex.
Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
J Vasc Surg. 2020 Jan;71(1):23-29. doi: 10.1016/j.jvs.2019.03.054. Epub 2019 Jul 4.
Fenestrated endovascular aneurysm repair (FEVAR) is an alternative to treat complex abdominal aortic aneurysms. Patency of visceral vessels remains high when covered stents are used. The use of distal uncovered stents to prevent kinking has been associated with loss of branch patency. The aim of this study was to evaluate branch-related outcomes of FEVAR using covered stents only vs the use of uncovered stents distal to covered stents.
During a 4-year period, 142 patients underwent FEVAR. Patients with suprarenal, juxtarenal, and type IV thoracoabdominal aneurysms were included. Patients treated with side branch devices were excluded. Covered iCAST (Maquet, Hudson, NH) stents were used as bridging stents in all cases. The primary end point was primary patency, defined as the absence of stenosis or occlusion that required intervention. Secondary end points included secondary patency, branch-related outcomes (kidney injury and gastrointestinal complications), branch instability, and mortality rates.
A total of 442 target vessels were incorporated (49 scallops and 393 fenestrations). Uncovered stents were used in 38 (9.6%) visceral vessels. Median follow-up time was 11 (interquartile range, 6-13) months. Overall, visceral vessel primary patency was 91% at 12 and 24 months. The overall primary patency rate was 86% in the distal extension group vs 93% when only covered stents were used at 12 and 24 months (P = .8). Similarly, the rate of branch-related reinterventions at 12 months was 9% and 15% for each group, respectively, and 22% vs 32% at 24 months, respectively (P = .5). Overall, freedom from branch instability was 87% at 12 months and 81% at 24 months. Freedom from branch instability in the distal extension group was 82% at 12 and 24 months vs 89% at 12 months and 81% at 24 months when only covered stents were used (P =. 08). Mortality rate at 24 months was 15% for the bare-metal stent extension group vs 14% for the covered stent only group (P = .4). We found no statistical difference in acute kidney injury at any Kidney Disease: Improving Global Outcomes stage (P = 1.0) or gastrointestinal complications (P = 1.0) between the groups.
The use of distal uncovered stents to prevent kinks was not associated with decreased early branch patency. The long-term outcomes of bare-metal stents remain to be determined. For now, the use of uncovered stents distal to covered stents may be considered to prevent kinks in complex anatomy.
腔内血管修复术（FEVAR）是治疗复杂型腹主动脉瘤的一种替代方法。使用覆膜支架时，内脏血管的通畅率仍然较高。使用远端无覆盖支架来防止扭结与分支通畅丧失有关。本研究的目的是评估仅使用覆膜支架与在覆膜支架远端使用无覆盖支架治疗分支相关结果。
在 4 年期间，142 例患者接受了 FEVAR。纳入了肾上、肾周和 IV 型胸腹主动脉瘤患者。排除使用侧支装置治疗的患者。所有病例均使用覆膜 iCAST（Maquet，Hudson，NH）支架作为桥接支架。主要终点是通畅率，定义为无需要介入治疗的狭窄或闭塞。次要终点包括通畅率、分支相关结局（肾脏损伤和胃肠道并发症）、分支不稳定和死亡率。
共纳入 442 个靶血管（49 个瓣和 393 个开窗）。38 个（9.6%）内脏血管使用了无覆盖支架。中位随访时间为 11（四分位距，6-13）个月。总体而言，内脏血管通畅率在 12 和 24 个月时分别为 91%。在远端延伸组，整体通畅率为 86%，而仅在 12 和 24 个月时使用覆膜支架组为 93%（P=.8）。同样，在 12 个月时，每组分支相关再干预率分别为 9%和 15%，在 24 个月时分别为 22%和 32%（P=.5）。总体而言，12 个月时分支不稳定的无事件率为 87%，24 个月时为 81%。在远端延伸组，12 个月和 24 个月时无分支不稳定的比例分别为 82%和 89%，而仅使用覆膜支架组 12 个月和 24 个月时分别为 89%和 81%（P=.08）。24 个月时死亡率在裸金属支架延伸组为 15%，在仅覆膜支架组为 14%（P=.4）。两组之间任何阶段的急性肾损伤（P=1.0）或胃肠道并发症（P=1.0）均无统计学差异。
使用远端无覆盖支架防止扭结不会导致早期分支通畅率降低。裸金属支架的长期结果仍有待确定。目前，在覆膜支架的远端使用无覆盖支架可能有助于防止复杂解剖结构中的扭结。
