Piffaretti Gabriele, Fontana Federico, Tadiello Marco, Guttadauro Chiara, Piacentino Filippo, Bush Ruth L, Socrate Anna Maria, Tozzi Matteo
Vascular Surgery, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy.
Interventional Radiology, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy.
Ann Cardiothorac Surg. 2019 Jul;8(4):471-482. doi: 10.21037/acs.2019.06.07.
To analyze our experience and to describe access and arch-related challenges when performing thoracic endovascular aortic repair (TEVAR) for penetrating aortic ulcers (PAUs).
This is a single-center, observational, cohort study. Between October 2003 and February 2019, 48 patients with PAU were identified; 37 (77.1%) treated with TEVAR were retrospectively analyzed. Primary major outcomes were early (<30 days) and late survival, freedom from aortic-related mortality (ARM), and a composite endpoint of arch/vascular access-related complications.
On admission, 17 (45.9%) patients were symptomatic with 4 (10.8%) presenting with rupture. In-hospital mortality was 8.1% (n=3). We observed 10 (27.0%) arch/access-related complications. There were 4 (10.8%) arch issues: 2 transient ischemic attacks and 2 retrograde acute type A dissections which required emergent open conversion for definitive repair. Access issues occurred in 6 (16.2%) patients: 3 (8.1%) required common iliac artery conduit, and 1 (2.7%) patient required iliac artery angioplasty to deliver the stent-graft. In addition, 2 (5.4%) patients developed access complications which required operative repair [femoral patch angioplasty (n=2), and femoral pseudoaneurysmectomy (n=1)]. Arch/access-related mortality rate was 5.4% (n=2) and median follow-up was 24 (range, 1-156; IQR, 3-52) months. Estimated survival was 87.1% (standard error: 0.6; 95% CI: 71.2-84.9%) at 1 year, and 63.3% (SE: 0.9; 95% CI: 44.1-79%) at 4 years. Estimated freedom from reintervention was 88.9% (SE: 0.5; 95% CI: 74.8-95.6%) at 1 year, and 84.2% (SE: 0.7; 95% CI: 67.3-93.2%) at 4 years. No arch/access-related issues developed during the follow-up period.
Our experience confirms that vascular access and aortic arch issues are still a challenging aspect of performing TEVAR for PAUs. Our cumulative 27% rate of access/arch issues is lower than previously reported due to both technological advancements and meticulous management of both access routes and arch anatomy.
分析我们在对穿透性主动脉溃疡（PAU）进行胸主动脉腔内修复术（TEVAR）时的经验，并描述手术入路和与主动脉弓相关的挑战。
这是一项单中心、观察性队列研究。2003年10月至2019年2月期间，共确定48例PAU患者；对37例（77.1%）接受TEVAR治疗的患者进行回顾性分析。主要主要结局为早期（<30天）和晚期生存率、无主动脉相关死亡率（ARM）以及主动脉弓/血管入路相关并发症的复合终点。
入院时，17例（45.9%）患者有症状，4例（10.8%）出现破裂。住院死亡率为8.1%（n = 3）。我们观察到10例（27.0%）与主动脉弓/入路相关的并发症。有4例（10.8%）主动脉弓问题：2例短暂性脑缺血发作和2例逆行性急性A型夹层，需要紧急开放转换进行确定性修复。6例（16.2%）患者出现入路问题：3例（8.1%）需要髂总动脉导管，1例（2.7%）患者需要髂动脉血管成形术以输送覆膜支架。此外，2例（5.4%）患者出现需要手术修复的入路并发症[股动脉补片血管成形术（n = 2）和股动脉假性动脉瘤切除术（n = 1）]。与主动脉弓/入路相关的死亡率为5.4%（n = 2），中位随访时间为24（范围1 - 156；四分位间距3 - 52）个月。1年时估计生存率为87.1%（标准误：0.6；95%可信区间：71.2 - 84.9%），4年时为63.3%（标准误：0.9；95%可信区间：44.1 - 79%）。1年时估计无再次干预率为88.9%（标准误：0.5；95%可信区间：74.8 - 95.6%），4年时为84.2%（标准误：0.7；95%可信区间：67.3 - 93.2%）。随访期间未出现与主动脉弓/入路相关的问题。
我们的经验证实，血管入路和主动脉弓问题仍然是对PAU进行TEVAR手术的一个具有挑战性的方面。由于技术进步以及对入路途径和主动脉弓解剖结构的精心管理，我们27%的入路/主动脉弓问题累积发生率低于先前报道。
