Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida; Cardiothoracic Surgery Department, Assiut University, Assiut, Egypt.
Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida.
Ann Thorac Surg. 2020 Jul;110(1):27-38. doi: 10.1016/j.athoracsur.2019.10.015. Epub 2019 Nov 27.
The indications for and technology surrounding thoracic endovascular aortic repair (TEVAR) have undergone significant evolution with increasing adoption. The purpose of this report is to evaluate pathology-specific incidence, timing, and types of secondary aortic intervention (SAI) after TEVAR and their impact on survival.
A single-center retrospective review was made of all TEVAR and SAI performed from 2004 to 2018. Kaplan-Meier and multivariable logistic regression were used to estimate freedom from SAI and survival, and to identify SAI predictors.
Of 1037 patients (mean age 65.4 ± 15.1 years), 155 (14.9%) underwent 212 SAIs (median 5 months; interquartile range, 1.5 to 18) with 37 (3.6%) requiring more than one SAI. The primary aortic pathology at index TEVAR significantly (P = .0001) affected the incidence of SAI: chronic dissection, 26.5%; postsurgical anastomotic pseudoaneurysm, 19.4%; degenerative aneurysm, 15.3%; and acute dissection, 11.2%. The most common indications for SAI were endoleaks (44.8%), disease progression or remote aortic procedure (23.1%), and persistent false lumen flow (9.9%). After exclusion of 30-day mortality events, patients who did not undergo a SAI had better survival compared with patients having SAI: no SAI 1 year 88.8% ± 1.1%, 5 years 75.2% ± 1.7%, and 10 years, 66.5% ± 2.3%; SAI 1 year 91.7% ± 2.4%, 5 years 61.9% ± 4.9%, and 10 years 33.5% ± 8.4% (log rank P = .004).
Secondary aortic intervention after TEVAR is not uncommon, particularly among patients with chronic dissection pathology. Patients surviving their index hospitalization who undergo SAI have worse long-term survival. The varying incidence of SAI by indication identifies the need for pathology-specified patient selection, surveillance strategies after TEVAR, and better device design that addresses the limitations of TEVAR, particularly in dealing with dissection-related indications.
随着胸主动脉腔内修复术（TEVAR）的应用日益广泛，其适应证和技术也经历了重大演变。本报告旨在评估 TEVAR 后特定病理的继发性主动脉干预（SAI）的发生率、时间和类型，及其对生存率的影响。
对 2004 年至 2018 年间所有接受 TEVAR 和 SAI 的患者进行单中心回顾性分析。采用 Kaplan-Meier 法和多变量逻辑回归分析来估计无 SAI 生存率和总生存率，并识别 SAI 的预测因素。
1037 例患者（平均年龄 65.4 ± 15.1 岁）中，155 例（14.9%）接受了 212 次 SAI（中位数 5 个月；四分位间距 1.5 至 18），其中 37 例（3.6%）需要进行不止一次 SAI。TEVAR 时的主要主动脉病变显著影响 SAI 的发生率：慢性夹层占 26.5%；手术后吻合口假性动脉瘤占 19.4%；退行性动脉瘤占 15.3%；急性夹层占 11.2%。SAI 的最常见适应证是内漏（44.8%）、疾病进展或远处主动脉手术（23.1%）和持续假腔血流（9.9%）。排除 30 天死亡率事件后，未行 SAI 的患者生存率优于行 SAI 的患者：无 SAI 1 年为 88.8% ± 1.1%，5 年为 75.2% ± 1.7%，10 年为 66.5% ± 2.3%；行 SAI 1 年为 91.7% ± 2.4%，5 年为 61.9% ± 4.9%，10 年为 33.5% ± 8.4%（对数秩检验 P =.004）。
TEVAR 后发生 SAI 并不少见，特别是在慢性夹层病变患者中。接受 SAI 的患者在指数住院期间存活下来，但长期生存率较差。不同适应证的 SAI 发生率表明，需要根据病变选择患者，在 TEVAR 后进行有针对性的监测策略，并设计更好的器械来解决 TEVAR 的局限性，特别是在处理与夹层相关的适应证时。
