Banno Hiroshi, Ikeda Shuta, Kawai Yohei, Meshii Katsuaki, Takahashi Noriko, Sugimoto Masayuki, Kodama Akio, Komori Kimihiro
Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
J Vasc Surg. 2020 Nov;72(5):1552-1557. doi: 10.1016/j.jvs.2020.02.025. Epub 2020 Apr 4.
In thoracic endovascular aortic repair (TEVAR), covering the celiac artery (CA) is sometimes necessary to secure the distal seal. We report the outcomes of planned CA coverage in our experience with TEVAR.
Cases requiring CA coverage during TEVAR from October 2008 to September 2018 were retrospectively reviewed. Patient demographics, indications for CA coverage, communication between the CA and the superior mesenteric artery (SMA), concomitant CA embolization, and perioperative and late results were collected in a prospective database and analyzed.
During the study decade, 357 patients underwent TEVAR at our institution. Of these patients, 15 (4.2%) required CA coverage. All 15 patients were male, and the mean age was 72.8 years (range, 44-80 years). The mean aneurysm size was 67.5 mm (range, 50-82 mm). The etiologies included 10 degenerative aneurysms (66.7%; 2 ruptures [13.3%], 4 dissecting aneurysms [26.7%], and 1 case of type IB endoleak [6.7%]) after TEVAR. Communicating collaterals between the CA and the SMA were confirmed by preoperative computed tomography angiography in eight patients (53.3%) and by intraoperative angiography in four patients (26.7%). Seven patients (46.7%) underwent concomitant embolization of the CA. CA coverage offered a mean extension of 20.3 mm (range, 12-22 mm) in the length of the distal seal. Postoperative computed tomography angiography revealed a type IB endoleak that resolved spontaneously in one patient (6.7%). Postoperative complications included splenic infarction/pancreatitis in one patient (6.7%) and spinal cord ischemia in two patients (13.3%). There were no cases of postoperative in-hospital mortality. During the follow-up period (mean, 3.6 years; range, 0.9-8.0 years), two patients developed a new type IB endoleak. One patient underwent distal extension of the stent graft with ilio-SMA bypass, and one patient was observed conservatively in accordance with the patient's decision. There were no cases of type II endoleak via the CA. Most aneurysms (86.7%) were stable or reduced in size at the most recent follow-up. There were no cases of targeted aneurysm-related death during the follow-up period.
Our study demonstrates the safety and efficacy of CA coverage in facilitating adequate distal sealing in selected patients undergoing TEVAR. Because the distal sealing length is not completely sufficient in most cases requiring CA coverage, the long-term efficacy of CA coverage during TEVAR should be determined in a large prospective study.
在胸主动脉腔内修复术（TEVAR）中，有时需要覆盖腹腔干动脉（CA）以确保远端密封。我们报告了我们在TEVAR经验中计划性覆盖CA的结果。
回顾性分析2008年10月至2018年9月期间TEVAR术中需要覆盖CA的病例。患者人口统计学资料、CA覆盖的指征、CA与肠系膜上动脉（SMA）之间的交通、同期CA栓塞以及围手术期和远期结果均收集于前瞻性数据库并进行分析。
在研究的十年间，我院357例患者接受了TEVAR。其中，15例（4.2%）需要覆盖CA。所有15例患者均为男性，平均年龄72.8岁（范围44 - 80岁）。动脉瘤平均大小为67.5mm（范围50 - 82mm）。病因包括10例退行性动脉瘤（66.7%；2例破裂[13.3%]，4例夹层动脉瘤[26.7%]，1例TEVAR术后ⅠB型内漏[6.7%]）。术前计算机断层扫描血管造影证实8例患者（53.3%）、术中血管造影证实4例患者（26.7%）存在CA与SMA之间的交通支。7例患者（46.7%）同期进行了CA栓塞。CA覆盖使远端密封长度平均延长20.3mm（范围12 - 22mm）。术后计算机断层扫描血管造影显示1例患者（6.7%）出现ⅠB型内漏并自发消失。术后并发症包括1例患者（6.7%）出现脾梗死/胰腺炎，2例患者（13.3%）出现脊髓缺血。无术后院内死亡病例。在随访期（平均3.6年；范围0.9 - 8.0年），2例患者出现新的ⅠB型内漏。1例患者接受了带髂 - SMA旁路的支架移植物远端延伸术，1例患者根据其决定进行了保守观察。无经CA的Ⅱ型内漏病例。在最近一次随访时，大多数动脉瘤（86.7%）稳定或缩小。随访期间无目标动脉瘤相关死亡病例。
我们的研究证明了在接受TEVAR的特定患者中，CA覆盖在促进充分远端密封方面的安全性和有效性。由于在大多数需要覆盖CA的病例中远端密封长度并不完全足够，TEVAR术中CA覆盖的长期疗效应在大型前瞻性研究中确定。
