Division of Vascular Surgery, University of California Davis Medical Center, Sacramento, Calif.
Division of Vascular Surgery, University of California Davis Medical Center, Sacramento, Calif.
J Vasc Surg. 2020 Dec;72(6):1883-1890. doi: 10.1016/j.jvs.2020.03.033. Epub 2020 Apr 11.
Success of thoracic endovascular aortic repair (TEVAR) relies heavily on the proximal landing zone (PLZ) sealing. Most instructions for use of thoracic endografts recommend a PLZ length of at least 2 cm. Because of the complex aortic anatomic features, TEVAR landing in zone 1 to zone 3 may not meet this requirement. The aim of this study was to examine whether 2-cm PLZ nonadherence was related to adverse outcomes after TEVAR.
A retrospective review was performed of patients who underwent zone 1, zone 2, and zone 3 landing TEVAR at a single institution between November 2013 and October 2018. Preoperative and postoperative computed tomography angiography images were analyzed using three-dimensional reconstruction. The patients were categorized into two groups: PLZ ≥2 cm (adherence group) and PLZ <2 cm (nonadherence group). Collected data included patient and anatomic characteristics. Primary outcomes were type IA endoleak, retrograde dissection, and graft migration.
The cohort comprised 63 patients (18 in the adherence group and 45 in the nonadherence group) with a mean age of 53.3 ± 20.6 years. Indications for TEVAR were blunt thoracic aortic injury (65.1%), thoracic aneurysm (23.8%), penetrating ulcer (9.5%), and type B dissection (1.6%). Mean PLZ length was significantly shorter for the nonadherence group (8 ± 7 mm for the nonadherence group vs 34 ± 15 mm for the adherence group; P < .0001). PLZ location (2 zone 1, 15 zone 2, 46 zone 3) and oversizing (19.4% ± 8.3% for the adherence group; 20.3% ± 10.2% for the nonadherence group; P = .7) were similar between the groups. The mean PLZ aortic diameter of the adherence group was significantly larger than that of the nonadherence group (29 ± 5 mm for the adherence group; 25 ± 5 mm for the nonadherence group; P = .004). Mean follow-up time was 126.7 days (range, 0-644 days) for the adherence group and 233.8 days (range, 0-1750 days) for the nonadherence group (P = .2). During the study period, no primary outcome was observed in the adherence group, whereas 12 adverse events occurred in 10 patients in the nonadherence group (type IA endoleak, n = 10; graft migration, n = 1; retrograde dissection, n = 1). Of 10 type IA endoleaks, five were immediate (4 resolved spontaneously, 1 remained persistent) and five were delayed (1 resolved spontaneously, 1 remained persistent, 1 ruptured causing death, 2 required total arch replacement).
Achieving recommended sealing zone of 2-cm centerline length is paramount to avoid device-related adverse outcomes. We recommend careful surveillance in patients undergoing urgent TEVAR with <2-cm PLZ.
胸主动脉腔内修复术（TEVAR）的成功在很大程度上依赖于近端锚定区（PLZ）的封闭。大多数胸主动脉覆膜支架的使用说明都建议 PLZ 长度至少为 2cm。由于主动脉解剖结构复杂，TEVAR 在 1 区至 3 区的锚定可能无法满足这一要求。本研究旨在探讨 2cm PLZ 不依从是否与 TEVAR 后不良结局有关。
回顾性分析 2013 年 11 月至 2018 年 10 月在一家机构接受 1 区、2 区和 3 区 TEVAR 的患者。使用三维重建分析术前和术后的 CT 血管造影图像。将患者分为两组：PLZ≥2cm（依从组）和 PLZ＜2cm（不依从组）。收集的数据包括患者和解剖特征。主要结局为 1A 型内漏、逆行夹层和移植物迁移。
该队列包括 63 名患者（18 名在依从组，45 名在不依从组），平均年龄为 53.3±20.6 岁。TEVAR 的适应证为钝性胸主动脉损伤（65.1%）、胸主动脉瘤（23.8%）、穿透性溃疡（9.5%）和 B 型夹层（1.6%）。不依从组的平均 PLZ 长度明显较短（不依从组为 8±7mm，依从组为 34±15mm；P＜0.0001）。PLZ 位置（2 区 1 个，2 区 15 个，3 区 46 个）和过度扩张（依从组 19.4%±8.3%，不依从组 20.3%±10.2%；P=0.7）在两组间相似。依从组的平均 PLZ 主动脉直径明显大于不依从组（依从组为 29±5mm，不依从组为 25±5mm；P=0.004）。依从组的平均随访时间为 126.7 天（0-644 天），不依从组为 233.8 天（0-1750 天）（P=0.2）。在研究期间，依从组未观察到主要结局，而不依从组 10 名患者中有 12 例发生不良事件（1A 型内漏，n=10；移植物迁移，n=1；逆行夹层，n=1）。10 例 1A 型内漏中，5 例为即刻（4 例自发缓解，1 例持续存在），5 例为延迟（1 例自发缓解，1 例持续存在，1 例破裂导致死亡，2 例需要全弓置换）。
达到推荐的 2cm 中心线长度的密封区是避免器械相关不良结局的关键。我们建议对接受紧急 TEVAR 且 PLZ＜2cm 的患者进行密切监测。
