Department of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif.
Department of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif.
J Vasc Surg. 2021 Jan;73(1):31-38. doi: 10.1016/j.jvs.2020.04.522. Epub 2020 May 20.
Suprarenal aortic neck dilation (AND) after fenestrated endovascular aneurysm repair (FEVAR) with commercially available devices has not yet been well characterized. The aim of this study was to measure diameter changes in the supravisceral aorta after FEVAR.
This is a single-center retrospective review involving patients with juxtarenal aneurysms treated with Cook ZFEN devices (Cook Medical, Bloomington, Ind). Patients with at least 1 year of cross-sectional radiologic follow-up were included. AND was defined as ≥3 mm at any measured location. Aortic diameter, defined as the average outer to outer diameter on three-dimensional centerline imaging, was measured at seven locations along the length of the ZFEN device from the proximal fixation struts to the bottom of the second seal stent. The first postoperative CT scan (≤1 month) served as a baseline from which subsequent measurements at annual intervals were compared.
A total of 43 patients who underwent FEVAR from 2012 to 2018 met inclusion criteria, with a total of 119 target vessels (83 renal stents, 41 superior mesenteric artery scallops or large fenestrations). Mean follow-up time was 30.3 months. Any AND was found to occur in 32 (74.4%) patients. Aortic diameter dilation at latest follow-up was found to occur at all measured locations from the top of the fixation struts (1.9 ± 2.4 mm; P < .0001) to the middle of the second seal stent (1.3 ± 3.8 mm; P < .01). Diameter growth was most pronounced in the middle of the first seal stent, with mean AND of 3.6 ± 3.2 mm. At this location, the aorta experienced nearly linear annual growth of 0.99 mm (95% confidence interval, 0.7-1.28 mm) per year. Increasing device oversizing relative to the native visceral aorta was the strongest predictor of postoperative neck diameter growth (1.34 mm per 10% increase in oversizing; P = .02), whereas increasing proximal seal length was protective of growth (-1.82 mm per 10-mm increase in seal length; P = .016). Proximal seal lengths ≥3 cm were associated with less neck dilation compared with <3 cm (2.6 mm vs 4.9 mm; P = .022). Type IA endoleak in this cohort was rare (n = 1) and not associated with AND (P = .256).
Dilation of the suprarenal aorta is a common finding in midterm follow-up after FEVAR and not associated with proximal endoleak. Aggressive device oversizing is predictive of dilation, whereas longer seal lengths are associated with less dilation along the suprarenal seal zone. These results support the continued use of FEVAR for juxtarenal aneurysms, particularly in patients in whom ≥3 cm of healthy seal length can be obtained.
在使用市售设备进行开窗血管内动脉瘤修复（fenestrated endovascular aneurysm repair，FEVAR）后，肾上腹主动脉颈扩张（suprarenal aortic neck dilation，AND）尚未得到很好的描述。本研究的目的是测量 FEVAR 后内脏上主动脉的直径变化。
这是一项单中心回顾性研究，涉及接受 Cook ZFEN 设备（Cook Medical，Bloomington，Ind）治疗的肾下型动脉瘤患者。纳入至少有 1 年横断面影像学随访的患者。AND 定义为任何测量部位的直径增加≥3mm。主动脉直径定义为三维中心线成像中外层到外层的平均直径，在 ZFEN 装置的长度上从近端固定支柱到第二个密封支架的底部测量 7 个部位。第一个术后 CT 扫描（≤1 个月）作为基线，随后每年进行比较。
2012 年至 2018 年间，共有 43 例患者接受 FEVAR 治疗，符合纳入标准，共 119 个靶血管（83 个肾支架，41 个肠系膜上动脉瓣或大开窗）。平均随访时间为 30.3 个月。发现任何 AND 均发生于 32 例（74.4%）患者。发现最新随访时所有测量部位的主动脉直径均有扩张，从固定支柱的顶部（1.9±2.4mm；P<0.0001）到第二个密封支架的中部（1.3±3.8mm；P<0.01）。在第一个密封支架的中部，直径增长最为明显，平均 AND 为 3.6±3.2mm。在此部位，主动脉每年以 0.99mm（95%置信区间，0.7-1.28mm）的速度呈近线性增长。与内脏固有主动脉相比，装置过度扩张越大是术后颈直径生长的最强预测因素（每增加 10%的过度扩张，直径增加 1.34mm；P=0.02），而增加近端密封长度可保护生长（密封长度每增加 10mm，生长减少 1.82mm；P=0.016）。与<3cm 相比，近端密封长度≥3cm 与颈扩张程度较小相关（2.6mm 比 4.9mm；P=0.022）。本队列中 I 型内漏罕见（n=1），与 AND 无关（P=0.256）。
FEVAR 后中期随访中肾上腹主动脉扩张是一种常见现象，与近端内漏无关。过度扩张的装置与扩张有关，而较长的密封长度与肾上密封区的扩张程度较小有关。这些结果支持继续使用 FEVAR 治疗肾下型动脉瘤，特别是在能够获得≥3cm 健康密封长度的患者中。
