Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
J Vasc Surg. 2021 Mar;73(3):844-849. doi: 10.1016/j.jvs.2020.06.120. Epub 2020 Jul 21.
Thoracic endovascular aortic repair (TEVAR) results have been studied in short-term time frames. This study aimed to evaluate midterm and long-term outcomes of TEVAR, emphasizing postoperative aortic remodeling and need for reintervention.
This is an institutional retrospective review of TEVAR for isolated descending thoracic aortic aneurysms. Data were collected from 2004 to 2018. Primary outcomes studied included aneurysm sac remodeling, freedom from reintervention, and all-cause mortality. Other outcomes studied include endoleak rates, neurologic complication rates, and any overall postoperative complication rates.
During the study period, 219 patients underwent TEVAR for descending thoracic aortic aneurysms. The median effect of TEVAR on sac diameter was a 0.7-cm decrease in size (interquartile range, -1.4 to 0.0 cm). During the study period, 80% (n = 147) of patients experienced aneurysm sac regression or stability. Perioperative neurologic complications occurred in 16% (n = 34) of patients. Significant predictors of sac growth were endoleak (odds ratio [OR], 65; P < .001), preoperative carotid-subclavian bypass (OR, 8; P = .003), and graft oversizing <20% (OR, 15; P = .046). Every 1-mm increase in aortic diameter at the proximal TEVAR landing zone led to an increased odds of endoleak (OR, 2; P = .049). Access complications (OR, 8) and subclavian artery coverage (OR, 6) significantly increased the odds of reintervention, whereas every percentage of graft oversizing protected against reintervention (OR, 0.005). Life-table analysis revealed an overall survival of 78% (71%-83%) at median follow-up. At 3 years, survival was 88% (80%-93%) for those with aneurysm sac stability or regression, whereas it was 70% (49%-84%) for those with aneurysm sac growth (P = .0402). Cox proportional hazards model showed that the only protective factor for mortality was percentage oversizing, with every 1% of oversizing having a hazard ratio (HR) of <.001 (P = .032). This was counterbalanced by the fact that patients with graft oversizing >30% had an increased odds of mortality with HR >10 (P = .049). Other significant factors that increased the odds of mortality included endoleak (HR, 3.6; P = .033), diabetes (HR, 4.1; P = .048), age (every 1-year increase in age; HR, 1.2; P = .002), year of surgery (every year subsequent to 2004; HR, 1.3; P = .012), and peripheral artery disease (HR, 5.2; P = .041).
The majority of patients (80%) experience sac stability or regression after TEVAR, which offers a clear survival advantage. Endoleaks are predictive of sac growth, conferring increased mortality. Rigorous surveillance is necessary to prevent future aortic events through reintervention.
胸主动脉腔内修复术（TEVAR）的研究结果已在短期时间框架内进行了研究。本研究旨在评估 TEVAR 的中期和长期结果，重点是术后主动脉重塑和再次干预的需求。
这是一项对孤立性降主动脉夹层动脉瘤进行 TEVAR 的机构回顾性研究。数据收集自 2004 年至 2018 年。主要研究结果包括动脉瘤囊重塑、免于再次干预和全因死亡率。其他研究结果包括内漏率、神经并发症发生率和任何总体术后并发症发生率。
在研究期间，219 例患者因降主动脉夹层动脉瘤接受 TEVAR。TEVAR 对囊直径的平均影响为直径缩小 0.7cm（四分位距，-1.4 至 0.0cm）。在研究期间，80%（n=147）的患者经历了动脉瘤囊的缩小或稳定。围手术期发生神经并发症的患者占 16%（n=34）。囊生长的显著预测因素包括内漏（比值比[OR]，65；P<0.001）、术前颈动脉-锁骨下旁路（OR，8；P=0.003）和移植物过度扩张<20%（OR，15；P=0.046）。近端 TEVAR 着陆区主动脉直径每增加 1mm，发生内漏的几率就会增加（OR，2；P=0.049）。血管通路并发症（OR，8）和锁骨下动脉覆盖（OR，6）显著增加再次干预的几率，而移植物过度扩张的百分比每增加 1%则会降低再次干预的几率（OR，0.005）。生存表分析显示，中位随访时总体生存率为 78%（71%-83%）。3 年时，动脉瘤囊稳定或缩小的患者生存率为 88%（80%-93%），而动脉瘤囊增大的患者生存率为 70%（49%-84%）（P=0.0402）。Cox 比例风险模型显示，死亡率的唯一保护因素是过度扩张的百分比，每增加 1%过度扩张的风险比（HR）<0.001（P=0.032）。这与移植物过度扩张>30%的患者死亡率增加的事实相平衡，HR>10（P=0.049）。其他增加死亡率的显著因素包括内漏（HR，3.6；P=0.033）、糖尿病（HR，4.1；P=0.048）、年龄（每增加 1 岁；HR，1.2；P=0.002）、手术年份（每随后 1 年；HR，1.3；P=0.012）和外周动脉疾病（HR，5.2；P=0.041）。
大多数患者（80%）在 TEVAR 后经历了囊的稳定或缩小，这提供了明显的生存优势。内漏是囊生长的预测因素，会增加死亡率。需要进行严格的监测，以通过再次干预预防未来的主动脉事件。
