Division of Vascular and Endovascular Surgery, Cooper University Hospital, Camden, NJ.
Bassett Healthcare, Cooperstown, NY.
J Vasc Surg. 2021 Apr;73(4):1189-1196.e3. doi: 10.1016/j.jvs.2020.07.087. Epub 2020 Aug 25.
We evaluated the effect of the achieved proximal seal length on the outcomes after endovascular repair of acute type B aortic dissection (aTBAD).
A post hoc analysis was performed using data from two prospective, multicenter investigational studies of the Zenith Dissection Endovascular System (STABLE I and II). Patients treated for aTBAD within 14 days of symptom onset were included if complete preoperative and postoperative imaging data were available for review. The patients were divided into four groups according to the length of the achieved proximal seal according to the centerline imaging findings: ≥20 mm, ≥10 to <20 mm, ≥0 to <10 mm, and <0 mm. The outcomes stratified by the achieved proximal seal length were evaluated. All imaging findings were based on core laboratory analysis.
A total of 110 patients were included in the present analysis; 51 were from STABLE I and 59 from STABLE II. Although the study protocol criteria required a ≥20 mm length of nondissected aorta distal to the left common carotid artery to serve as a proximal seal zone, an achieved proximal seal length of ≥20 mm was observed in only 19 of the 110 patients (17.3%) according to the location of stent-graft placement. After a mean follow-up duration of 41.6 ± 21 months, the cumulative rate of the composite device outcome (ie, proximal entry flow, retrograde dissection, transaortic growth, and stent-graft migration) was lowest in patients with an achieved proximal seal length of ≥20 mm (15.8%; 3 of 19). The cumulative rate increased as the seal length decreased (32.0% [8 of 25], 55.6% [20 of 36], and 60.0% [18 of 30] with a proximal seal length of ≥10 to <20 mm, ≥0 to <10 mm, and <0 mm, respectively; P < .01, Cochran-Armitage trend test).
A clear inverse relationship was found between the proximal seal length achieved and associated adverse outcomes. This finding underscores the importance of landing the stent-graft in healthy, nondissected aorta to minimize the risk of complications and provide a durable repair in patients with aTBAD.
评估近端密封长度对急性 B 型主动脉夹层（aTBAD）血管内修复后结局的影响。
对 Zenith 夹层血管内系统（STABLE I 和 II）两项前瞻性、多中心研究的资料进行了事后分析。如果有完整的术前和术后影像学资料可供复查，则将症状发作后 14 天内接受 aTBAD 治疗的患者纳入研究。根据中心线影像学检查结果，根据近端密封长度将患者分为四组：≥20mm、≥10mm 至＜20mm、≥0mm 至＜10mm 和＜0mm。根据获得的近端密封长度对结局进行分层评估。所有影像学发现均基于核心实验室分析。
本分析共纳入 110 例患者；STABLE I 组 51 例，STABLE II 组 59 例。尽管研究方案标准要求左颈总动脉下游不夹层的主动脉长度≥20mm 作为近端密封区，但根据支架移植物放置位置，110 例患者中仅 19 例（17.3%）获得了≥20mm 的近端密封长度。在平均随访 41.6±21 个月后，获得的近端密封长度≥20mm 的患者复合装置结局（即近端入口血流、逆行夹层、跨主动脉生长和支架移植物迁移）发生率最低（15.8%，3/19）。随着密封长度的减少，累积率增加（密封长度≥10mm 至＜20mm 的患者为 32.0%[8/25]，密封长度≥0mm 至＜10mm 的患者为 55.6%[20/36]，密封长度＜0mm 的患者为 60.0%[18/30]；P＜.01，Cochran-Armitage 趋势检验）。
近端密封长度与不良结局呈明显负相关。这一发现强调了将支架移植物植入健康无夹层的主动脉中以最大限度降低并发症风险并为 aTBAD 患者提供持久修复的重要性。
