Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
J Vasc Surg. 2021 Apr;73(4):1167-1177.e1. doi: 10.1016/j.jvs.2020.07.092. Epub 2020 Aug 27.
To report the effect of median arcuate ligament (MAL) compression on outcomes and technical aspects of celiac artery (CA) stenting during fenestrated-branched endovascular aneurysm repair for thoracoabdominal aortic aneurysms (TAAA) or pararenal aortic aneurysms.
We retrospectively reviewed the clinical and anatomic data on 300 consecutive patients enrolled in a prospective nonrandomized physician-sponsored investigational device exemption study from 2013 to 2018. From this group, 230 patients with CA incorporation by fenestration or directional branch were included. MAL compression was defined by preoperative computed tomography angiogram as a J-hook narrowing of the proximal CA at the level of the ligament; the shift angle between the downward and upward segments within the CA was measured. End points were technical success, rates of intraoperative or early (30-days) CA branch revision, and freedom from target vessel instability, defined by any death or rupture owing to target vessel complication, occlusion, or reintervention for stenosis, endoleak, or disconnection.
CA incorporation was performed using fenestrations in 118 patients (51%) and directional branches in 112 (49%). MAL compression was present in 97 patients (42%), resulting in a stenosis of more than 50% in 48 (49%). MAL compression was more often present in patients with extent I to III TAAAs compared with extent IV TAAA-pararenal aortic aneurysms (56% vs 31%; P < .001). Technical success rate was 99%. Patients with MAL compression more often received a directional branch (65% vs 37%; P < .001), self-expanding bridging stent grafts (32% vs 16%; P = .007), adjunctive bare metal stents (46% vs 24%; P = .001), and coverage of the gastric artery (44% vs 22%; P < .001). An intraoperative (n = 6, 2.6%) or early (n = 1, 0.4%) revision of the CA branch was required in seven patients (3%) owing to dissection/occlusion (n = 2 [0.9%]), kinking/stenosis (n = 3 [1.3%]), stent dislodgement (n = 1 [0.4%]), or type IC endoleak (n = 1 [0.4%]). A shift angle of less than 120° was the most significant factor associated with CA branch revision (odds ratio, 10.9; 95% confidence interval, 2.3-88.9; P = .013). Freedom from CA branch instability was 97 ± 2% at 4 years, and this outcome was not associated with MAL compression (hazard ratio, 0.83; 95% confidence interval, 0.14-5.02; P = .588) or any other predictor.
MAL compression was more common in extent I to III TAAAs, and related to additional challenges for CA stenting in fenestrated-branched endovascular aneurysm repair. This process may include bare metal stenting, gastric artery coverage, or early revision, especially in presence of an angulation of less than 120°. However, durable results can be achieved for CA incorporation despite these difficulties.
报告在胸主动脉瘤或肾周动脉瘤的开窗分支腔内血管修复术中，由于正中弓状韧带（MAL）压迫对腹腔干（CA）支架置入术的结果和技术方面的影响。
我们回顾性分析了 2013 年至 2018 年期间前瞻性、非随机、医生赞助的器械豁免研究中连续 300 例患者的临床和解剖学数据。在这一组中，纳入了 230 例通过开窗或定向分支置入 CA 的患者。术前 CT 血管造影将 MAL 压迫定义为韧带水平近端 CA 的 J 形狭窄；测量 CA 内向下和向上段之间的移位角。终点是技术成功、术中或早期（30 天）CA 分支修正的发生率以及目标血管不稳定的无失效率，定义为任何因目标血管并发症、闭塞或再介入引起的死亡率或破裂，包括狭窄、内漏或断开。
118 例患者（51%）采用开窗，112 例患者（49%）采用定向分支。97 例患者（42%）存在 MAL 压迫，导致狭窄超过 50%的患者 48 例（49%）。与 IV 型 TAAA-肾周动脉瘤相比，I 至 III 型 TAAA 患者中 MAL 压迫更为常见（56%比 31%；P<0.001）。技术成功率为 99%。MAL 受压患者更常接受定向分支（65%比 37%；P<0.001）、自膨式搭桥支架（32%比 16%；P=0.007）、辅助裸金属支架（46%比 24%；P=0.001）和胃动脉覆盖（44%比 22%；P<0.001）。由于夹层/闭塞（n=2[0.9%]）、扭曲/狭窄（n=3[1.3%]）、支架移位（n=1[0.4%]）或 IC 型内漏（n=1[0.4%]），7 例患者（3%）需要进行术中（n=6，2.6%）或早期（n=1，0.4%）CA 分支修正。小于 120°的移位角是 CA 分支修正最显著的相关因素（比值比，10.9；95%置信区间，2.3-88.9；P=0.013）。4 年时，CA 分支不稳定的无失效率为 97±2%，与 MAL 压迫（风险比，0.83；95%置信区间，0.14-5.02；P=0.588）或任何其他预测因素无关。
MAL 压迫在 I 至 III 型 TAAA 中更为常见，与开窗分支腔内血管修复术中 CA 支架置入的额外挑战相关。这一过程可能包括裸金属支架、胃动脉覆盖或早期修正，尤其是在存在小于 120°的角度时。然而，尽管存在这些困难，仍能获得持久的 CA 纳入效果。
