Bedfordshire - Milton Keynes Vascular Centre, Bedfordshire Hospitals NHS Foundation Trust, Kempston Road, Bedford MK42 9DJ, UK.
Vascular. 2021 Jun;29(3):315-322. doi: 10.1177/1708538120958837. Epub 2020 Sep 24.
Aortic endografts used for endovascular aneurysm repair (EVAR) are based on varying skeletal platforms such as stainless steel or nitinol stents, using radial force applied to seal at the aneurysm neck, and varying proximal fixation methods, applying either suprarenal or infrarenal fixation. This study assesses whether varying skeleton/fixation platforms affect neck-related outcomes after primary endostapling with Heli-FX EndoAnchors at EVAR.
Retrospective analysis of a prospective database of infrarenal EVAR undertaken at a single centre. Chimney-EVAR, secondary cases were excluded. Primary outcomes analysed included neck diameter evolution from pre-EVAR to latest imaging follow-up, including a comparison of stent platforms to see if there was any outcome difference between those using stainless steel or nitinol, as also freedom from type I endoleakage and migration. Secondary outcomes assessed included average number of EndoAnchors, and sac size patterns before and after EVAR.
A total of 101 patients underwent endostapled infrarenal EVAR between September 2013 and March 2020. After exclusion of ineligible patients, 84 patients (76 male, 8 female, age 73.7 ± 7.8 years) were available for analysis. 57/27 endografts used suprarenal/infrarenal fixation, whilst 16/68 devices were based on stainless steel/nitinol platforms, respectively. Mean oversizing was higher for stainless steel/suprarenal fixation endografts ( = 0.02). A total of 582 EndoAnchors were deployed, averaging 7 ± 2 per patient. Median neck diameter was 25 mm (IQR 22-31) with 22 necks having non-parallel morphology (conical, tapered or bubble). Median follow-up period was 28.5 (IQR 12-43) months. Neck evolution studies suggested aortic neck dilatation of 5 ± 4 mm ( <0.001, paired T-test), independent of platforms employed ( = NS, ANOVA). There was no endograft migration; one immediate post-EVAR endoleak settled by eight weeks. There was a mean 5.7 ± 8.2 mm sac size reduction ( < 0.001, paired T-test).
Aortic neck dilatation occurs after EVAR with primary endostapling, but the process may be independent of stainless steel/nitinol platforms, possibly due to the attenuating effect of EndoAnchors. Adjunct aneurysm neck fixation by primary endostapling prevents migration regardless of whether suprarenal/infrarenal fixation is the primary fixative method. Device platform choice therefore may be left to the operator discretion if primary endostapling is applied at EVAR. Freedom from complications such as migration and endoleakage in the intermediate term suggests a higher level of 'tolerance' to aortic neck dilatation with primary endostapling. We would therefore suggest routine usage of EndoAnchors at EVAR when not otherwise contraindicated.
用于血管内动脉瘤修复术 (EVAR) 的主动脉内移植物基于不同的骨架平台，如不锈钢或镍钛诺支架，利用施加在动脉瘤颈部的径向力进行密封，并采用不同的近端固定方法，采用肾上或肾下固定。本研究评估在 EVAR 中使用 Heli-FX EndoAnchors 进行原发性血管内吻合时，不同的骨架/固定平台是否会影响颈部相关结果。
对单中心进行的肾下 EVAR 的前瞻性数据库进行回顾性分析。排除烟囱-EVAR、二次病例。分析的主要结果包括从 EVAR 前到最新影像学随访的颈部直径演变，包括比较支架平台，以确定使用不锈钢或镍钛诺的支架平台之间是否存在任何结果差异，以及是否无 I 型内漏和迁移。评估的次要结果包括平均使用的 EndoAnchors 数量，以及 EVAR 前后的囊腔大小模式。
2013 年 9 月至 2020 年 3 月期间，共 101 例患者接受了血管内吻合的肾下 EVAR。排除不符合条件的患者后，84 例患者（76 名男性，8 名女性，年龄 73.7±7.8 岁）可进行分析。57/27 个移植物采用肾上/肾下固定，而 16/68 个装置分别基于不锈钢/镍钛诺平台。不锈钢/肾上固定移植物的平均过度扩张更大（ = 0.02）。共放置了 582 个 EndoAnchors，平均每个患者放置 7±2 个。中位数颈部直径为 25mm（IQR 22-31），22 个颈部存在非平行形态（圆锥形、锥形或气泡状）。中位随访时间为 28.5（IQR 12-43）个月。颈部演变研究表明，主动脉颈部扩张 5±4mm（ <0.001，配对 t 检验），与使用的平台无关（ = NS，方差分析）。没有移植物迁移；1 例即刻 EVAR 后内漏在 8 周内得到解决。囊腔大小平均减少 5.7±8.2mm（ < 0.001，配对 t 检验）。
EVAR 后原发性血管内吻合会导致主动脉颈部扩张，但该过程可能与不锈钢/镍钛诺平台无关，可能是由于 EndoAnchors 的衰减作用。原发性血管内吻合对动脉瘤颈部的辅助固定可防止迁移，无论肾上/肾下固定是否为主要固定方法。因此，如果在 EVAR 中应用原发性血管内吻合，那么装置平台的选择可能取决于术者的判断。中期无并发症（如迁移和内漏）表明，原发性血管内吻合对主动脉颈部扩张具有更高的“耐受性”。因此，我们建议在没有其他禁忌证的情况下，在 EVAR 时常规使用 EndoAnchors。
