Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France; Servicio de Cirugía Vascular y Endovascular, Clínica Universidad de los Andes, Las Condes, Chile.
Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.
J Vasc Surg. 2021 Jun;73(6):1898-1905.e1. doi: 10.1016/j.jvs.2020.09.041. Epub 2020 Nov 20.
Our aim was to evaluate the early- and medium-term outcomes of using double fenestrated physician-modified endovascular grafts (PMEGs) for total endovascular aortic arch repair.
The present single-center retrospective analysis of prospectively collected data included 50 patients from January 2017 through October 2019, who had undergone thoracic endovascular aortic repair (TEVAR). The fenestrations were a proximal larger fenestration that incorporated the brachiocephalic trunk and left common carotid artery and a distal smaller fenestration for the left subclavian artery (LSA). Only the LSA fenestration was stented.
The median duration for stent graft modification was 26 ± 6 minutes. Of the 50 patients, 41 were men. The mean patient age was 68 ± 11.5 years. The indications for treatment included degenerative aortic arch aneurysm (n = 17), dissecting aortic arch aneurysm after type A dissection (n = 13), type B dissection (n = 13), aortic ulcer (n = 3), and other pathologies (n = 4). The technical success rate was 94% (47 of 50) overall, and 100% (28 of 28) after a technical modification incorporating a preloaded guide wire for the LSA fenestration (P < .05). The 30-day mortality was 2% (n = 1). Two patients (4%) had a minor stroke with full recovery. One patient (2%) had a type IB and two patients (4%) had a type II endoleak from the LSA. Four patients (8%) required reintervention: one because of a type IB endoleak and three because of access-related complications. All supra-aortic trunks were patent. During a mean follow-up of 16 ± 8.3 months, no conversions to open surgical repair were required and no aortic rupture, paraplegia, or retrograde dissection occurred.
Using double fenestrated PMEGs for TEVAR is both feasible and effective for total endovascular aortic arch repair, avoiding the need for anatomic and extra-anatomic surgical revascularization. The absence of brachiocephalic trunk stenting was not associated with endoleaks or treatment failure and resulted in a lower stroke risk than alternative strategies. The midterm results suggest that stenting of the brachiocephalic trunk and right common carotid artery might not be necessary for a large proportion of patients undergoing total endovascular aortic arch repair. The persistence of the seal and ongoing durability require assessment in studies with long-term follow-up data available.
我们旨在评估使用双开窗式医生改良血管内移植物（PMEG）进行全主动脉弓血管内修复的早期和中期结果。
本研究为单中心前瞻性数据回顾性分析，纳入 2017 年 1 月至 2019 年 10 月期间接受胸主动脉腔内修复术（TEVAR）的 50 例患者。开窗为近端较大的开窗，包括头臂干和左颈总动脉，以及远端较小的开窗用于左锁骨下动脉（LSA）。仅对 LSA 开窗进行支架置入。
支架移植物修改的中位时间为 26±6 分钟。50 例患者中，41 例为男性。患者平均年龄为 68±11.5 岁。治疗指征包括退行性主动脉弓动脉瘤（n=17）、A型夹层后主动脉弓夹层动脉瘤（n=13）、B 型夹层（n=13）、主动脉溃疡（n=3）和其他病变（n=4）。总体技术成功率为 94%（50 例中有 47 例），在对 LSA 开窗进行预加载导丝的技术修改后，成功率为 100%（28 例中有 28 例）（P<.05）。30 天死亡率为 2%（n=1）。2 例（4%）发生轻微中风，完全恢复。1 例（2%）出现 LSA 型 I 型内漏，2 例（4%）出现 II 型内漏。4 例（8%）需要再次介入治疗：1 例因 I 型内漏，3 例因入路相关并发症。所有主动脉弓以上血管均通畅。在平均 16±8.3 个月的随访期间，无需转为开放手术修复，无主动脉破裂、截瘫或逆行夹层发生。
使用双开窗式 PMEG 进行 TEVAR 对于全主动脉弓血管内修复既可行又有效，避免了解剖和非解剖血管重建的需要。不进行头臂干支架置入与内漏或治疗失败无关，且与替代策略相比，卒中风险较低。中期结果表明，对于大多数接受全主动脉弓血管内修复的患者，可能不需要对头臂干和右颈总动脉进行支架置入。随着时间的推移，需要评估密封的持久性和持续的耐久性，以获得长期随访数据的研究。
