Department of Vascular Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan.
J Vasc Surg. 2021 Aug;74(2):556-568.e2. doi: 10.1016/j.jvs.2020.12.091. Epub 2021 Feb 4.
The present study used data from the Japanese Committee for Stentgraft Management's national registry, which contains unique surgical data, including surgical timing, anatomic factors, and pathologic factors, to determine the generalized community experience with thoracic endovascular abdominal aortic repair (TEVAR).
The medical background and short-term outcomes were reviewed for patients who had undergone TEVAR for a thoracic aortic aneurysm (TAA; 14,235 cases) or aortic dissection (AD; 990 type A and 4259 type B) from 2008 to 2015. TEVAR for AD was separated from that for TAAs; only the background and short-term outcomes were evaluated. The technical outcomes of TEVAR for TAA were also evaluated. All the cases were categorized as follows: elective, urgent (within 24 hours after admission), or emergent (immediately after admission). The outcomes included in-hospital mortality and persistent stroke and paraplegia diagnosed at discharge. The number of debranching bypasses, proximal landing zone (0, 1, 2, ≥3), and zone length were included in the logistic regression analysis.
The mortality, stroke, and paraplegia rates in the TAA and AD groups were 4.4%, 4.6%, and 3.7% and 4.0%, 2.9%, and 2.8%, respectively. After analyzing the TAA cohort, we found that urgent and emergent cases were associated with all adverse outcomes. The rate of paraplegia increased drastically in the patients with stent graft coverage that extended for six or more zones. Massive atheroma was associated with stroke and paraplegia. The cumulative survival rate of the TAA group was stratified by the urgency (ie, elective, urgent, emergent; P < .001). We found that the more proximal (0, 1, and 2) the landing zone, the greater the risk of stroke. Likewise, the longer (six or more zones) the coverage, the greater the risk of paraplegia.
Urgency was strongly associated with mortality, stroke, and paraplegia, and the classification of urgent and emergent, according to the surgical timing after admission, successfully stratified the population in the long-term overall survival analysis. A proximal landing zone involving the aortic arch and debranching bypasses were associated with the occurrence of stroke, and the length of stent graft coverage for six or more zones was associated with paraplegia. Identifying these risk factors will help operators of TEVAR develop appropriate operative strategies to mitigate patient risk.
本研究利用日本支架管理委员会国家注册中心的数据，该数据库包含独特的手术数据，包括手术时机、解剖因素和病理因素，以确定胸主动脉腔内修复术（TEVAR）在一般人群中的应用经验。
回顾 2008 年至 2015 年间接受 TEVAR 治疗的胸主动脉瘤（TAA；14235 例）或主动脉夹层（AD；990 例 A 型和 4259 例 B 型）患者的医疗背景和短期结果。将 AD 的 TEVAR 与 TAA 分开；仅评估背景和短期结果。还评估了 TAA 的 TEVAR 的技术结果。所有病例均分为以下几类：择期、紧急（入院后 24 小时内）或急诊（入院后立即）。结果包括住院死亡率和出院时诊断为持续性中风和截瘫。Logistic 回归分析中包括去分支旁路术、近端着陆区（0、1、2、≥3）和区域长度。
TAA 和 AD 组的死亡率、中风和截瘫发生率分别为 4.4%、4.6%和 3.7%和 4.0%、2.9%和 2.8%。对 TAA 队列进行分析后发现，紧急和急诊病例与所有不良结局相关。支架移植物覆盖范围延伸至 6 个或更多区域的患者截瘫发生率急剧增加。大粥样斑块与中风和截瘫相关。TAA 组的累积生存率按紧迫性（即择期、紧急、急诊；P<.001）分层。我们发现着陆区越靠近近端（0、1 和 2），中风风险越大。同样，覆盖范围越长（6 个或更多区域），截瘫风险越大。
紧急情况与死亡率、中风和截瘫密切相关，根据入院后手术时机进行紧急和急诊分类，成功地对长期总体生存率分析中的人群进行了分层。近端涉及主动脉弓的着陆区和去分支旁路术与中风的发生相关，支架移植物覆盖范围为 6 个或更多区域与截瘫相关。确定这些危险因素将有助于 TEVAR 的操作者制定适当的手术策略来降低患者风险。
