Pima Heart and Vascular, Tucson, AZ; The University of Arizona School of Medicine, Tucson, AZ.
Section of Vascular Surgery, The University of Arizona, Tucson, AZ.
Ann Vasc Surg. 2021 May;73:500-507. doi: 10.1016/j.avsg.2021.01.094. Epub 2021 Feb 5.
Type Ia endoleaks after endovascular aortic repair (EVAR) almost always mandate secondary percutaneous reinterventions. Several patients, however, will require conversion to open surgical repair with complete graft explant, which is associated with significant morbidity and mortality. We herein present 3 cases of hybrid surgical repair for type Ia endoleaks, using a limited open exposure for proximal stent graft edge revision to achieve graft preservation and effective aneurysm sac exclusion.
Angiography was used to confirm type Ia endoleak in 3 patients (2 males) who had previous EVAR between October 2017 and October 2019. Time to the endoleak after the index EVAR was immediate in 1 patient during repair of a ruptured aneurysm, 2 months in 1 patient and 2 years in 1 patient. The aorta was exposed through a limited transabdominal (n = 1) or retroperitoneal (n = 2) approach and circumferential aortic control was achieved below the renal arteries. A row of interrupted horizontal mattress sutures of 3-0 polypropylene reinforced with Teflon pledgets was placed along the aortic neck circumference. Multi-planar angiography was then repeated to verify the absence of sac filling and successful type Ia endoleak exclusion. Follow-up abdominal duplex was obtained for all 3 patients after discharge to monitor the stent graft and confirm endoleak resolution. Furthermore, there were no instances of acute renal failure.
In the period of review, 77 patients underwent EVAR. In the 3 patients described, we were able to achieve complete aneurysm sac exclusion and stent graft preservation in all cases. Follow-up imaging was available on 2 patients at 4-6 weeks after surgery demonstrating sustained exclusion of the endoleak. Two patients died during follow-up: one from a myocardial infarction 7 weeks after surgery and one from metastatic lung cancer at 8 months after surgery. Follow up duplex imaging at one year on the single survivor demonstrated sac shrinkage and absence of endoleak.
Type Ia endoleaks represent a significant source of morbidity and mortality after EVAR and typically require repair to avoid aneurysm rupture. Our use of limited proximal revision without explant provides an alternative approach to resolve the endoleaks while reducing the magnitude of physiological stress when compared to an open explant. It represents a feasible option for high-risk patients.
血管内主动脉修复（EVAR）后 I 型内漏几乎总是需要二次经皮介入治疗。然而，一些患者需要转为开放式手术修复，完全取出移植物，这与显著的发病率和死亡率相关。我们在此介绍 3 例 I 型内漏的杂交手术修复，采用有限的开放式暴露近端支架移植物边缘修正，以实现移植物保留和有效动脉瘤囊排除。
在 2017 年 10 月至 2019 年 10 月期间，3 例（2 例男性）先前接受 EVAR 的患者经血管造影证实存在 I 型内漏。1 例患者在修复破裂的动脉瘤时，在 EVAR 后立即出现内漏，1 例患者在 2 个月时出现内漏，1 例患者在 2 年内出现内漏。通过有限的经腹（n=1）或腹膜后（n=2）入路暴露主动脉，并在肾动脉以下实现主动脉环周控制。在主动脉颈部周围放置一排 3-0 聚丙稀增强带特氟隆补片的间断水平褥式缝线。然后重复多平面血管造影以验证囊腔无填充和成功排除 I 型内漏。所有 3 例患者出院后均进行腹部双功能超声检查以监测支架移植物并确认内漏解决。此外，无急性肾功能衰竭发生。
在审查期间，77 例患者接受了 EVAR。在描述的 3 例患者中，我们能够在所有病例中实现完全的动脉瘤囊排除和支架移植物保留。2 例患者在手术后 4-6 周的随访影像学检查中显示内漏持续排除。2 例患者在随访期间死亡：1 例患者在手术后 7 周死于心肌梗死，1 例患者在手术后 8 个月死于肺癌转移。单存活患者的 1 年随访双功能超声检查显示囊腔缩小，内漏消失。
I 型内漏是 EVAR 后发病率和死亡率的重要原因，通常需要修复以避免动脉瘤破裂。我们使用有限的近端修正而不取出移植物提供了一种替代方法来解决内漏，同时与开放式取出移植物相比，减少生理应激的程度。它是高危患者的可行选择。
