Department of Surgery, Faculty of Medicine, Kuwait University, Kuwait; Department of Vascular Surgery, MedStar Washington Hospital Center, Washington DC.
Department of Vascular Surgery, MedStar Washington Hospital Center, Washington DC.
Ann Vasc Surg. 2021 Jul;74:237-245. doi: 10.1016/j.avsg.2020.12.043. Epub 2021 Feb 5.
Parallel grafting presents a viable method for treating patients with complex aortic aneurysms. The current literature is limited to mostly pararenal configurations. We examined our results in patients with SMA and/or Celiac artery involvement.
A retrospective analysis was performed for all patients undergoing parallel grafting during the period of 2014 to 2018 at a single institution. All patients had at least SMA with and/or without Celiac artery parallel grafting.
Seventy-nine patients (65% male, median age 74) were treated with 208 parallel grafts. Median ASA score is 4. Forty-nine cases were elective, 22 urgent, and 8 emergent. Mean pre-operative aneurysm diameter was 7.1 cm (4.6-15 cm). Self-expanding covered stents were used for the renal arteries (mean 6.3mm), and balloon-expandable covered stents were used for the SMA and Celiac (mean SMA 8.6 mm, mean celiac 8.3 mm). Axillary exposure was the choice of access in 68 patients (86%). Technical success was achieved in all cases. We defined this as aneurysm sac exclusion with patent visceral stent grafts, and absent to mild gutter leaks. Mean aortic graft proximal seal achieved was 48mm. Coverage extended above the celiac artery in 75% (10% stented and 65% covered). Median contrast volume was 145ml, operative duration was 4 hours, fluoroscopy time was 56 min, and EBL was 250 ml. Perioperative mortality was 6.1%. 4.5%, and 25%, for the elective, urgent, and emergent groups, respectively. There was no incidence of spinal cord ischemia. Axillary access was complicated in 4 patients, requiring patch closure of the axillary artery. One patient developed postprocedural ESRD from a rupture and ATN despite patent renal stents. Of those patients with a patent GDA and celiac coverage, 2 required a cholecystectomy. Nine patients had a persistent gutter leak at the conclusion of the procedure. Median follow-up was 12 months. On follow-up imaging, all SMA and Celiac stents were patent. Six renal stents were occluded and 2 patients progressed to ESRD, both solitary renal periscope configurations at the index procedure. Only 4 patients had persistent gutter leaks with 2 requiring reintervention. Ninety-five percent of patients demonstrated sac regression or stabilization with a mean sac size of 6.5 cm.
Parallel grafting presents a safe, efficacious and off the shelf alternative to conventional repair of complex aortic aneurysms involving the visceral aorta.
平行移植为治疗复杂主动脉瘤患者提供了一种可行的方法。目前的文献主要局限于肾旁部位的配置。我们检查了在涉及 SMA 和/或腹腔动脉的患者中的结果。
对 2014 年至 2018 年期间在一家机构接受平行移植的所有患者进行了回顾性分析。所有患者均至少接受了 SMA 和/或腹腔动脉平行移植。
79 例患者（65%为男性，中位年龄为 74 岁）接受了 208 个平行移植。中位 ASA 评分为 4 分。49 例为择期手术，22 例为急诊手术，8 例为紧急手术。术前动脉瘤直径的中位数为 7.1cm（4.6-15cm）。自膨式覆膜支架用于肾动脉（平均直径 6.3mm），球囊扩张覆膜支架用于 SMA 和腹腔动脉（平均 SMA 8.6mm，平均腹腔动脉 8.3mm）。腋动脉暴露是 68 例患者（86%）的首选入路。所有病例均达到技术成功。我们将其定义为动脉瘤囊排除，内脏支架通畅，无或轻度沟漏。平均主动脉移植物近端密封距离为 48mm。覆盖范围延伸至腹腔动脉上方，占 75%（10%支架和 65%覆盖）。中位数对比剂用量为 145ml，手术时间为 4 小时，透视时间为 56 分钟，出血量为 250ml。围手术期死亡率分别为 6.1%、4.5%和 25%，分别为择期手术、急诊手术和紧急手术组。无脊髓缺血发生。4 例患者腋动脉入路复杂，需要腋动脉修补。1 例患者尽管肾支架通畅，但因破裂和 ATN 导致术后出现 ESRD。在有 GDA 和腹腔动脉通畅的患者中，2 例需要行胆囊切除术。9 例患者在手术结束时存在持续性沟漏。中位随访时间为 12 个月。在随访影像学检查中，所有 SMA 和腹腔动脉支架均通畅。6 个肾支架闭塞，2 例患者进展为 ESRD，均为指数手术时孤立的肾镜配置。只有 4 例患者存在持续性沟漏，其中 2 例需要再次介入治疗。95%的患者显示出囊腔缩小或稳定，平均囊腔大小为 6.5cm。
平行移植为涉及内脏主动脉的复杂主动脉瘤的常规修复提供了一种安全、有效且现成的替代方法。
