Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IIl.
Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IIl.
J Vasc Surg. 2021 Sep;74(3):895-901. doi: 10.1016/j.jvs.2021.02.028. Epub 2021 Mar 5.
Thoracic endovascular aortic repair (TEVAR) has been shown to effectively treat malperfusion associated with acute type B thoracic aortic dissection (TBAD). A subset of patients might still require adjunctive peripheral or visceral artery branch interventions during TEVAR to remedy persistent end organ malperfusion. Our objectives were to determine the incidence of these adjunctive interventions and to compare the outcomes between patients who had and had not undergone such interventions.
We performed a retrospective review of the TEVAR and complex EVAR module of the Vascular Quality Initiative from 2010 to 2019 to identify all patients treated for malperfusion due to acute TBAD. The anatomic branch and procedure performed at TEVAR were recorded. The 30-day mortality, need for reintervention, complication rates, and overall survival were compared between these patients stratified by adjunctive intervention status.
A total of 426 patients had undergone TEVAR for acute TBAD with end organ malperfusion. Of the 426 patients, 126 (29.6%) had undergone 182 adjunctive branch interventions during TEVAR. The most common interventions were stenting (n = 86; 47.3%) and stent grafting (n = 49; 26.9%), with the most common site being the left renal artery (n = 49; 26.9%). The patients in both groups had similar 30-day mortality (12.4% with branch intervention vs 15.6% without; P = .511) and rates of in-hospital reintervention (19.2% with branch intervention vs 20.7% without; P = .732). No differences were found in the rates of postoperative complications or overall survival at 3 years between the two groups.
Adjunctive peripheral and visceral artery branch interventions in conjunction with TEVAR for acute TBAD with malperfusion occurred in one third of index cases, but did not predispose patients to worse overall outcomes. Adjunctive arterial branch interventions should be included in the treatment paradigm for acute TBAD with end organ malperfusion that does not improve with primary entry tear coverage alone.
胸主动脉腔内修复术（TEVAR）已被证明可有效治疗急性 B 型胸主动脉夹层（TBAD）相关的灌注不良。在 TEVAR 期间，一部分患者可能仍需要辅助外周或内脏动脉分支介入治疗，以纠正持续的终末器官灌注不良。我们的目的是确定这些辅助介入的发生率，并比较接受和未接受此类介入治疗的患者的结局。
我们对 2010 年至 2019 年血管质量倡议的 TEVAR 和复杂 EVAR 模块进行了回顾性研究，以确定所有因急性 TBAD 导致灌注不良而接受治疗的患者。记录 TEVAR 时的解剖分支和进行的手术。根据辅助干预状态对这些患者进行分层，比较 30 天死亡率、再干预需求、并发症发生率和总体生存率。
共有 426 例患者因急性 TBAD 合并终末器官灌注不良而行 TEVAR。在 426 例患者中，126 例（29.6%）在 TEVAR 期间进行了 182 次辅助分支介入。最常见的干预措施是支架置入术（n=86；47.3%）和支架移植术（n=49；26.9%），最常见的部位是左肾动脉（n=49；26.9%）。两组患者的 30 天死亡率（分支干预组为 12.4%，无分支干预组为 15.6%；P=0.511）和住院期间再干预率（分支干预组为 19.2%，无分支干预组为 20.7%；P=0.732）相似。两组患者术后并发症发生率或 3 年总生存率无差异。
在急性 TBAD 合并灌注不良的患者中，TEVAR 联合外周和内脏动脉分支介入治疗的比例为三分之一，但并未导致患者总体预后恶化。对于单纯原发破口覆盖不能改善的终末器官灌注不良的急性 TBAD，应将辅助动脉分支介入治疗纳入治疗方案。
