标准血管内动脉瘤修复术后主动脉颈扩张的危险因素、动态变化及临床后果。
Risk Factors, Dynamics, and Clinical Consequences of Aortic Neck Dilatation after Standard Endovascular Aneurysm Repair.
机构信息
Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; Department of Angiology and Vascular Surgery, Hospital do Divino Espírito Santo, Ponta Delgada, Azores, Portugal.
Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; Department of Angiology and Vascular Surgery, Hospital de São João, Porto, Portugal.
出版信息
Eur J Vasc Endovasc Surg. 2021 Jul;62(1):26-35. doi: 10.1016/j.ejvs.2021.03.020. Epub 2021 Jun 2.
OBJECTIVE
Aortic neck dilatation (AND) occurs after endovascular aneurysm repair (EVAR) with self expanding stent grafts (SESs). Whether it continues, ultimately exceeding the endograft diameter leading to abdominal aortic aneurysm (AAA) rupture, remains uncertain. Dynamics, risk factors, and clinical relevance of AND were investigated after EVAR with standard SESs.
METHODS
All intact EVAR patients treated from 2000 to 2015 at a tertiary institution were included. Demographic, anatomical, and device related characteristics were investigated as risk factors for AND. Outer to outer diameters were measured at a single standardised aortic level on reconstructed computed tomography (CT) images.
RESULTS
A total of 460 patients were included (median follow up 5.2 years, interquartile range [IQR] 3.0, 7.7 years; CT imaging follow up 3.3 years, IQR 1.3, 5.4). Baseline neck diameter was 24 mm (IQR 22, 26) and increased 11.1% (IQR 1.5%, 21.9%) at last CT imaging. Endograft oversizing was 20.0% (IQR 13.6, 28.0). AND was greater during the first year (5.2% [IQR 0, 11.7]) decreasing subsequently (two to four years to 1.4%/year [IQR 0.0, 4.5%], p ≤ .001) and was associated with suprarenal fixation endografts (t value = 7.9, p < .001) and oversizing (t value = 4.4, p < .001). AND exceeding the endograft was 3.5% (95% CI 2.2% - 4.8%) and 14.4% (95% CI 11.0% - 17.8%) at five and eight years, respectively. Excessive AND was associated with baseline neck diameter (OR 1.2/mm, 95% CI 1.05 - 1.41) while the Excluder endograft had a protective effect (OR 0.15, 95% CI 0.04 - 0.58). Excessive AND was associated with type 1A endoleak (HR 3.3, 95% CI 1.1 - 9.7) and endograft migration > 5 mm (HR 3.1, 95% CI 1.4 - 6.9).
CONCLUSION
AND after EVAR with SES is associated with endograft oversizing and radial force but decelerates after the first post-operative year. Baseline aortic neck diameter and suprarenal stent bearing endografts were associated with an increased risk of AND beyond nominal stent graft diameter. However, it remains unclear whether patient selection, differences in endograft radial force or the suprarenal stent are accountable for this difference.
目的
在使用自膨式支架移植物（SES）进行血管内腹主动脉瘤修复（EVAR）后，会发生主动脉颈扩张（AND）。然而，仍不确定它是否会继续扩张，最终超过内移植物直径，导致腹主动脉瘤（AAA）破裂。本研究旨在探讨使用标准 SES 进行 EVAR 后 AND 的动力学、危险因素和临床相关性。
方法
本研究纳入了 2000 年至 2015 年在一家三级医疗机构接受治疗的所有完整 EVAR 患者。调查了人口统计学、解剖学和器械相关特征，以确定其是否为 AND 的危险因素。在重建 CT 图像上的单一标准主动脉水平测量外-外直径。
结果
本研究共纳入 460 例患者（中位随访时间为 5.2 年，四分位距[IQR]为 3.0-7.7 年；CT 影像学随访时间为 3.3 年，IQR 为 1.3-5.4 年）。基线颈直径为 24mm（IQR 为 22-26），最后一次 CT 成像时增加了 11.1%（IQR 为 1.5%-21.9%）。内移植物过度扩张率为 20.0%（IQR 为 13.6%-28.0%）。AND 在术后第一年增长较大（5.2%[IQR 为 0-11.7%]），随后逐渐减少（2-4 年时每年减少 1.4%/年[IQR 为 0.0%-4.5%]，p≤0.001），与肾上固定内移植物（t 值=7.9，p<0.001）和过度扩张（t 值=4.4，p<0.001）相关。内移植物超过 AND 的比例为 3.5%（95%CI 为 2.2%-4.8%）和 14.4%（95%CI 为 11.0%-17.8%），分别在 5 年和 8 年时。AND 过度扩张与基线颈直径相关（OR 1.2/mm，95%CI 为 1.05-1.41），而 Excluder 内移植物具有保护作用（OR 0.15，95%CI 为 0.04-0.58）。AND 过度扩张与 1A 型内漏（HR 3.3，95%CI 为 1.1-9.7）和内移植物迁移>5mm（HR 3.1，95%CI 为 1.4-6.9）相关。
结论
SES 进行 EVAR 后发生的 AND 与内移植物过度扩张和径向力有关，但在术后第一年之后会减速。基线主动脉颈直径和肾上支架内移植物与超过标称支架移植物直径的 AND 风险增加相关。然而，目前尚不清楚是患者选择、内移植物径向力差异还是肾上支架导致了这种差异。
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