Department of Vascular Surgery, University Medical Center Groningen, Groningen, the Netherlands -
Department of Vascular Surgery, University Medical Center Groningen, Groningen, the Netherlands.
J Cardiovasc Surg (Torino). 2021 Dec;62(6):600-608. doi: 10.23736/S0021-9509.21.11972-X. Epub 2021 Sep 14.
Sufficient apposition and oversizing of the endograft in the aortic neck are both essential for durable endovascular aneurysm repair (EVAR). These measures are however not regularly stated on post-EVAR computed tomography angiography (CTA) scan reports. In this study endograft apposition and neck enlargement (NE) after EVAR with an Endurant II(s) endograft were analyzed and associated with supra- and infrarenal aortic neck morphology.
In 97 consecutive elective patients, the aortic neck morphology was measured on the pre-EVAR CTA scan on a 3mensio vascular workstation. The distance between the lowest renal artery and the proximal edge of the fabric (shortest fabric distance, SFD), and the shortest length of circumferential apposition between endograft and aortic wall (shortest apposition length, SAL) were determined on the early post-EVAR CTA scan. NE, defined as the aortic diameter change between pre- and post-EVAR CTA scan, was determined at eight levels: +40, +30, +20, +15, +10, 0, -5 and -10 mm relative to the lowest renal artery baseline. The aortic neck diameter and preoperative oversizing were correlated to NE with the Pearson correlation coefficient. The effective post-EVAR endograft oversizing is calculated from the nominal endograft diameter and the post-EVAR neck diameter where the endograft is circumferentially apposed.
The median time (interquartile range, IQR) between the EVAR procedure and the pre- and post-EVAR CTA scan was 40 (25, 71) days and 36 (30, 46) days, respectively. The Endurant II(s) endograft was deployed with a median (IQR) SFD of 1.0 (0.0, 3.0) mm. The SAL was <10 mm in 9% of patients and significantly influenced by the pre-EVAR aortic neck length (P=0.001), hostile neck shape (P=0.017), and maximum curvature at the suprarenal aorta (P=0.039). The median (interquartile range) SAL was 21.0 (15.0, 27.0) mm with a median (IQR) pre-EVAR infrarenal neck length of 23.5 (13.0, 34.8) mm. The median (IQR) difference between the SAL and neck length was -5.0 (-12.0, 2.8) mm. Significant (P<0.001) NE of 1.7 (0.9, 2.5) mm was observed 5 mm below the renal artery baseline, which resulted in an effective post-EVAR endograft oversizing <10% in 43% of the patients. No correlation was found between NE and aortic neck diameter or preoperative oversizing.
Circumferential apposition between an endograft and the infrarenal aortic neck, SAL, and NE can be derived from standard postoperative CT scans. These variables provide essential information about the post-procedural endograft and aortic neck morphology regardless of the preoperative measurements. Patients with SAL<10 mm or effective oversizing <10% due to NE may benefit from intensified follow-up, but clinical consequences of SAL and NE should be evaluated in future longitudinal studies with longer term follow-up.
在主动脉颈部进行充分的血管内移植物对位和过度扩张对于持久的血管内腹主动脉瘤修复（EVAR）至关重要。然而，这些措施在 EVAR 后计算机断层血管造影（CTA）扫描报告中并没有经常说明。在这项研究中，分析了使用 Endurant II(s) 血管内移植物进行 EVAR 后的血管内移植物对位和颈部扩大（NE），并与肾上和肾下主动脉颈部形态相关联。
在 97 例连续进行的择期患者中，在 EVAR 前的 CTA 扫描上使用 3mensio 血管工作站测量主动脉颈部形态。在早期 EVAR CTA 扫描上确定了最低肾动脉和织物近端边缘之间的最短织物距离（最短织物距离，SFD）以及血管内移植物和主动脉壁之间最短的圆周贴附长度（最短贴附长度，SAL）。NE 定义为相对于最低肾动脉基线，在 EVAR 前和 EVAR CTA 扫描之间的主动脉直径变化。在 8 个水平上确定：+40、+30、+20、+15、+10、0、-5 和-10 mm。使用 Pearson 相关系数将主动脉颈部直径和术前过度扩张与 NE 相关联。有效术后血管内移植物过度扩张是从标称血管内移植物直径和血管内移植物圆周贴附的颈后直径计算得出的。
EVAR 手术与 EVAR 前后 CTA 扫描之间的中位时间（四分位数范围，IQR）分别为 40（25，71）天和 36（30，46）天。Endurant II(s) 血管内移植物的中位（IQR）SFD 为 1.0（0.0，3.0）mm。9%的患者 SAL<10mm，并且 SAL 显著受 EVAR 前主动脉颈部长度（P=0.001）、敌对颈部形状（P=0.017）和肾上主动脉最大曲率（P=0.039）的影响。中位（IQR）SAL 为 21.0（15.0，27.0）mm，中位（IQR）EVAR 前肾下颈部长度为 23.5（13.0，34.8）mm。SAL 和颈部长度之间的中位（IQR）差异为-5.0（-12.0，2.8）mm。在肾动脉基线以下 5mm 处观察到显著（P<0.001）的 1.7（0.9，2.5）mm 的 NE，导致 43%的患者术后血管内移植物有效过度扩张<10%。未发现 NE 与主动脉颈部直径或术前过度扩张之间存在相关性。
血管内移植物与肾下主动脉颈部之间的圆周贴附、SAL 和 NE 可以从标准的术后 CT 扫描中得出。这些变量提供了有关术后血管内移植物和主动脉颈部形态的重要信息，无论术前测量如何。由于 NE 导致 SAL<10mm 或有效过度扩张<10%的患者可能受益于强化随访，但 SAL 和 NE 的临床后果应在具有更长随访期的未来纵向研究中进行评估。
