Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex; Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
J Vasc Surg. 2022 Mar;75(3):783-793.e4. doi: 10.1016/j.jvs.2021.10.026. Epub 2021 Nov 3.
To evaluate the incidence of intraoperative adverse events (IAEs) and their impact on outcomes after fenestrated-branched endovascular aortic repair (FB-EVAR) of complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysm (TAAAs).
We reviewed the clinical and imaging data of 600 consecutive patients (445 males; mean age, 75 ± 8 years) who underwent FB-EVAR between 2007 and 2019 in a single institution. IAE was defined as any intraoperative complication or technical problem requiring additional and unplanned procedures, and was classified as access-related, target artery (TA)-related, or graft-related. End points included rates of IAEs, 30-day or in-hospital mortality, major adverse events, patient survival, freedom from secondary intervention, and TA instability.
A total of 122 IAEs were identified in 105 patients (18%). IAEs were TA-related in 55 patients (9%), access-related in 46 patients (8%), and graft-related in seven patients (1%). Female sex was more frequent among patients with IAEs (44% vs 22%; P < .001). Patients with IAEs had smaller renal artery diameter (-0.4 mm, 5.4 ± 0.8 mm vs 5.8 ± 0.9 mm; P < .001), and were treated more often for TAAAs (72% vs 54%; P < .03). Technical success was achieved in 96.5% of patients and was lower for patients with IAEs (82% vs 99%; P < .001). Major adverse events were significantly more frequent among patients who had IAEs (odds ratio [OR], 1.98; 95% confidence interval [CI], 1.21-3.25), most due to acute kidney injury (27% vs 11%; P < .001) including new-onset dialysis (5% vs 1%; P = .01). On multivariate logistic regression model, female sex (OR, 2.5; 95% CI, 1.5-4.0), TA stenosis >50% (OR, 2.0; 95% CI, 1.3-3.3), and Crawford Extent II TAAA (OR, 1.9; 95% CI, 1.1-3.3) were predictive of IAEs, whereas preloaded design (OR, 0.6; 95% CI, 0.4-0.9) and TA diameter (+1 mm; OR, 0.6; 95% CI, 0.4-0.9) were protective of IAEs. IAEs negatively affected secondary intervention (hazard ratio [HR], 1.6; 95% CI, 1.1-2.3) and TA instability (HR, 2.5; 95% CI, 1.2-5.4); however, IAEs did not affect patient survival (HR, 1.0; 95% CI, 0.7-1.4).
IAEs are common, occurring in nearly one of five patients treated with FB-EVAR for complex aortic aneurysms, and have a negative impact on clinical outcomes. IAEs were associated with female sex, TA diameter, and more extensive aortic disease.
评估开窗分支腔内血管修复术（fenestrated-branched endovascular aortic repair，FB-EVAR）治疗复杂腹主动脉瘤和胸腹主动脉瘤（thoracoabdominal aortic aneurysm，TAAA）的术中不良事件（intraoperative adverse events，IAEs）发生率及其对结局的影响。
我们回顾了 2007 年至 2019 年期间在一家单中心接受 FB-EVAR 治疗的 600 例连续患者（445 例男性；平均年龄 75±8 岁）的临床和影像学数据。IAE 定义为任何需要额外和计划外手术的术中并发症或技术问题，并分为入路相关、靶动脉（target artery，TA）相关或移植物相关。终点包括 IAE 发生率、30 天或住院死亡率、主要不良事件、患者生存率、免于二次干预和 TA 不稳定。
在 105 例患者（18%）中发现了 122 例 IAE。55 例（9%）患者的 IAE 与 TA 相关，46 例（8%）与入路相关，7 例（1%）与移植物相关。有 IAE 的患者中女性比例更高（44% vs. 22%；P<0.001）。有 IAE 的患者肾动脉直径更小（-0.4mm，5.4±0.8mm vs. 5.8±0.9mm；P<0.001），并且更常接受 TAAA 治疗（72% vs. 54%；P<0.03）。96.5%的患者达到了技术成功，有 IAE 的患者技术成功率较低（82% vs. 99%；P<0.001）。有 IAE 的患者主要不良事件发生率显著更高（优势比[odds ratio，OR]，1.98；95%置信区间[confidence interval，CI]，1.21-3.25），主要是由于急性肾损伤（27% vs. 11%；P<0.001），包括新发透析（5% vs. 1%；P=0.01）。多变量逻辑回归模型显示，女性（OR，2.5；95%CI，1.5-4.0）、TA 狭窄>50%（OR，2.0；95%CI，1.3-3.3）和 Crawford Ⅱ型 TAAA（OR，1.9；95%CI，1.1-3.3）是 IAE 的预测因素，而预加载设计（OR，0.6；95%CI，0.4-0.9）和 TA 直径增加 1mm（OR，0.6；95%CI，0.4-0.9）是 IAE 的保护因素。IAE 对二次干预（危险比[hazard ratio，HR]，1.6；95%CI，1.1-2.3）和 TA 不稳定（HR，2.5；95%CI，1.2-5.4）有负面影响；然而，IAE 对患者生存率（HR，1.0；95%CI，0.7-1.4）没有影响。
IAE 在接受 FB-EVAR 治疗复杂主动脉瘤的患者中较为常见，近五分之一的患者会发生 IAE，并且对临床结局有负面影响。IAE 与女性、TA 直径和更广泛的主动脉疾病相关。
