Ketting Shirley, Zoethout Aleksandra C, Heyligers Jan M M, Wiersema Arno M, Yeung Kak K, Schurink Geert W H, Verhagen Hence J M, de Vries Jean-Paul P M, Reijnen Michel M P J, Mees Barend M E
Department of Vascular Surgery, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.
Department of Surgery, Rijnstate, Arnhem, The Netherlands; Department of Vascular Surgery, University Medical Center Groningen, Groningen, the Netherlands.
Ann Vasc Surg. 2022 Aug;84:250-264. doi: 10.1016/j.avsg.2021.12.077. Epub 2022 Jan 5.
Relining of a previously placed surgical graft or endograft for an abdominal aortic aneurysm (AAA) is a reintervention to treat progression of disease or failure of the primary (endo)graft. Endovascular Aneurysm Sealing (EVAS) relining is a technique with potential advantages due to the absence of a bifurcation, the possibility for a unilateral approach, and sealing concept of the endobags. The purpose of this study was to describe the nationwide experience with EVAS relining of previous AAA repair in the Netherlands.
A retrospective analysis of all patients who underwent EVAS relining in 7 high volume vascular centres in the Netherlands between 2014 and 2019 was performed. Primary outcomes were technical and clinical success. Secondary outcomes were perioperative outcomes, complications and survival.
Thirty-three patients underwent EVAS relining of open (n = 10) or endovascular (n = 23) repair. 26 were elective cases, 5 were urgent and 2 were acute (ruptured). Mean time between primary treatment and EVAS relining was 99 ± 74 months. Indications after open repair were proximal progression of disease (n = 7) and graft defect (n = 3). Indications after EVAR were type IA (n = 10), type IB (n = 3), type IIIA (n = 4), type IIIB (n = 3) endoleak, and endotension (n = 3). 18 patients underwent regular EVAS, 4 unilateral EVAS and 11 chimney-EVAS. In-hospital mortality was 6% (both patients with rAAA). Technical success was achieved in 97%. Median follow-up after EVAS relining was 20 months (range 0-43). Freedom from reintervention at 1-year and 2-year were 83% and 61% and the estimated survival 79% and 71%, respectively. EVAS relining after open repair had a clinical success of 90% at 1-year and of 70% at latest follow-up, while after EVAR clinical success rates were 70% and 52%, respectively.
EVAS relining of previous AAA repair is associated with high technical success, however with limited clinical success at median follow-up of 20 months. Clinical success was higher in patients with EVAS relining after open repair than after EVAR. In patients with failed AAA repair, EVAS relining should only be considered, when established techniques such as fenestrated repair or open conversion are not available or indicated.
对先前放置的用于治疗腹主动脉瘤（AAA）的外科移植物或腔内移植物进行内衬修复是一种用于治疗疾病进展或原发性（腔内）移植物失败的再次干预措施。血管腔内动脉瘤封闭术（EVAS）内衬修复是一种具有潜在优势的技术，因为它不存在分叉，可采用单侧入路，并且具有内袋封闭的理念。本研究的目的是描述荷兰全国范围内对先前AAA修复进行EVAS内衬修复的经验。
对2014年至2019年间在荷兰7个高容量血管中心接受EVAS内衬修复的所有患者进行回顾性分析。主要结局指标为技术成功和临床成功。次要结局指标为围手术期结局、并发症和生存率。
33例患者接受了开放手术（n = 10）或腔内修复（n = 23）后的EVAS内衬修复。26例为择期病例，5例为急诊病例，2例为急性（破裂）病例。初次治疗与EVAS内衬修复之间的平均时间为99±74个月。开放修复后的指征为疾病近端进展（n = 7）和移植物缺陷（n = 3）。腔内修复术后的指征为IA型（n = 10）、IB型（n = 3）、IIIA型（n = 4）、IIIB型（n = 3）内漏以及内张力（n = 3）。18例患者接受了常规EVAS，4例接受了单侧EVAS，11例接受了烟囱式EVAS。住院死亡率为6%（均为破裂性AAA患者）。技术成功率为97%。EVAS内衬修复后的中位随访时间为20个月（范围0 - 43个月）。1年和2年时无需再次干预的比例分别为83%和61%，估计生存率分别为79%和71%。开放修复后进行EVAS内衬修复的临床成功率在1年时为90%，在最新随访时为70%，而腔内修复术后的临床成功率分别为70%和52%。
先前AAA修复后的EVAS内衬修复技术成功率高，但在中位随访20个月时临床成功率有限。开放修复后进行EVAS内衬修复的患者临床成功率高于腔内修复术后。在AAA修复失败的患者中，只有在无法获得或不适合采用开窗修复或开放转换等成熟技术时，才应考虑EVAS内衬修复。
