Division of Vascular Surgery and Endovascular Therapy, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
Division of Cardiothoracic Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
J Vasc Surg. 2022 Jul;76(1):53-60.e1. doi: 10.1016/j.jvs.2022.01.127. Epub 2022 Feb 9.
With the expanding application of endovascular technology, the need to deploy into zone 0 has been encountered on occasion. In the present study, we evaluated the outcomes of great vessel debranching (GVD) as a method of extending the proximal landing zone to facilitate thoracic endovascular aortic repair (TEVAR).
We performed a single-center retrospective review of all patients who had undergone GVD followed by TEVAR between May 2013 and December 2020. The primary outcome was primary patency of all targeted vessels, with all-cause perioperative mortality as a secondary outcome. Kaplan-Meier analysis was used to account for censoring of mortality and primary patency. The extent of hybrid aortic repairs was characterized into type I (GVD plus TEVAR without ascending aorta or aortic arch reconstruction, type II (GVD plus TEVAR with ascending aorta reconstruction), and type III (GVD plus TEVAR with ascending aorta and aortic arch reconstruction with an elephant trunk (soft [surgical] or frozen [endovascular]]).
A total of 42 patients (23 men [54.8%]; mean age, 62.2 ± 11.2 years) had undergone GVD, with 122 vessels revascularized (42 innominate, 42 left common carotid, and 38 left subclavian arteries). The indication for TEVAR was aneurysmal degeneration from aortic dissection in 32 patients (76.2%), a thoracic aneurysm in 9 patients (21.4%), and a perforated aortic ulcer in 1 patient (2.4%). The median duration between GVD and TEVAR was 82 days. The mean follow-up period was 25.7 ± 23.5 months. Type I repair was performed in 4, type II in 16, and type III in 22 patients. The perioperative mortality, stroke, and paraplegia rates were 9.5%, 7.1%, and 2.4%, respectively. Neither the extent of repair (P = .80) nor a history of aortic repair (P = .90) was associated with early mortality. Of the 38 patients who had survived the perioperative period, 6 had died >30 days postoperatively. At 36 months, the survival estimate was 68.6% (95% confidence interval, 45.7%-83.4%). The overall primary patency of the innominate artery, left common carotid artery, and left subclavian artery was 100%, 89.5%, and 94.1%, respectively. The primary-assisted patency rate was 100% for all the vessels.
We found GVD to be a safe and effective method of extending the proximal landing zone into zone 0 with outstanding primary patency rates. Further studies are required to confirm the safety and longer term durability for these patients.
随着腔内技术应用的不断扩展，有时需要将近端着陆区扩展到零区。本研究评估了大动脉分支重建术（GVD）作为一种延长近端着陆区以促进胸主动脉腔内修复术（TEVAR）的方法的效果。
我们对 2013 年 5 月至 2020 年 12 月期间接受 GVD 联合 TEVAR 的所有患者进行了单中心回顾性研究。主要结局是所有目标血管的通畅率，全因围手术期死亡率为次要结局。Kaplan-Meier 分析用于考虑死亡率和通畅率的删失。杂交主动脉修复的程度分为 I 型（GVD 加 TEVAR 无升主动脉或主动脉弓重建）、II 型（GVD 加 TEVAR 加升主动脉重建）和 III 型（GVD 加 TEVAR 加升主动脉和主动脉弓重建，包括象鼻（软[手术]或冷冻[腔内]））。
共有 42 例患者（23 例男性[54.8%]；平均年龄 62.2±11.2 岁）接受了 GVD，122 支血管进行了血运重建（42 支无名动脉、42 支左颈总动脉和 38 支左锁骨下动脉）。TEVAR 的适应证为主动脉夹层引起的动脉瘤退行性变 32 例（76.2%），胸主动脉瘤 9 例（21.4%），穿透性主动脉溃疡 1 例（2.4%）。GVD 与 TEVAR 之间的中位间隔时间为 82 天。平均随访时间为 25.7±23.5 个月。I 型修复 4 例，II 型修复 16 例，III 型修复 22 例。围手术期死亡率、卒中率和截瘫率分别为 9.5%、7.1%和 2.4%。修复的程度（P=0.80）或主动脉修复史（P=0.90）均与早期死亡率无关。38 例围手术期存活患者中，有 6 例在术后 30 天以上死亡。36 个月时，生存率估计为 68.6%（95%置信区间，45.7%-83.4%）。无名动脉、左颈总动脉和左锁骨下动脉的总通畅率分别为 100%、89.5%和 94.1%。所有血管的一级辅助通畅率均为 100%。
我们发现 GVD 是一种安全有效的将近端着陆区扩展到零区的方法，其通畅率非常高。需要进一步的研究来证实这些患者的安全性和更长期的耐久性。
