Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn; Division of Vascular and Endovascular Surgery, Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Tex.
J Vasc Surg. 2022 Jul;76(1):79-87.e4. doi: 10.1016/j.jvs.2022.01.135. Epub 2022 Feb 16.
Target artery (TA) instability has been the most frequent indication for secondary intervention after fenestrated and branched endovascular aortic repair (FB-EVAR) of pararenal and thoracoabdominal aortic aneurysms (TAAAs). The aim of the present study was to evaluate the effect of the gap distance between the endograft reinforced fenestration and TA origin at the aortic wall (fenestration gap [FG]) on target-related outcomes after FB-EVAR.
The clinical data and imaging studies of 430 patients enrolled in a prospective, nonrandomized study to evaluate FB-EVAR using manufactured stent grafts were reviewed. Of the 430 patients, 340 (79%) had had more than one vessel incorporated by fenestration. The FG was retrospectively measured on postoperative imaging studies and classified into three groups: no gap (FG, 0 mm), FG 1 to 4 mm, and FG ≥5 mm. The primary outcome was freedom from TA instability. The secondary end points included TA-related endoleak, TA secondary intervention, and TA patency.
A total of 1558 renal-mesenteric TAs were incorporated by 1104 reinforced fenestrations and 454 directional branches (DBs), with a mean of 3.9 ± 0.5 vessels per patient. The mean FG was 2.8 ± 4.5 mm, with an FG of 0 mm for 646 TAs, 1 to 4 mm for 209 TAs, and ≥5 mm for 249 TAs. An FG of ≥5 mm was associated with significantly lower (P < .001) freedom from TA instability, type Ic or IIIc endoleak, and secondary interventions at 5 years. Compared with DBs, fenestrations with an FG of ≥5 mm had similar primary patency and freedom from TA instability but significantly lower freedom from type Ic or IIIc endoleak (91% ± 2% vs 95% ± 1%; log rank, P = .02) and secondary interventions (87% ± 3% vs 93% ± 2%; log-rank, P = .02) at 5 years. The independent predictors of TA instability included postdissection TAAAs (hazard ratio, 2.5; 95% confidence interval, 1.2-5.4) and FG ≥5 mm (hazard ratio, 1.6; 95% confidence interval, 1.2-1.8). TAs incorporated by reinforced fenestrations had higher primary (99% ± 0.8% vs 97% ± 1.0%; P = .039) and secondary (100% vs 98% ± 1.0%; P = .012) patency rates at 5 years compared with DBs, with the lowest primary patency observed for renal DBs (80% ± 6% vs 92% ± 2%; P = .008).
An FG of ≥5 mm was independently associated with an increased risk of TA instability, type Ic or IIIc endoleaks, and secondary interventions for patients treated by FB-EVAR using fenestrated designs. TAs incorporated by DBs had lower 5-year primary and secondary patency compared with those with reinforced fenestrations, with the lowest 5-year patency of 80% for renal branches. Compared with DBs, fenestrations with an FG of ≥5 mm carried a greater risk of type Ic or IIIc endoleak and secondary interventions. Independent predictors of TA instability included postdissection TAAAs and a greater FG. In contrast, dual antiplatelet therapy and larger TA diameters were protective.
在肾下腹主动脉瘤和胸腹主动脉瘤（TAAA）的分支型和开窗型腔内修复（FB-EVAR）后，靶动脉（TA）不稳定是再次介入治疗最常见的指征。本研究旨在评估内漏强化开窗与主动脉壁 TA 起源之间的间隙距离（开窗间隙[FG]）对 FB-EVAR 后靶相关结局的影响。
回顾性分析了前瞻性、非随机研究中使用定制支架移植物评估 FB-EVAR 的 430 例患者的临床数据和影像学研究。在 430 例患者中，340 例（79%）有超过 1 个血管通过开窗术融合。术后影像学研究回顾性测量 FG，并将其分为三组：无间隙（FG，0mm）、FG 1 至 4mm 和 FG≥5mm。主要结局是 TA 稳定性不受影响。次要终点包括 TA 相关内漏、TA 二次干预和 TA 通畅性。
共纳入 1104 个强化开窗和 454 个定向分支（DB），共融合了 1558 个肾肠系膜 TA，每位患者平均融合 3.9±0.5 个血管。平均 FG 为 2.8±4.5mm，FG 为 0mm 的 TA 有 646 个，1 至 4mm 的 TA 有 209 个，FG≥5mm 的 TA 有 249 个。FG≥5mm 与较低的（P<0.001）TA 不稳定、Ic 或 IIIc 型内漏以及 5 年时的二次干预相关。与 DB 相比，FG≥5mm 的开窗术有相似的主要通畅率和 TA 稳定性，但明显较低的 Ic 或 IIIc 型内漏（91%±2%比 95%±1%；log-rank，P=0.02）和二次干预（87%±3%比 93%±2%；log-rank，P=0.02），5 年时。TA 不稳定的独立预测因素包括夹层 TAAA（风险比，2.5；95%置信区间，1.2-5.4）和 FG≥5mm（风险比，1.6；95%置信区间，1.2-1.8）。强化开窗术融合的 TA 具有更高的主要（99%±0.8%比 97%±1.0%；P=0.039）和次要（100%比 98%±1.0%；P=0.012）通畅率，而肾 DB 的主要通畅率最低（80%±6%比 92%±2%；P=0.008）。
FG≥5mm 与 FB-EVAR 中使用开窗设计的患者的 TA 不稳定、Ic 或 IIIc 型内漏以及二次干预的风险增加独立相关。与强化开窗相比，DB 融合的 TA 5 年主要和次要通畅率较低，肾分支的 5 年通畅率最低为 80%。与 DB 相比，FG≥5mm 的开窗术发生 Ic 或 IIIc 型内漏和二次干预的风险更高。TA 不稳定的独立预测因素包括夹层 TAAA 和更大的 FG。相比之下，双联抗血小板治疗和更大的 TA 直径是保护性的。
