Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany; Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy.
Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy.
J Vasc Surg. 2022 Sep;76(3):714-723.e1. doi: 10.1016/j.jvs.2022.01.142. Epub 2022 Feb 25.
To report a two-centers evaluation of the effects of iliac axis tortuosity on iliac branch device (IBD) results.
From 2015 to 2021, all IBD procedures performed at two European centers were analyzed retrospectively. The preoperative pelvic tortuosity index (PTI), external tortuosity index (ETI), and double iliac sign (DIS) were assessed for each iliac axis submitted to IBD. The primary endpoints were technical success, early and mid-term IBD complications (occlusion, stenosis, endoleaks [ELs]) and reinterventions, and the association with the PTI, ETI, and DIS. The 30-day mortality, survival, freedom from complications and freedom from reinterventions (FFR) were the secondary endpoints.
During the study period, 224 patients had undergone 256 IBD procedures for 165 (64.5%) aortoiliac aneurysms, 44 (17.2%) isolated iliac aneurysms, 11 (4.3%) abdominal aortic aneurysms with a short iliac landing zone, and 36 (14.1%) type Ib ELs. IBD was planned with endovascular aortic aneurysm repair for 158 (61.7%), fenestrated/branched endovascular aortic aneurysm repair for 45 (7.6%), and isolated for 53 (20.7%) cases. Technical success and 30-day mortality were 99.2% (254 of 256) and 0.9% (2 of 224), respectively. A PTI >1.4, an ETI >1.7, and the DIS were tested to identify the risk factors for the endpoints. No ELs and 9 (3.5%) IBD occlusions, requiring five reinterventions (2%), had occurred within 30 days. No association with the PTI, ETI, or DIS was identified; IBD oversizing of ≥25% on the external iliac artery was independently related to occlusion (odds ratio, 4.3; 95% confidence interval [CI], 1-18.1; P = .045). The mean follow-up was 31 ± 27 months, with 11 IBD occlusions, 14 ELs, and 21 reinterventions. At 1, 3, and 5 years of follow-up survival, IBD patency, and FFR were 95%, 89%, and 80%; 93%, 91%, and 90%; and 93%, 89%, and 83%, respectively. The risk factors for overall complications (n = 34; 13.3%) and reinterventions (n = 26; 10.2%) were an ETI >1.7 (P = .037 and P = .019), a PTI >1.4 (P = .016 and P = .012), and a type Ib EL as the indication (P = .025 and P = .001), respectively. Cox regression confirmed PTI >1.4 as an independent predictor of overall complications and reinterventions (hazard ratio [HR], 2.3; 95% CI, 1.1-4.4; P = .018; and HR, 3 95% CI, 1.3-6.8; P = .018, respectively) and ETI >1.7 as an independent risk factor for ELs (HR 6; 95% CI, 2.1-17.5; P = .001). The freedom from complications and FFR were significantly lower with a PTI >1.4 at 3 years (73% vs 92% [log-rank P = .01] and 77% vs 93% [log-rank P = .001], respectively).
We found IBDs to be safe and effective in the treatment of aortoiliac aneurysms. Early complications are uncommon and related to endograft oversizing rather than anatomic characteristics in the present study. Iliac tortuosity is a risk factor for overall complications and reinterventions, in particular for IBD-related ELs.
报告 2 个中心关于髂内动脉迂曲对髂分支装置（IBD）结果影响的评估结果。
回顾性分析 2015 年至 2021 年期间在 2 个欧洲中心进行的所有 IBD 手术。对每个接受 IBD 的髂内动脉进行术前骨盆扭曲指数（PTI）、外扭曲指数（ETI）和双髂标志（DIS）评估。主要终点是技术成功率、早期和中期 IBD 并发症（闭塞、狭窄、内漏[ELs]）和再干预，以及与 PTI、ETI 和 DIS 的关系。30 天死亡率、生存率、无并发症和无再干预（FFR）是次要终点。
在研究期间，224 例患者接受了 256 例 IBD 手术，其中 165 例（64.5%）为腹主动脉瘤，44 例（17.2%）为孤立性髂动脉瘤，11 例（4.3%）为短髂支落地区腹主动脉瘤，36 例（14.1%）为 Ib 型 ELs。158 例（61.7%）计划行血管内腹主动脉瘤修复，45 例（7.6%）行开窗/分支血管内腹主动脉瘤修复，53 例（20.7%）行孤立性治疗。技术成功率和 30 天死亡率分别为 99.2%（254 例中的 254 例）和 0.9%（224 例中的 2 例）。PTI＞1.4、ETI＞1.7 和 DIS 用于确定终点的危险因素。30 天内无 ELs 和 9 例（3.5%）IBD 闭塞，需要 5 例再干预（2%）。PTI、ETI 或 DIS 均与闭塞无关，而髂外动脉的 IBD 过度扩张≥25% 与闭塞独立相关（比值比，4.3；95%置信区间[CI]，1-18.1；P=.045）。平均随访时间为 31±27 个月，随访期间发生 11 例 IBD 闭塞、14 例 ELs 和 21 例再干预。1、3 和 5 年的随访生存率、IBD 通畅率和 FFR 分别为 95%、89%和 80%、93%、91%和 90%、93%、89%和 83%。总体并发症（n=34；13.3%）和再干预（n=26；10.2%）的危险因素是 ETI＞1.7（P=.037 和 P=.019）、PTI＞1.4（P=.016 和 P=.012）和 Ib 型 EL 为适应证（P=.025 和 P=.001）。Cox 回归证实 PTI＞1.4 是总体并发症和再干预的独立预测因素（危险比[HR]，2.3；95%CI，1.1-4.4；P=.018；和 HR，3.95%CI，1.3-6.8；P=.018），ETI＞1.7 是 ELs 的独立危险因素（HR 6；95%CI，2.1-17.5；P=.001）。PTI＞1.4 时，3 年时的并发症和 FFR 显著降低（73% vs 92%[对数秩 P=.01]和 77% vs 93%[对数秩 P=.001]）。
我们发现 IBD 在治疗腹主动脉瘤方面是安全有效的。早期并发症罕见，与本研究中支架内过度扩张有关，而与解剖特征无关。髂内动脉迂曲是总体并发症和再干预的危险因素，特别是与 IBD 相关的 ELs。
