Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA; Baystate Vascular Services, University of Massachusetts Chan Medical School, Baystate Campus, Springfield, MA.
Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA.
J Vasc Surg. 2023 Jul;78(1):29-37. doi: 10.1016/j.jvs.2023.02.016. Epub 2023 Mar 6.
Endoleaks are more common after fenestrated/branched endovascular aneurysm repair (F/B-EVAR) than infrarenal EVAR secondary to the length of aortic coverage and number of component junctions. Although reports have focused on type I and III endoleaks, less is known regarding type II endoleaks after F/B-EVAR. We hypothesized that type II endoleaks would be common and often complex (associated with additional endoleak types), given the potential for multiple inflow and outflow sources. We sought to describe the incidence and complexity of type II endoleaks after F/B-EVAR.
F/B-EVAR data prospectively collected at a single institution in an investigational device exemption clinical trial (G130210) were retrospectively analyzed (2014-2021). Endoleaks were characterized by type, time to detection, and management. Primary endoleaks were defined as those present on completion imaging or at first postoperative imaging, and secondary were those on subsequent imaging. Recurrent endoleaks were those that developed after a successfully resolved endoleak. Reinterventions were considered for type I or III endoleaks or any endoleak associated with sac growth >5 mm. Technical success defined as the absence of flow in the aneurysm sac at procedure conclusion and methods of intervention were captured.
Among 335 consecutive F/B-EVARs (mean ± standard deviation follow-up: 2.5 ± 1.5 years), 125 patients (37%) experienced 166 endoleaks (81 primary, 72 secondary, and 13 recurrent). Of these 125 patients, 50 (40% of patients) underwent 71 interventions for 60 endoleaks. Type II endoleaks were the most frequent (n = 100, 60%), with 20 identified during the index procedure, 12 (60%) of which resolved before 30-day follow-up. Of the 100 type II endoleaks, 20 (20%; 12 primary, 5 secondary, and 3 recurrent) were associated with sac growth; 15 (75%) of those with associated sac growth underwent intervention. At intervention, 6 (40%) were reclassified as complex, with a concomitant type I or type III endoleak. Initial technical success for endoleak treatment was 96% (68 of 71). There were 13 recurrences, all of which were associated with complex endoleaks.
Nearly half of the patients who underwent F/B-EVAR experienced an endoleak. The majority were classified as type II, with nearly a fifth associated with sac expansion. Interventions for a type II endoleak frequently led to reclassification as complex, with a concomitant type I or III endoleak not appreciated on computed tomography angiography and/or duplex. Further study is needed to determine if the primary treatment goal for complex aneurysm repair is sac stability or sac regression, as this would inform both the importance of properly classifying endoleaks noninvasively and the intervention threshold for managing type II endoleaks.
与肾下型腹主动脉瘤腔内修复术（EVAR）相比，开窗/分支型 EVAR 后更常见Ⅰ型和Ⅲ型内漏，这是由于主动脉覆盖长度和组件连接处数量增加所致。虽然已有研究报告集中于Ⅰ型和Ⅲ型内漏，但对于开窗/分支型 EVAR 后Ⅱ型内漏的研究则较少。我们假设，由于可能存在多个流入和流出源，因此Ⅱ型内漏会更常见，且往往更复杂（与其他内漏类型相关联）。我们旨在描述开窗/分支型 EVAR 后Ⅱ型内漏的发生率和复杂性。
我们回顾性分析了在一家机构前瞻性收集的用于研究性器械豁免临床试验（G130210）的开窗/分支型 EVAR 数据（2014 年至 2021 年）。内漏通过类型、检测时间和处理方法进行特征描述。主要内漏是指在完成影像检查或术后首次影像检查时存在的内漏，而次要内漏是指在后续影像检查中存在的内漏。复发性内漏是指成功解决的内漏后再次出现的内漏。对于Ⅰ型或Ⅲ型内漏或任何与囊腔生长>5mm 相关的内漏，考虑进行再次干预。将术中无动脉瘤囊内血流作为技术成功的定义，并记录干预方法。
在 335 例连续接受开窗/分支型 EVAR 的患者中（平均±标准差随访时间：2.5±1.5 年），125 例患者（37%）经历了 166 例内漏（81 例为原发性，72 例为继发性，13 例为复发性）。在这 125 例患者中，50 例（40%的患者）因 60 例内漏接受了 71 次干预。Ⅱ型内漏最为常见（n=100，60%），其中 20 例在指数手术期间发现，12 例（60%）在 30 天随访前得到解决。在 100 例Ⅱ型内漏中，20 例（20%；12 例原发性，5 例继发性，3 例复发性）与囊腔生长相关；其中 15 例（75%）与囊腔生长相关的内漏接受了干预。在干预时，6 例（40%）被重新分类为复杂型，同时伴有Ⅰ型或Ⅲ型内漏。内漏治疗的初始技术成功率为 96%（71 例中的 68 例）。有 13 例复发，均与复杂型内漏有关。
近一半接受开窗/分支型 EVAR 的患者经历了内漏。大多数被归类为Ⅱ型，其中近五分之一与囊腔扩张有关。针对Ⅱ型内漏的干预措施通常会导致重新分类为复杂型，同时伴有 CT 血管造影和/或双功能超声检查未发现的Ⅰ型或Ⅲ型内漏。需要进一步研究以确定复杂型动脉瘤修复的主要治疗目标是囊腔稳定还是囊腔消退，因为这将影响对内漏进行无创分类的重要性以及处理Ⅱ型内漏的干预阈值。
