Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN; Mayo Clinic Center for Aortic Disorders, Mayo Clinic, Rochester, MN.
J Vasc Surg. 2023 Oct;78(4):874-882. doi: 10.1016/j.jvs.2023.05.049. Epub 2023 Jun 7.
Staged endovascular repair of complex aortic aneurysms with first-stage thoracic endovascular aortic repair may decrease the risk of spinal cord ischemia (SCI) associated with fenestrated-branched endovascular aortic repair (FB-EVAR) of thoracoabdominal aortic aneurysms or optimize the proximal landing zone in the cases requiring total aortic arch repair. However, a limitation of multistaged procedures is the risk of interval aortic events (IAEs) including mortality from a ruptured aneurysm. We aim to identify the incidence of and risk factors associated with IAEs during staged FB-EVAR.
This was a single-center, retrospective review of patients who underwent planned staged FB-EVAR from 2013 to 2021. Clinical and procedural details were reviewed. End points were the incidence of and risk factors associated with IAEs (defined as rupture, symptoms, and unexplained death) and outcomes in patients with or without IAEs.
Of 591 planned FB-EVAR patients, 142 underwent first-stage repairs. Twenty-two did not have a planned second stage because of frailty, preference, severe comorbidities, or complications after the first stage and were excluded. The remaining 120 patients (mean age: 73 ± 6 years, 51% female) were planned for second-stage completion FB-EVAR and comprised our cohort. The incidence of IAEs was 13% (16 of 120). This included confirmed rupture in 6 patients, possible rupture in 4, symptomatic presentation in 4, and early unexplained interval death with possible rupture in 2. The median time to IAEs was 17 days (range: 2-101 days), and the median time to uncomplicated completion repairs was 82 days (interquartile range: 30-147 days). Age, sex, and comorbidities were similar between the groups. There were no differences in familial aortic disease, genetically triggered aneurysms, aneurysm extent, or presence of chronic dissection. Patients with IAEs had significantly larger aneurysm diameters than those without IAEs (76.6 vs 66.5 mm, P ≤ .001). This difference persisted with indexing for body surface area (aortic size index: 3.9 vs 3.5 cm/m, P = .04) and height (aortic height index: 4.5 vs 3.9 cm/m, P ≤ .001). IAE mortality was 69% (11 of 16) compared with no perioperative deaths for those with uncomplicated completion repairs.
The incidence of IAEs was 13% in patients planned for staged FB-EVAR. This represented a notable morbidity, including rupture, which must be balanced with SCI and landing zone optimization when planning repair. Larger aneurysms, especially when adjusted for body surface area, are associated with IAEs. Minimizing time between stages vs single-stage repairs for larger (>7 cm) complex aortic aneurysms in patients with reasonable SCI risk should be considered when planning repair.
分期血管内修复复杂主动脉瘤，一期行胸主动脉腔内修复术（TEVAR），可能降低开窗分支腔内主动脉修复术（FB-EVAR）治疗胸腹主动脉瘤时脊髓缺血（SCI）的风险，或优化需要全主动脉弓修复的病例近端着陆区。然而，多阶段手术的一个局限性是间隔期主动脉事件（IAE）的风险，包括破裂动脉瘤导致的死亡率。我们旨在确定分期 FB-EVAR 期间 IAE 的发生率和相关风险因素。
这是一项回顾性研究，回顾了 2013 年至 2021 年期间在我院接受计划分期 FB-EVAR 的患者。回顾了临床和手术细节。终点是患者发生 IAE（定义为破裂、症状和不明原因死亡）的发生率和相关风险因素，以及有无 IAE 的患者的结局。
在 591 例计划行 FB-EVAR 的患者中，142 例行一期修复。由于虚弱、偏好、严重合并症或一期手术后并发症，22 例患者未行二期计划修复，并被排除在外。其余 120 例（平均年龄：73±6 岁，51%为女性）计划行二期完成 FB-EVAR，构成了我们的研究队列。IAE 的发生率为 13%（16/120）。这包括 6 例经证实的破裂、4 例可能破裂、4 例有症状表现、2 例早期不明原因间隔期死亡伴可能破裂。IAE 的中位时间为 17 天（范围：2-101 天），无并发症的完成修复中位时间为 82 天（四分位距：30-147 天）。两组的年龄、性别和合并症相似。家族性主动脉疾病、遗传性动脉瘤、动脉瘤范围和慢性夹层的存在无差异。发生 IAE 的患者的动脉瘤直径明显大于无 IAE 的患者（76.6 与 66.5mm，P≤0.001）。这种差异在按体表面积（主动脉大小指数：3.9 与 3.5cm/m，P=0.04）和身高（主动脉高度指数：4.5 与 3.9cm/m，P≤0.001）校正后仍然存在。IAE 死亡率为 69%（16 例中有 11 例），而无并发症完成修复的患者围手术期无死亡。
分期 FB-EVAR 患者的 IAE 发生率为 13%。这是一种显著的发病率，包括破裂，在计划修复时必须权衡 SCI 和着陆区优化。较大的动脉瘤，特别是按体表面积校正时，与 IAE 相关。对于具有合理 SCI 风险的较大（>7cm）复杂主动脉瘤患者，应考虑在分期之间的时间间隔与单阶段修复之间取得平衡，以规划修复。
