Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
Eur J Vasc Endovasc Surg. 2024 May;67(5):765-774. doi: 10.1016/j.ejvs.2023.10.016. Epub 2023 Oct 17.
This single centre, retrospective study (2014 - 2022) on juxta-, pararenal, or thoraco-abdominal aortic aneurysms treated by fenestrated endovascular aortic repair (FEVAR) was conducted to investigate the clinical impact and determinants of fenestration to target vessel misalignment in FEVAR.
Pre-operative supracoeliac, pararenal, and infrarenal aortic angles were measured on three dimensional computed tomography angiography (CTA) reconstructions. Two components of misalignment were measured on the first post-operative CTA: horizontal misalignment (angle between the fenestration and the target vessel ostium on perpendicular CTA cuts) and vertical misalignment (vertical distance between the fenestration and the target vessel at its origin). Endpoints were freedom from target vessel instability (TVI) and alignment change over time.
Of 65 patients treated by FEVAR, 60 (202 target arteries) with juxta-, pararenal (80%), or thoraco-abdominal aortic aneurysm (20%) were included. Mean horizontal misalignment was 9 ± 12° (median 5°; IQR 0 - 16) and mean vertical misalignment was 0.7 ± 1 mm (median 0 mm, IQR 0 - 1). Freedom from TVI was 92% (95% CI 88 - 98) at 36 months. Horizontal misalignment > 15° was significantly associated with TVI (HR 5.19; 95% CI 1.54 - 17.48; p = .008); vertical misalignment did not significantly impact TVI (HR 0.99; 95% CI 0.56 - 1.73; p = .97). By multivariable analysis, pararenal aortic angle (OR 1.01 per increased degree of angulation; 95% CI 1.00 - 1.02; p = .044), bridging distance > 5 mm (OR 1.07; 95% CI 1.02 - 1.11; p = .003), and use of higher profile endografts in tortuous iliac access (OR 7.55; 95% CI 4.55 - 1.11; p = .003) were associated with clinically significant misalignment. Bridging distance > 5 mm (OR 2.00; 95% CI 1.02 - 11.29; p = .044), degree of baseline misalignment (OR 1.04; 95% CI 1.01 - 1.08; p = .036), and persistence of any primary endoleak for > 6 months (OR 5.85; 95% CI 1.23 - 29.1; p = .023) were associated with misalignment increase during follow up.
Horizontal misalignment > 15° is associated with worsened target vessel outcomes. This may occur as a result of excessive iliac access tortuosity, high pararenal aortic angulation, and bridging distance > 5 mm.
本研究回顾性分析了 2014 年至 2022 年间接受开窗腔内修复术（fenestrated endovascular aortic repair，FEVAR）治疗的肾周、胸腹主动脉瘤患者，旨在探讨 FEVAR 中开窗至目标血管吻合口的对位不良的临床影响和决定因素。
在三维计算机断层血管造影术（CTA）重建中测量肾上、肾周和肾下主动脉角。在术后首次 CTA 上测量两个对位不良的指标：水平对位不良（在垂直 CTA 切面上测量的开窗与目标血管口之间的角度）和垂直对位不良（在目标血管起源处测量的开窗与目标血管之间的垂直距离）。终点为目标血管不稳定（target vessel instability，TVI）和对位不良的随时间变化。
65 例接受 FEVAR 治疗的患者中，60 例（202 个目标血管）接受了肾周（80%）、胸腹主动脉瘤（20%）治疗，纳入研究。平均水平对位不良为 9 ± 12°（中位数 5°；IQR 0-16），平均垂直对位不良为 0.7 ± 1 mm（中位数 0 mm，IQR 0-1）。术后 36 个月时，TVI 的无事件率为 92%（95%CI 88-98）。水平对位不良>15°与 TVI 显著相关（HR 5.19；95%CI 1.54-17.48；p=0.008）；垂直对位不良与 TVI 无显著相关性（HR 0.99；95%CI 0.56-1.73；p=0.97）。多变量分析显示，肾周主动脉角（每增加 1°的 OR 为 1.01；95%CI 1.00-1.02；p=0.044）、桥接距离>5 mm（OR 1.07；95%CI 1.02-1.11；p=0.003）和在迂曲的髂内动脉入路中使用更大口径的内支架（OR 7.55；95%CI 4.55-1.11；p=0.003）与临床显著对位不良相关。桥接距离>5 mm（OR 2.00；95%CI 1.02-11.29；p=0.044）、基线对位不良程度（OR 1.04；95%CI 1.01-1.08；p=0.036）和>6 个月的任何原发性内漏持续存在（OR 5.85；95%CI 1.23-29.1；p=0.023）与随访期间对位不良的增加相关。
水平对位不良>15°与目标血管预后恶化相关。这可能是由于髂内动脉入路迂曲、肾周主动脉角较高和桥接距离>5 mm所致。
