Gallitto Enrico, Faggioli Gian Luca, Campana Federica, Feroldi Francesca Maria, Cappiello Antonio, Caputo Stefania, Pini Rodolfo, Gargiulo Mauro
Vascular Surgery, University of Bologna, Bologna, Italy; Vascular Surgery, IRCCS, Sant'Orsola Malpighi, Bologna, Italy.
Vascular Surgery, University of Bologna, Bologna, Italy; Vascular Surgery, IRCCS, Sant'Orsola Malpighi, Bologna, Italy.
J Vasc Surg. 2024 Jun;79(6):1295-1304.e2. doi: 10.1016/j.jvs.2024.01.197. Epub 2024 Jan 26.
Persistent type II endoleaks (pEL2s) are not uncommon after endovascular aneurysm repair and their impact on long-term outcomes is well-documented. However, their occurrence and natural history after fenestrated/branched endografting (F/B-EVAR) for juxtarenal and pararenal aneurysms (J/P-AAAs) have been scarcely investigated. Aim of this study was to report incidence, risk factors, and natural history of pEL2 after F/B-EVAR in J/P-AAAs.
Between 2016 and 2022, all J/P-AAAs undergoing F/B-EVAR were prospectively collected and retrospectively analyzed. EL2 were assessed at the completion angiography, at 30 days and after 6 months as primary outcomes. Preoperative risk factors for pEL2, follow-up survival, freedom from reinterventions (FFR) and aneurysm shrinkage (≥5 mm) were considered as secondary outcomes.
Of 132 patients, there were 88 (67%) JAAAs and 44 (33%) PAAAs. Seventeen EL2 (13%) were detected at the completion angiography and 36 (27%) at 30-day computed tomography angiography. The mean follow-up was 28 ± 23 months. Eleven (31%) EL2 sealed spontaneously within 6 months and three new cases were detected, for an overall of 28 pEL2/107 patients (26%) with available radiological follow-up of ≥6 months. Preoperative antiplatelet therapy (odds ratio, 4.7; 95% confidence interval [CI[, 1-22.1; P = .05), aneurysm thrombus volume of ≤40% and six or more patent aneurysm afferent vessels (odds ratio, 7.2; 95% CI, 1.8-29.1; P = .005) were independent risk factors for pEL2. The estimated 3-year survival was 80%, with no difference between cases with and without pEL2 (78% vs 85%; P = .08). The estimated 3-year FFR was 86%, with no difference between cases with and without pEL2 (81% vs 87%; P = .41). Four cases (3%) of EL2-related reinterventions were performed. In 65 cases (49%), aneurysm shrinkage was detected. pEL2 was an independent risk factor for absence of aneurysm shrinkage during follow-up (hazard ratio, 3.2; 95% CI, 1.2-8.3; P = .014). Patients without shrinkage had lower follow-up survival (64% vs 86% at 3-year; P = .009) and FFR (74% vs 90% at 3 years; P = .014) than patients with shrinkage.
PEL2 is not infrequent (26%) after F/B-EVAR for J/P-AAAs and is correlated with preoperative antiplatelet therapy, aneurysm thrombus volume of ≤40%, and six or more patent sac afferent vessels. Patients with pEL2 have a diminished aneurysm shrinkage, which is correlated with lower follow-up survival and FFR compared with patients with aneurysm shrinkage.
持续性Ⅱ型内漏（pEL2）在血管内动脉瘤修复术后并不少见，其对长期预后的影响已有充分记录。然而，关于开窗/分支型腔内移植物置入术（F/B-EVAR）治疗近肾和肾旁动脉瘤（J/P-AAAs）后pEL2的发生情况及自然病程，鲜有研究。本研究旨在报告J/P-AAAs行F/B-EVAR术后pEL2的发生率、危险因素及自然病程。
2016年至2022年期间，前瞻性收集并回顾性分析所有接受F/B-EVAR治疗的J/P-AAAs患者。将血管造影完成时、术后30天及6个月时评估的EL2作为主要观察指标。将pEL2的术前危险因素、随访生存率、无再次干预生存期（FFR）及动脉瘤缩小（≥5 mm）作为次要观察指标。
132例患者中，有88例（67%）为近肾动脉瘤（JAAAs），44例（33%）为肾旁动脉瘤（PAAAs）。血管造影完成时检测到17例EL2（13%），术后30天计算机断层扫描血管造影检测到36例（27%）。平均随访时间为28±23个月。11例（31%）EL2在6个月内自发闭合，另外检测到3例新病例，共有28例pEL2/107例有≥6个月有效影像学随访的患者（26%）。术前抗血小板治疗（比值比，4.7；95%置信区间[CI]，1-22.1；P = .05）、动脉瘤血栓体积≤40%以及六条或更多条动脉瘤输入血管通畅（比值比，7.2；95%CI，1.8-29.1；P = .005）是pEL2的独立危险因素。估计3年生存率为80%，有pEL2和无pEL2的病例之间无差异（78%对85%；P = .08）。估计3年FFR为86%，有pEL2和无pEL2的病例之间无差异（81%对87%；P = .41）。进行了4例（3%）与EL2相关的再次干预。65例（49%）患者检测到动脉瘤缩小。pEL2是随访期间动脉瘤未缩小的独立危险因素（风险比，3.2；95%CI，1.2-8.3；P = .014）。未出现缩小的患者随访生存率（3年时为64%对86%；P = .009）和FFR（3年时为74%对90%；P = .014）低于出现缩小的患者。
J/P-AAAs行F/B-EVAR术后pEL2并不罕见（26%），且与术前抗血小板治疗、动脉瘤血栓体积≤40%以及六条或更多条瘤腔输入血管通畅相关。有pEL2的患者动脉瘤缩小程度减小，与动脉瘤缩小的患者相比，其随访生存率和FFR较低。
