Wang Jizhong, Hu Xiaolu, Liu Jie, Liu Jitao, Li Ting, Huang Jing, Yang Yi, Fan Ruixin, Yang Fan, Luo Songyuan, Li Jie, Chen Zhengbo, Luo Jianfang
School of Medicine, South China University of Technology, Guangzhou, China.
Department of Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China.
J Endovasc Ther. 2024 May 28:15266028241255549. doi: 10.1177/15266028241255549.
BACKGROUND: Secondary aortic intervention (SAI) following thoracic endovascular aortic repair (TEVAR) is not uncommon. However, a satisfactory management system has not been established for these patients. We aimed to report our single-center experience with SAI after prior TEVAR for type B aortic dissection (TBAD). METHODS: From January 2010 to May 2017, 860 eligible patients with TBAD underwent TEVAR. One hundred seven (12.4%) patients required SAI, either endovascularly (n=76) or surgically (n=31). The main indications for SAI were entry flow (n=58 [54.2%]), aneurysm expansion of the proximal or remote aorta (n=26 [24.3%]), retrograde type A aortic dissection (n=11 [10.3%]), distal stent-graft-induced new entry tear (n=6 [5.6%]), and stent migration (n=4 [3.7%]). The Kaplan-Meier curves were generated to determine the degree of freedom from SAI and the prognosis. Cox proportional hazards were used to screen for risk factors for SAI and poor prognosis. RESULTS: The overall 30-day mortality rate after SAI was 4.7% (n=5): endovascular (n=2 [2.6%]) vs open surgery (n=3 [9.7%]; p=0.145). The cumulative survival rates with or without SAI were 86.3%±3.6% vs 95.7%±0.8% at 3 years and 82.0%±4.2% vs 92.2%±1.1% at 5 years, respectively (log-rank p<0.001). Although no significant difference in survival was observed, the incidence of SAI was significantly greater in patients who underwent TEVAR during the chronic phase (acute [11.6%] vs subacute [9.6%] vs chronic [27.8]; p<0.001). Multivariate regression analysis revealed that prior TEVAR in the chronic phase (hazard ratio [HR]=1.73, 95% confidence interval [CI]=1.03-2.90; p=0.039), maximum aortic diameter (HR=1.05, 95% CI=1.04-1.07; p<0.001), and arch involvement (HR=1.48, 95% CI=1.01-2.18; p=0.048) were predictors of the incidence of SAI. In addition, the maximum aortic diameter was demonstrated to be the only risk factor for prognosis after adjusting for confounding factors. CONCLUSIONS: Thoracic endovascular aortic repair for chronic TBAD patients should be reconsidered. Open surgery is preferable for those with proximal progression, whereas endovascular treatment is more suitable for distal lesions. Close surveillance and timely reintervention after TEVAR, whether via endovascular techniques or open surgery, are necessary to prevent devastating complications. CLINICAL IMPACT: The management of patients with type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR) is challenging. We summarized our single-center experience regarding secondary aortic intervention after TEVAR for TBAD. We found that TEVAR for chronic TBAD patients should be carefully evaulated, and open surgery is recommended for those with proximal progession, while endovascular treatment is more preferable for distal lesions.
背景：胸主动脉腔内修复术（TEVAR）后进行二次主动脉干预（SAI）并不罕见。然而，尚未为这些患者建立令人满意的管理系统。我们旨在报告我们单中心对于B型主动脉夹层（TBAD）患者在先前TEVAR术后进行SAI的经验。 方法：2010年1月至2017年5月，860例符合条件的TBAD患者接受了TEVAR。107例（12.4%）患者需要进行SAI，其中血管腔内治疗（n = 76）或外科手术（n = 31）。SAI的主要指征为入口血流（n = 58 [54.2%]）、近端或远端主动脉瘤扩张（n = 26 [24.3%]）、逆行性A型主动脉夹层（n = 11 [10.3%]）、远端覆膜支架引起的新入口撕裂（n = 6 [5.6%]）和支架移位（n = 4 [3.7%]）。绘制Kaplan-Meier曲线以确定无SAI的自由度和预后情况。使用Cox比例风险模型筛选SAI和预后不良的危险因素。 结果：SAI术后30天总体死亡率为4.7%（n = 5）：血管腔内治疗（n = 2 [2.6%]）与开放手术（n = 3 [9.7%]；p = 0.145）。有或无SAI的累积生存率在3年时分别为86.3%±3.6%和95.7%±0.8%，在5年时分别为82.0%±4.2%和92.2%±1.1%（对数秩检验p<0.001）。虽然在生存率方面未观察到显著差异，但在慢性期接受TEVAR的患者中SAI的发生率显著更高（急性期[11.6%] vs亚急性期[9.6%] vs慢性期[27.8%]；p<0.001）。多变量回归分析显示，慢性期先前的TEVAR（风险比[HR]=1.73，95%置信区间[CI]=1.03 - 2.90；p = 0.039）、最大主动脉直径（HR = 1.05，95% CI = 1.04 - 1.07；p<0.001）和弓部受累（HR = 1.48，95% CI = 1.01 - 2.18；p = 0.048）是SAI发生率的预测因素。此外，在调整混杂因素后，最大主动脉直径被证明是预后的唯一危险因素。 结论：对于慢性TBAD患者的胸主动脉腔内修复术应重新考虑。对于近端进展的患者，开放手术更可取，而血管腔内治疗更适合远端病变。TEVAR术后，无论是通过血管腔内技术还是开放手术，密切监测和及时再次干预对于预防灾难性并发症是必要的。 临床影响：胸主动脉腔内修复术（TEVAR）后B型主动脉夹层（TBAD）患者的管理具有挑战性。我们总结了我们单中心关于TEVAR术后TBAD二次主动脉干预的经验。我们发现对于慢性TBAD患者的TEVAR应仔细评估，对于近端进展的患者建议采用开放手术，而对于远端病变血管腔内治疗更可取。
Ann Thorac Surg. 2019-11-27
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