Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy; Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy.
Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy; Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy.
J Vasc Surg. 2024 Nov;80(5):1336-1349.e4. doi: 10.1016/j.jvs.2024.07.005. Epub 2024 Jul 9.
To report outcomes of urgent juxtarenal/pararenal aneurysms (J/P-AAAs) managed by off-the-shelf multibranched thoracoabdominal endografts (Cook, T-branch).
In this observational, multicenter, retrospective study, patients with J/P-AAAs treated by urgent endovascular repair by T-branch in 23 European aortic centers, from 2013 to 2023, were analyzed. Contained J/P-AAAs rupture, presence of related symptoms, and aneurysm diameter of >70 mm were considered as indication for urgent repair. Technical success (TS), spinal cord ischemia (SCI), and 30-day/hospital mortality were assessed as early outcomes. Survival, freedom from reinterventions, and target artery instability (TAI) were evaluated during follow-up.
Overall, 197 patients (J-AAAs, n = 64 [33%]; P-AAAs, n = 95 [48%]; previous failed endovascular aneurysm repair (EVAR), n = 38 [19%]) were analyzed. The mean age and aneurysm diameter was 75 ± 8 years and 76 ± 4 mm, respectively. The American Society of Anesthesiologists score was 3 and 4 in 118 (60%) and 79 (40%) patients. Rupture, symptoms, and diameter of >70 mm were present in 51 (26%), 110 (56%), and 53 (27%) patients, respectively. An adjunctive proximal thoracic endograft was used in 28 cases (14%). The mean aortic coverage between the upper portion of the endograft and the lowest renal artery was 154 ± 49 mm. Single-stage repair and cerebrospinal fluid drainage were reported in 144 (73%) and 53 (27%) cases, respectively. TS was achieved in 182 (92%) cases (rupture, 84% vs no rupture, 95%; P = .02). Failures consist of TA loss (11 [6%]: renal artery, 9; celiac trunk, 2), type I to III endoleaks (2 [1%]), and 24-h mortality (2 [1%]). Rupture was a risk factor for technical failure (P = .02; odds ratio [OR], 3.8; 95% confidence interval [CI], 1.1-12.1). Overall, 15 patients (8%) had persistent SCI (rupture, 14% vs no rupture, 5%) with 11 (6%) , of paraplegia (rupture, 10% vs no rupture, 5%; P = .001). Rupture (P = .04; OR, 3.1; 95% CI, 1.1-8.9) and adjunctive proximal thoracic endograft (P = .01; OR, 4.1; 95% CI, 1.3-12.9) were risk-factors for SCI. Twenty-two patients (11%) died within 30 days or during a prolonged hospitalization. Previous failed EVAR (P = .04; OR, 3.6; 95% CI, 1.1-12.3), paraplegia (P < .001; OR, 9.9; 95% CI, 1.6-62.2) and postoperative mesenteric complications (P = .03; OR, 10.4; 95% CI, 1.2-93.3), as well as cardiac (P = .03; OR, 8.2; 95% CI, 2.0-33.0) and respiratory (P < .001; OR, 10.1; 95% CI, 2.9-35.2) morbidities were associated with 30-day/hospital mortality. The mean follow-up was 19 ± 5 months. The estimated 3-year survival and freedom from reinterventions was 58% and 77%, respectively. TAI occurred in 27 patients (14%) (occlusion, 15; endoleak, 14) with an estimated 3-year freedom from TAI of 72%.
Urgent repair of J/P-AAAs by T-branch is feasible and effective with satisfactory TS and 30-day/hospital mortality in high-risk patients. However, extensive aortic coverage is necessary, leading to a non-negligible SCI rate, especially in case of aortic rupture or when adjunctive thoracic endografts are necessary. Previous failed EVAR and postoperative mesenteric complications, as well as cardiac and respiratory morbidities were associated with 30-day/hospital mortality and should be subjected to more research for the purposes of improving outcomes.
报告使用现成的多分支胸腹主动脉腔内移植物（Cook，T 型分支）治疗紧急肾周/肾旁动脉瘤（J/P-AAA）的结果。
在这项观察性、多中心、回顾性研究中，分析了 2013 年至 2023 年期间，23 个欧洲主动脉中心的 T 型分支紧急腔内修复治疗的 J/P-AAA 患者。包含 J/P-AAA 破裂、存在相关症状和动脉瘤直径>70mm 被认为是紧急修复的指征。评估技术成功率（TS）、脊髓缺血（SCI）和 30 天/住院死亡率作为早期结果。在随访期间评估生存率、免于再次干预和目标动脉不稳定（TAI）。
共有 197 例患者（J-AAA，n=64[33%]；P-AAA，n=95[48%]；先前失败的血管内动脉瘤修复（EVAR），n=38[19%]）被纳入分析。平均年龄和动脉瘤直径分别为 75±8 岁和 76±4mm。美国麻醉医师协会评分 3 分和 4 分的患者分别为 118 例（60%）和 79 例（40%）。破裂、症状和直径>70mm 的患者分别为 51 例（26%）、110 例（56%）和 53 例（27%）。28 例患者使用了辅助近端胸主动脉内支架。移植物上缘与最低肾动脉之间的平均主动脉覆盖长度为 154±49mm。144 例（73%）患者进行了单阶段修复，53 例（27%）患者进行了脑脊液引流。182 例（92%）患者达到了 TS（破裂患者为 84%，无破裂患者为 95%；P=0.02）。失败的原因包括 TA 丢失（11 例[6%]：肾动脉 9 例，腹腔干 2 例）、I 型至 III 型内漏（2 例[1%]）和 24 小时死亡率（2 例[1%]）。破裂是技术失败的危险因素（P=0.02；优势比[OR]，3.8；95%置信区间[CI]，1.1-12.1）。总体上，15 例（8%）患者持续存在 SCI（破裂患者为 14%，无破裂患者为 5%），其中 11 例（6%）为截瘫（破裂患者为 10%，无破裂患者为 5%；P=0.001）。破裂（P=0.04；OR，3.1；95%CI，1.1-8.9）和辅助近端胸主动脉内支架（P=0.01；OR，4.1；95%CI，1.3-12.9）是 SCI 的危险因素。22 例（11%）患者在 30 天内或住院期间死亡。先前失败的 EVAR（P=0.04；OR，3.6；95%CI，1.1-12.3）、截瘫（P<0.001；OR，9.9；95%CI，1.6-62.2）和术后肠系膜并发症（P=0.03；OR，10.4；95%CI，1.2-93.3）以及心脏并发症（P=0.03；OR，8.2；95%CI，2.0-33.0）和呼吸并发症（P<0.001；OR，10.1；95%CI，2.9-35.2）与 30 天/住院死亡率相关。平均随访时间为 19±5 个月。估计 3 年生存率和免于再次干预的生存率分别为 58%和 77%。27 例（14%）患者发生 TAI（闭塞 15 例；内漏 14 例），估计 3 年 TAI 无事件生存率为 72%。
使用 T 型分支紧急修复 J/P-AAA 在高危患者中是可行且有效的，具有令人满意的 TS 和 30 天/住院死亡率。然而，需要广泛的主动脉覆盖，导致 SCI 发生率不可忽视，尤其是在主动脉破裂或需要辅助性胸主动脉内支架的情况下。先前失败的 EVAR 和术后肠系膜并发症以及心脏和呼吸并发症与 30 天/住院死亡率相关，应进一步研究这些因素，以改善预后。
