Suzuki Takahiro, Mitsuoka Hiroshi, Terai Yasuhiko, Miyano Yuta
Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan.
Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan.
Ann Vasc Surg. 2024 Dec;109:47-54. doi: 10.1016/j.avsg.2024.06.029. Epub 2024 Jul 17.
Variations in sac shrinkage (SS) are noted between endovascular aneurysm repair for abdominal aortic aneurysm (AAA) and fenestrated endovascular aneurysm repair for short neck AAA. These variations may originate from difference in the geometry and length of proximal sealing, which influences the quality and durability of the seal. This study aimed to explore the disparities in aneurysm exclusion and sac remodeling across these 2 scenarios.
This study involved a retrospective analysis of prospectively collected data from 2014 to 2021. Of 486 endovascular abdominal aortic repair cases, 33 that exclusively used a low permeability expanded polytetrafluoroethylene infrarenal device, strictly adhering to the instructions for use (IFUs), were selected. Concurrently, 30 cases of fenestrated repair that utilized modified polyester woven fabric devices proximally with consistent use of the aforementioned low-permeability devices infrarenally were examined. The quality of both proximal and distal sealing zones in fenestrated repairs was maintained within the range specified in the expanded polytetrafluoroethylene infrarenal device's IFUs, ensuring consistent sealing integrity for reliable group comparisons. Key metrics used for analysis were the detection of endoleaks and measurements of sac dimensions. Additional analyses included comparisons of demographic data and postoperative diameter changes in the proximal sealing zone (PZ) (encompassing 0, 5, 10, 15, and 20 mm below the most proximal sealing stent).
The demographic data and preoperative maximum-minimum diameter of the aneurysms did not differ between the groups. Proximal neck dilatation was similarly observed after both procedures. Immediately after the procedure, the incidence of lumbar arterial type II endoleaks was significantly lower after fenestrated repair than that after endovascular aortic repair (EVAR, 10% vs. 39.4%, P = 0.0094). At the final observation, EVAR substantially reduced the PZ length (-4.73 ± 15.30%), while fenestrated repair maintained the length (21.98 ± 24.34%; P < 0.0001). The preservation of the sealing length in fenestrated repairs was attributable to dilation occurring within the sealing range of the proximal device, oversized to accommodate the larger diameters in the more proximal sections of the aorta. The cumulative occurrence of SS (>5 mm) following fenestrated repair increased faster than that after endovascular repair (P = 0.002).
Although aortic neck dilatation progressed similarly in both groups, fenestrated repair maintained the sealing length and demonstrated a greater extent of SS, even under the challenging circumstances in PZ. The superior postoperative results were linked to both the durability of proximal sealing and a lower occurrence of lumbar arterial type II endoleaks, stemming from the effective shuttering of the collateral sources in the proximal lumbar or intercostal arteries.
腹主动脉瘤（AAA）的血管内动脉瘤修复术与短颈AAA的开窗血管内动脉瘤修复术之间存在囊袋收缩（SS）差异。这些差异可能源于近端密封的几何形状和长度不同，这会影响密封的质量和耐久性。本研究旨在探讨这两种情况下动脉瘤排除和囊袋重塑的差异。
本研究对2014年至2021年前瞻性收集的数据进行回顾性分析。在486例血管内腹主动脉修复病例中，选择了33例仅使用低渗透性膨体聚四氟乙烯肾下装置且严格遵循使用说明书（IFU）的病例。同时，检查了30例开窗修复病例，这些病例近端使用改良聚酯编织织物装置，肾下一致使用上述低渗透性装置。开窗修复中近端和远端密封区的质量保持在膨体聚四氟乙烯肾下装置IFU规定的范围内，确保密封完整性一致以进行可靠的组间比较。用于分析的关键指标是内漏的检测和囊袋尺寸的测量。额外的分析包括人口统计学数据比较以及近端密封区（PZ）（包括最近端密封支架下方0、5、10、15和20毫米处）术后直径变化。
两组间的人口统计学数据和术前动脉瘤最大 - 最小直径无差异。两种手术术后均同样观察到近端颈部扩张。术后即刻，开窗修复后腰动脉II型内漏的发生率显著低于血管内主动脉修复术（EVAR）（10%对39.4%，P = 0.0094）。在最后一次观察时，EVAR使PZ长度大幅缩短（-4.73 ± 15.30%），而开窗修复保持了该长度（21.98 ± 24.34%；P < 0.0001）。开窗修复中密封长度得以保留归因于近端装置密封范围内发生的扩张，该装置尺寸过大以适应主动脉更近端部分的更大直径。开窗修复后SS（>5毫米）的累积发生率比血管内修复后增加得更快（P = 0.002）。
尽管两组中主动脉颈部扩张进展相似，但开窗修复保持了密封长度，并且即使在PZ具有挑战性的情况下也表现出更大程度的SS。术后更好的结果与近端密封的耐久性以及腰动脉II型内漏发生率较低有关，这源于近端腰动脉或肋间动脉侧支来源的有效封堵。
