Bontinis Vangelis, Koutsoumpelis Andreas, Bontinis Alkis, Giannopoulos Argirios, Ktenidis Kiriakos
Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, 54621 Thessaloniki, Greece.
Rev Cardiovasc Med. 2022 Jun 1;23(6):208. doi: 10.31083/j.rcm2306208. eCollection 2022 Jun.
Type II endoleak (T2E), often generated by persistent retrograde flow through the inferior mesenteric artery (IMA) is the most frequent complication following endovascular aortic aneurysm repair (EVAR). T2E treatment revolves around transarterial and translumbar embolization of the feeding artery and/or sac, with mediocre results. The aim of this study is to assess the safety feasibility and efficacy of laparoscopic IMA ligation for the treatment of T2E.
We conducted a systematic electronic research on Medline, Scopus, EMBASE, and Cochrane Library according to Preferred Reporting Items for Systematic Review and Meta-Analysis protocol (PRISMA) for articles published up to February 2022, describing laparoscopic IMA ligation for the treatment of T2E. Publications describing hand assisted or prophylactic IMA ligation were excluded. A metanalysis was performed utilizing both the random and common effects model and the DerSimonian and Laird method. Additionally, we carried out a post hoc power analysis.
Fifteen studies, including one prospective case series (CS), five retrospective CS and nine case reports, including 33 patients (91% male) met the inclusion criteria. The mean abdominal aortic aneurysm diameter at the time of diagnosis was 58.8 mm. The mean operational duration was 117.5 minutes. The mean follow-up for the included studies was 17 months. The mean reported time of T2E identification was 9.1 months post-intervention, while the mean reported aneurysmal sac diameter increase at the time of diagnosis was 11.5 mm. T2E type a (T2aE) and type b (T2bE) patterns were 57.6% and 42.4% respectively. Six CS incorporating 24 patients were included in the meta-analysis. The pooled technical success and postoperative mortality rates are 100% (95% CI: 93.13-100), ( = 0.0%, = 0.99) (power = 99%) and 0.00% (95% CI: 0.00-6.87) ( = 0.0%, = 0.99). The pooled reintervention and conversion to open surgical repair rates are 15.08% (95% CI: 0.79-37.28), ( = 0.0%, = 0.66) (power = 13.6%), and 0.69% (95% CI: 0.00-14.80) ( = 0.0%, = 0.99) (power = 7.05%) respectively.
We demonstrated the safety and feasibility of IMA ligation for the treatment of T2E. Definitive conclusions about its efficacy cannot be drawn due to underpowered results warrantying further research. Identification and proper classification of T2E remain an obstacle affecting treatment outcomes and reintervention rates throughout the entire spectrum of available treatments.
II型内漏（T2E）通常由通过肠系膜下动脉（IMA）的持续性逆行血流产生，是血管内主动脉瘤修复术（EVAR）后最常见的并发症。T2E的治疗主要围绕经动脉和经腰动脉栓塞供血动脉和/或瘤腔，效果一般。本研究的目的是评估腹腔镜IMA结扎治疗T2E的安全性、可行性和有效性。
我们根据系统评价和Meta分析的首选报告项目（PRISMA），对截至2022年2月发表的关于腹腔镜IMA结扎治疗T2E的文章，在Medline、Scopus、EMBASE和Cochrane图书馆进行了系统的电子检索。排除描述手辅助或预防性IMA结扎的出版物。使用随机效应模型和固定效应模型以及DerSimonian和Laird方法进行Meta分析。此外，我们进行了事后功效分析。
15项研究，包括1项前瞻性病例系列（CS）、5项回顾性CS和9项病例报告，共33例患者（91%为男性）符合纳入标准。诊断时腹主动脉瘤的平均直径为58.8mm。平均手术时间为117.5分钟。纳入研究的平均随访时间为17个月。报告的T2E识别平均时间为干预后9.1个月，而诊断时报告的瘤腔直径平均增加为11.5mm。T2E a型（T2aE）和b型（T2bE）模式分别为57.6%和42.4%。Meta分析纳入了6项包含24例患者的CS。汇总的技术成功率和术后死亡率分别为100%（95%CI：93.13 - 100），（I² = 0.0%，P = 0.99）（功效 = 99%）和0.00%（95%CI：0.00 - 6.87）（I² = 0.0%，P = 0.99）。汇总的再次干预率和转为开放手术修复率分别为15.08%（95%CI：0.79 - 37.28），（I² = 0.0%，P = 0.66）（功效 = 13.6%）和0.69%（95%CI：0.00 - 14.80）（I² = 0.0%，P = 0.99）（功效 = 7.05%）。
我们证明了IMA结扎治疗T2E的安全性和可行性。由于结果的功效不足，无法得出关于其疗效的确切结论，需要进一步研究。T2E的识别和正确分类仍然是影响整个可用治疗范围内治疗结果和再次干预率的一个障碍。
