Porez Florent, Fabre Dominique, Maurel Blandine, Gaudin Antoine, Costanzo Alessandro, Tyrrell Mark R, Le Houérou Thomas, Haulon Stéphan
Department of Vascular Surgery, Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, INSERM UMR_S 999, Université Paris Saclay, Le Plessis-Robinson, France.
Vascular and Endovascular Surgery, Hôpital Nord Laennec, Nantes, France.
J Vasc Surg. 2025 Feb;81(2):300-307. doi: 10.1016/j.jvs.2024.09.033. Epub 2024 Oct 3.
We present a review of our hybrid management (endovascular + open surgery) of large thoracic aortic aneurysms (>80 mm). The strategy comprises a primary endovascular repair using thoracic endovascular aortic repair (TEVAR), and/or fenestrated and branched endografts (FBEVAR), followed by open thoracotomy and aneurysmorraphy, specifically without the need for aortic cross-clamping.
We performed a retrospective review of all patients who had undergone aneurysmorraphy via thoracotomy following TEVAR and FBEVAR in two high-volume aortic centers between December 2017 and March 2024. We performed aneurysmorraphy in two clinical situations: (1) in the setting of a planned staged treatment, shortly after TEVAR or FBEVAR in young patients with aneurysm diameter >100 mm; and (2) as a secondary intervention during follow-up for patients with persistent sac enlargement and aneurysm diameters >80 mm. The primary end points were 30-day survival and aneurysm-related mortality during follow-up. Secondary endpoints were sac size evolution, perioperative and postoperative complications, freedom from further reintervention, and late aortic complications.
Twelve patients underwent aneurysmorraphy following TEVAR and/or FBEVAR during the study period. Mean patient age was 60 ± 12 years, and the mean sac diameter before thoracotomy was 101 ± 25 mm. Endovascular embolization of intercostal arteries prior to aneurysmorraphy was performed in four patients. The 30-day survival rate was 100%. During the mean follow up period of 21 months, two patients died-one of COVID and another of intra-cerebral hemorrhage. No aneurysm-related mortality occurred, and sac regression was achieved in all patients except one experiencing aortic growth below the aneurysmorraphy.
This study demonstrates that thoracic aneurysmorraphy performed after TEVAR and FBEVAR for complex thoracic aneurysms is a safe and effective technique. This procedure allows the eradication of endoleaks and an immediate sac volume reduction, which prevents aorta-bronchial or esophageal fistulation and secures the endovascular repair; the reduction of the aneurysm mass effect restores normal lung parenchyma expansion. This hybrid management strategy drastically reduces the morbidity associated with standard open surgery performed for thoracic endograft explantation.
我们对大胸主动脉瘤（>80mm）的杂交治疗（血管内治疗+开放手术）进行综述。该策略包括使用胸主动脉腔内修复术（TEVAR）和/或开窗及分支型腔内移植物（FBEVAR）进行一期血管内修复，随后行开胸手术和动脉瘤修补术，特别是无需主动脉阻断。
我们对2017年12月至2024年3月期间在两个高容量主动脉中心接受TEVAR和FBEVAR后经开胸进行动脉瘤修补术的所有患者进行了回顾性研究。我们在两种临床情况下进行动脉瘤修补术：（1）在计划分期治疗中，动脉瘤直径>100mm的年轻患者在TEVAR或FBEVAR后不久进行；（2）作为随访期间对囊袋持续增大且动脉瘤直径>80mm患者的二次干预。主要终点是30天生存率和随访期间与动脉瘤相关的死亡率。次要终点是囊袋大小变化、围手术期和术后并发症、无需进一步再次干预以及晚期主动脉并发症。
在研究期间，12例患者在TEVAR和/或FBEVAR后接受了动脉瘤修补术。患者平均年龄为60±12岁，开胸术前囊袋平均直径为101±25mm。4例患者在动脉瘤修补术前进行了肋间动脉的血管内栓塞。30天生存率为100%。在平均21个月的随访期内，2例患者死亡，1例死于新冠病毒感染，另1例死于脑出血。未发生与动脉瘤相关的死亡，除1例在动脉瘤修补术下方主动脉生长的患者外，所有患者的囊袋均缩小。
本研究表明，对于复杂胸主动脉瘤，在TEVAR和FBEVAR后进行胸主动脉瘤修补术是一种安全有效的技术。该手术可消除内漏并立即减少囊袋体积，防止主动脉-支气管或食管瘘形成，并确保血管内修复；动脉瘤肿块效应的减轻可恢复正常肺实质扩张。这种杂交治疗策略极大地降低了与胸主动脉腔内移植物取出的标准开放手术相关的发病率。
