Gallitto Enrico, Faggioli Gianluca, Vacirca Andrea, Tenorio Emanuel R, Mendes Bernardo C, Lodato Marcello, Cappiello Antonio, Chait Jesse, Oderich Gustavo S, Gargiulo Mauro
Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy; Vascular Surgery Unit, IRCCS Sant'Orsola, Bologna, Italy.
Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy; Vascular Surgery Unit, IRCCS Sant'Orsola, Bologna, Italy.
Eur J Vasc Endovasc Surg. 2025 Mar;69(3):422-431. doi: 10.1016/j.ejvs.2024.10.008. Epub 2024 Oct 10.
Target artery patency is crucial for fenestrated and branched endovascular aortic repair (FB-EVAR) in thoraco-abdominal aortic aneurysms (TAAAs). Occlusions more frequently occur in the renal arteries (RAs) than in the coeliac and superior mesenteric arteries, especially in patients with hostile anatomy treated by B-EVAR. This study aimed to report RA outcomes using a hybrid bridging stent graft technique with distal self expandable (SE) combined with proximal balloon expandable (BE) stent graft during B-EVAR with hostile RA anatomies.
Clinical data from consecutive patients treated for TAAA by FB-EVAR in three aortic centres (two in the USA, one in Europe) from 2016 to 2022 were collected prospectively. RA orientation was defined as hostile in case of upward (type B) or downward + upward (type D) orientation. Hostile RAs accommodated by B-EVAR and combination of SE + BE stent grafts were evaluated retrospectively. Intra-operative RA related complications, technical success (TS), and branch occlusions were assessed as early outcomes. Primary and secondary RA patency, freedom from RA related re-interventions, and freedom from RA instability were assessed during follow up.
Of 584 TAAAs managed by FB-EVAR, 83 patients (14.2%) had 125 hostile RAs (type B, 45.6%; type D, 54.4%) managed by B-EVAR with hybrid SE + BE stent grafts. Intra-operative complications occurred in three RAs (2.4%), including two dissections and one disconnection, all successfully managed with additional stents. TS was achieved in all cases, with no RA occlusions at 30 days. The median follow up was 21 (interquartile range 4, 38) months. Estimated three year RA primary patency was 97 ± 2%. Re-interventions were performed in five RAs (4.0%), including two RA branch embolisations for bleeding, two catheter thrombectomies with stent relining (bilateral occlusion in one patient), and one revision of type Ic endoleak. Freedom from RA related re-interventions and RA instability was 95 ± 2% and 91 ± 3% at three years, respectively. RA secondary patency was 99 ± 1% at three years.
In hostile RA anatomies, a combination of distal SE and proximal BE stent grafts as bridging stenting in B-EVAR is safe and effective, with low rates of occlusion, re-interventions, and branch instability at midterm follow up.
在胸腹主动脉瘤（TAAA）的开窗和分支型血管腔内主动脉修复术（FB-EVAR）中，靶动脉通畅对于手术成功至关重要。肾动脉（RA）闭塞的发生率高于腹腔干动脉和肠系膜上动脉，尤其是在接受分支型血管腔内主动脉修复术（B-EVAR）治疗的解剖结构复杂的患者中。本研究旨在报告在B-EVAR治疗解剖结构复杂的RA时，使用远端自膨式（SE）与近端球囊扩张式（BE）支架移植物相结合的混合桥接支架移植物技术的RA治疗效果。
前瞻性收集了2016年至2022年期间在三个主动脉中心（两个在美国，一个在欧洲）接受FB-EVAR治疗TAAA的连续患者的临床资料。如果RA呈向上（B型）或向下+向上（D型）走行，则定义为解剖结构复杂。对接受B-EVAR和SE+BE支架移植物联合治疗的解剖结构复杂的RA进行回顾性评估。术中评估与RA相关的并发症、技术成功率（TS）和分支闭塞情况作为早期结果。随访期间评估RA的一级和二级通畅率、无RA相关再干预情况以及无RA不稳定情况。
在584例接受FB-EVAR治疗的TAAA患者中，83例（14.2%）有125条解剖结构复杂的RA（B型，45.6%；D型，54.4%）接受了B-EVAR联合SE+BE混合支架移植物治疗。术中3条RA（2.4%）出现并发症，包括2例夹层和1例断裂，均通过额外置入支架成功处理。所有病例均实现了TS，30天时无RA闭塞。中位随访时间为21（四分位间距4，38）个月。估计三年的RA一级通畅率为97±2%。5条RA（4.0%）进行了再干预，包括2例因出血进行的RA分支栓塞、2例导管取栓并置入支架内衬（1例患者双侧闭塞）以及1例Ic型内漏修复。三年时无RA相关再干预和RA不稳定的发生率分别为95±2%和91±3%。三年时RA二级通畅率为99±1%。
在解剖结构复杂的RA中，在B-EVAR中使用远端SE和近端BE支架移植物联合作为桥接支架是安全有效的，中期随访时闭塞、再干预和分支不稳定的发生率较低。
