Zehner Kiera, Zack Jeremy, Schanzer Andres, Beck Adam W, Sweet Matthew P, Oderich Gustavo, Timaran Carlos H, Farber Mark A, Gasper Warren J, Lee W Anthony, Eagleton Matthew J, Li Xingsheng, Cantor Ryan, Wang Grace J, Schneider Darren B
Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA.
J Vasc Surg. 2025 Oct;82(4):1179-1187.e2. doi: 10.1016/j.jvs.2025.05.047. Epub 2025 May 29.
Aneurysm sac behavior after fenestrated or branched endovascular repair (FB-EVAR) of thoracoabdominal aortic aneurysms (TAAAs) remains a key knowledge gap. The purpose of this study was to identify independent predictors of sac behavior after FB-EVAR and assess the relationship between sac behavior and long-term survival.
Patients undergoing FB-EVAR between 2005 and 2023, in 10 physician-sponsored investigational device exemption studies in the United States, were analyzed. Patients who underwent elective FB-EVAR for juxtarenal, suprarenal, or extent 1 to 5 TAAAs and had 30-day and 1-year computed tomography follow-up imaging were included. Patients with chronic aortic dissections were excluded. Sac regression or expansion (≥5 mm) was defined using the Society for Vascular Surgery guidelines. Independent predictors of sac growth were identified using multivariable logistic regression analysis and survival rates were compared using Kaplan-Meier curves.
Of 3057 patients who underwent FB-EVAR, 1497 were eligible for analysis. Median follow-up was 2.9 years (interquartile range, 1.3-4.0 years). At 1 year, 103 (6.9%) patients experienced sac expansion, 694 (46.4%) experienced sac regression, and 700 (46.7%) had a stable sac. Variables independently associated with sac expansion were age (odds ratio [OR] 1.04; 95% confidence interval [CI], 1.01-1.07; P = .0057), prior aortic surgery (OR, 2.22; 95% CI, 1.32-3.40; P = .0026), prior EVAR (OR, 1.84; 95% CI, 1.07-3.14; P = .0264), larger aneurysm diameter (OR, 1.03; 95% CI, 1.01-1.04; P = .0014), type II endoleak observed on 30-day follow-up computed tomography (OR, 2.15; 95% CI, 1.36-3.41; P = .0011), and any secondary intervention during the first year (OR, 2.19; 95% CI, 1.35-3.55; P = .0016). Overall survival at 1 year was significantly lower in the expansion group compared with the stable and regression groups (85.6% vs 90.9% vs 93.1%, respectively). This effect persisted on 5-year evaluation (48.1% vs 63.0% vs 67.7%, respectively). Both expansion and stability at 1 year were both associated with increased long-term mortality in unadjusted cox model (expansion, hazard ratio, 2.083; 95% CI, 1.47-2.95; P < .0001; stability, hazard ratio, 1.26; 95% CI, 1.02-1.56; P = .0298) vs regression.
Both aneurysm sac expansion and stability (lack of regression) one year after FB-EVAR are associated with decreased long-term survival compared with sac regression. These outcomes underscore the need for vigilant monitoring of patients without sac regression and to better understand if interventions to address factors associated with unfavorable aneurysm sac behavior can improve long-term survival.
胸腹主动脉瘤（TAAA）开窗或分支型血管腔内修复术（FB-EVAR）后瘤囊行为仍是一个关键的知识空白。本研究的目的是确定FB-EVAR后瘤囊行为的独立预测因素，并评估瘤囊行为与长期生存之间的关系。
分析了2005年至2023年期间在美国10项医师发起的研究性器械豁免研究中接受FB-EVAR的患者。纳入接受择期FB-EVAR治疗近肾、肾上或1至5型TAAA且有30天和1年计算机断层扫描随访影像的患者。排除慢性主动脉夹层患者。根据血管外科学会指南定义瘤囊缩小或扩张（≥5 mm）。使用多变量逻辑回归分析确定瘤囊生长的独立预测因素，并使用Kaplan-Meier曲线比较生存率。
在3057例接受FB-EVAR的患者中，1497例符合分析条件。中位随访时间为2.9年（四分位间距，1.3 - 4.0年）。1年时，103例（6.9%）患者出现瘤囊扩张，694例（46.4%）患者出现瘤囊缩小，700例（46.7%）患者瘤囊稳定。与瘤囊扩张独立相关的变量包括年龄（比值比[OR] 1.04；95%置信区间[CI]，1.01 - 1.07；P = .0057）、既往主动脉手术（OR，2.22；95% CI，1.32 - 3.40；P = .0026）、既往血管腔内修复术（OR，1.84；95% CI，1.07 - 3.14；P = .0264）、较大的动脉瘤直径（OR，1.03；95% CI，1.01 - 1.04；P = .0014）、30天随访计算机断层扫描观察到的II型内漏（OR，2.15；95% CI，1.36 - 3.41；P = .0011）以及第一年的任何二次干预（OR，2.19；95% CI，1.35 - 3.55；P = .0016）。扩张组1年时的总生存率显著低于稳定组和缩小组（分别为85.6% vs 90.9% vs 93.1%）。在5年评估时这种效应仍然存在（分别为48.1% vs 63.0% vs 67.7%）。在未调整的Cox模型中，1年时的扩张和稳定均与长期死亡率增加相关（扩张，风险比，2.083；95% CI，1.47 - 2.95；P < .0001；稳定，风险比，1.26；95% CI，1.02 - 1.56；P = .0298），与缩小相比。
与瘤囊缩小相比，FB-EVAR后1年的动脉瘤瘤囊扩张和稳定（缺乏缩小）均与长期生存率降低相关。这些结果强调了对无瘤囊缩小患者进行密切监测的必要性，并更好地了解针对与不良动脉瘤瘤囊行为相关因素的干预措施是否可以提高长期生存率。
