Illig K A, Green R M, Ouriel K, Riggs P, Bartos S, DeWeese J A
Section of Vascular Surgery, University of Rochester Medical Center, NY, USA.
J Vasc Surg. 1997 Sep;26(3):492-9; discussion 499-501. doi: 10.1016/s0741-5214(97)70042-9.
Long-term success of endoluminally placed grafts for exclusion of abdominal aortic aneurysms (AAAs) relies on secure fixation at the proximal and distal cuffs and, as such, assumes that the fixation sites will not dilate over time. Data regarding this issue, however, are not yet available. This study was performed to evaluate the region of the proximal anastomosis in patients many years after having undergone conventional AAA repair to determine the potential for late dilatation after placement of an endoluminal device.
Three hundred forty-six patients underwent repair of an infrarenal AAA at our institution between January 1985 and December 1990. Of 97 eligible living patients, 33 both had their original CT scans available and underwent repeat scanning at a mean of 88.6 +/- 23.8 months (mean +/- SD; range, 40 to 134 months) after repair.
The overall 5-year survival rate was 73%. The mean preoperative infrarenal aortic cuff diameter by CT scan was 24.5 +/- 3.7 mm (range, 19 to 33 mm). At an average of 89 months after repair, the mean infrarenal aortic diameter increased 4.3 mm to 28.8 +/- 7.7 mm (range, 20 to 52 mm; p = 0.0004 by t test). The proximal cuff at this time measured 30 mm or more in 11 patients (33%), and as early as 6 years after operation three of the seven patients (43%) scanned within this time period had cuffs that were dilated to 30 mm or more. Late dilatation to 30 mm or more was rare (16%) in patients who had preoperative cuffs that measured 27 mm or less. The mean late iliac artery size was 16.9 +/- 8.9 mm (range, 10 to 52 mm), and 30% (10 of 33) measured 20 mm or more.
One third of all patients who survive AAA repair experience significant dilatation of their proximal aortic cuff over time. Proximal dilatation is rare but not absent in patients who have smaller initial aortic cuff diameters. This dilatation rarely causes problems after conventional suture fixation, but the long-term implications of cuff dilatation after endoluminal repair are unclear. Our findings suggest that endovascular aortic prostheses that have the ability to continue to self-expand many years after implantation may be required and that endovascular prostheses may not be the best option for patients who have a long life expectancy or for those who have preoperative proximal cuffs greater than 27 mm.
腔内植入移植物用于腹主动脉瘤（AAA）隔绝的长期成功依赖于在近段和远段袖口处的牢固固定，因此假定固定部位不会随时间扩张。然而，关于这个问题的数据尚不可得。本研究旨在评估接受传统AAA修复多年的患者的近段吻合口区域，以确定腔内装置植入后晚期扩张的可能性。
1985年1月至1990年12月期间，346例患者在我们机构接受了肾下腹主动脉瘤修复术。在97例符合条件的存活患者中，33例既有原始CT扫描图像，又在修复术后平均88.6±23.8个月（平均±标准差；范围，40至134个月）进行了重复扫描。
总体5年生存率为73%。术前通过CT扫描测得的肾下腹主动脉袖口平均直径为24.5±3.7mm（范围，19至33mm）。在修复术后平均89个月时，肾下腹主动脉平均直径增加了4.3mm，达到28.8±7.7mm（范围，20至52mm；t检验，p = 0.0004）。此时，11例患者（33%）的近段袖口测量值为30mm或更大，并且在术后最早6年时，在此时间段内接受扫描的7例患者中有3例（43%）的袖口扩张至30mm或更大。术前袖口测量值为27mm或更小的患者中，晚期扩张至30mm或更大的情况很少见（16%）。晚期髂动脉平均大小为16.9±8.9mm（范围，10至52mm），30%（33例中的10例）测量值为20mm或更大。
AAA修复术后存活的所有患者中，三分之一会随着时间推移出现近段主动脉袖口的显著扩张。初始主动脉袖口直径较小的患者中，近段扩张很少见但并非不存在。这种扩张在传统缝合固定后很少引起问题，但腔内修复后袖口扩张的长期影响尚不清楚。我们的研究结果表明，可能需要能够在植入多年后继续自我扩张的血管内主动脉假体，并且对于预期寿命长的患者或术前近段袖口大于27mm的患者，血管内假体可能不是最佳选择。
