May J, White G H, Yu W, Waugh R, Stephen M S, Arulchelvam M, Harris J P
Department of Surgery, University of Sydney, Australia.
Eur J Vasc Endovasc Surg. 1998 May;15(5):406-11. doi: 10.1016/s1078-5884(98)80201-3.
The aim of this study was to determine the influence of graft configuration on the outcome of endoluminal repair of abdominal aortic aneurysm (AAA).
The 5-year study period extended from May 1992 to May 1997 and included analysis of patients undergoing endoluminal AAA repair in the first 4.5-year period with a minimum follow-up period of 6 months. Between May 1992 and November 1996 136 patients underwent endoluminal AAA repair. Two patients who had endoluminal repair of anastomotic AAA and six patients who had secondary endoluminal repair of AAA were excluded, leaving 128 patients in the study group. There were 117 males and 11 females with a mean age for the group of 71 years. The configuration of the grafts was tubular aortic (T) (n = 50), tapered aortoiliac/femoral (AI) (n = 24) and bifurcated (B) (n = 54). Patient characteristics and co-morbidities were similar in the three groups. The procedures were performed in the operating room under radiographic control. Follow-up was complete and consisted of regular physical examination and contrast enhanced computed tomography. Outcome measures were perioperative mortality rate, need for conversion to open repair, presence of early and late endoleaks, successful exclusion of AAA from the circulation, and survival. Data were analysed by the life table method.
There was no significant difference in perioperative mortality for T (4%), AI (4%) and B (5.5%) configuration of endograft. Outcome for T, AI, and B configurations was respectively: primary conversion (%) 8, 12, 13; early endoleaks (n =) 5, 0, 1; late endoleaks (n =) 7, 0, 1. The overall incidence of failed procedures throughout the study period was higher in tube grafts compared with non-tube (aortoiliac and bifurcated) grafts (p < 0.05). Kaplan-Meier curves demonstrated a success probability at 40 months of 50% for tube grafts and 80% for non-tube grafts. However, a comparison of the time to procedure failure between tube versus non-tube after adjusting for competing risks (death without prior graft failure) was non-significant (p = 0.14).
The poor mid-term outcome for tube prostheses requires a reassessment of the criteria for selecting this configuration. It would be unwise to abandon the use of tube prostheses entirely in endoluminal repair. With increasing information on mid and long-term outcome of endoluminal AAA repair it is likely that there will be an increasing acceptance of treating smaller AAA while they are still suitable for treatment by the endoluminal method and most likely with tube grafts. A tightening of the criteria for using tube prostheses would seem sensible. In particular, the minimum length of distal neck required for endoluminal tube graft repair should be increased to the 2-2.5 cm range.
本研究旨在确定移植物构型对腹主动脉瘤（AAA）腔内修复结果的影响。
5年研究期从1992年5月至1997年5月，包括对在最初4.5年期间接受AAA腔内修复且最短随访期为6个月的患者进行分析。1992年5月至1996年11月，136例患者接受了AAA腔内修复。排除2例接受吻合口AAA腔内修复的患者和6例接受AAA二次腔内修复的患者，研究组剩余128例患者。其中男性117例，女性11例，该组平均年龄为71岁。移植物构型为管状主动脉（T）型（n = 50）、锥形主髂/股动脉（AI）型（n = 24）和分叉（B）型（n = 54）。三组患者的特征和合并症相似。手术在手术室的影像学控制下进行。随访完整，包括定期体格检查和增强CT扫描。观察指标包括围手术期死亡率、转为开放修复的必要性、早期和晚期内漏的存在、AAA成功从循环中排除以及生存率。数据采用生命表法进行分析。
T型（4%）、AI型（4%）和B型（5.5%）腔内移植物的围手术期死亡率无显著差异。T型、AI型和B型构型的结果分别为：初次转为开放修复（%）8、12、13；早期内漏（n =）5、0、1；晚期内漏（n =）7、0、1。在整个研究期间，管状移植物的手术失败总体发生率高于非管状（主髂和分叉）移植物（p < 0.05）。Kaplan-Meier曲线显示，管状移植物在40个月时的成功概率为50%，非管状移植物为80%。然而，在调整竞争风险（无先前移植物失败的死亡）后，管状与非管状移植物手术失败时间的比较无显著差异（p = 0.14）。
管状假体的中期效果较差，需要重新评估选择这种构型的标准。在腔内修复中完全放弃使用管状假体是不明智的。随着关于AAA腔内修复中长期结果的信息越来越多，越来越有可能接受在较小的AAA仍适合腔内治疗且很可能使用管状移植物时进行治疗。收紧使用管状假体的标准似乎是合理的。特别是，腔内管状移植物修复所需的远端颈部最小长度应增加到2 - 2.5厘米范围。
