Iliac fixation inhibits migration of both suprarenal and infrarenal aortic endografts
Iliac fixation inhibits migration of both suprarenal and infrarenal aortic endografts
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DOI：
10.1016/j.jvs.2006.09.061
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发表时间：
2007-02-01
影响因子：
4.3
通讯作者：
Zarins, Christopher K.
中科院分区：
文献类型：
--
作者：
Benharash, Peyman;Lee, Jason T.;Zarins, Christopher K.
目的：探讨髂内固定在预防肾上、肾下主动脉瓣内移植物移位中的作用。方法：对2000 ~ 2004年接受肾上（36例）或肾下（56例）主动脉瓣内移植术治疗的92例肾下动脉瘤患者（男76例，女16例）进行定量图像分析。在术前、植入后和1年三维计算机断层扫描中测量从肠系膜上动脉到支架顶部的纵向中心线距离，移动超过5mm被认为是显著的。垂直于中心线轴线测量主动脉直径。近端和远端固定长度分别定义为支架移植物靠近主动脉颈和髂总动脉的长度。结果：肾上组和肾下组在年龄、合并症、术前动脉瘤大小（肾上，6.0 cm；肾下，5.7 cm）方面无显著差异。然而，与肾下组相比，肾上组的主动脉颈较短（13 vs 25 mm, P < 0.0001），直径较大（27 vs 24 mm, P < 0.0001），成角较大（19度vs 11度，P = 0.007）。肾上组主动脉近端固定长度大于肾下组（22 vs 16 mm; P < 0.0001），由于15 mm的未覆盖肾上支架，装置顶部更接近肠系膜上动脉（8 vs 21 mm; P < 0.0001）。肾上组和肾下组的髂骨固定长度无差异（26 vs 25 mm; P =.8）。肾上组和肾下组1年纵向中心线支架运动相似（4.3 +/- 4.4 mm vs 4.8 +/- 4.3 mm; P = .6）。1年内纵向中心线移动超过5mm或在随访期间任何时间有临床迁移证据的患者组成各自的迁移组。与非肾上迁移者相比，肾上迁移者的髂固定长度较短（17 vs 29 mm; P = 0.006），主动脉固定长度相似（23 vs 22 mm; P = 0.999）。与非肾下迁移者相比，肾下迁移者的髂固定长度较短（18 vs 30 mm; P < 0.0001），主动脉固定长度相似（14 vs 17 mm; P = 0.1）。在肾上组（7 vs 17 mm, P = 0.009）和肾下组（8 vs 24 mm, P < 0.0001），非迁移者的装置更接近胃下动脉。在髂固定良好的患者中，两组均未发生移位。多因素logistic回归分析显示，髂固定，如髂固定长度（P = 0.004）和器械到胃下动脉的距离（P = 0.002），是迁移的显著独立预测因素，而肾上或肾下治疗不是迁移的显著预测因素。在45 - 22个月的临床随访期间（范围12-70个月），两组均未发生动脉瘤破裂、腹主动脉瘤相关死亡或手术转化。结论：髂远端固定对于防止具有纵向柱状支撑的肾上和肾下主动脉瓣内移植物迁移很重要。尽管主动脉颈近端解剖结构不理想，但安全的髂内固定可将移位风险降至最低。延伸髂双肢以覆盖整个髂总动脉至髂分叉处似乎可以阻止内移植物迁移。
Objective: To evaluate the role of iliac fixation in preventing migration of suprarenal and infrarenal aortic endografts.Methods: Quantitative image analysis was performed in 92 patients with infrarenal aortic aneurysms (76 men and 16 women) treated with suprarenal (n = 36) or infrarenal (n = 56) aortic endografts from 2000 to 2004. The longitudinal centerline distance from the superior mesenteric artery to the top of the stent graft was measured on preoperative, postimplantation, and 1-year three-dimensional computed tomographic scans, with movement more than 5 mm considered to be significant. Aortic diameters were measured perpendicular to the centerline axis. Proximal and distal fixation lengths were defined as the lengths of stent-graft apposition to the aortic neck and the common iliac arteries, respectively.Results: There were no significant differences in age, comorbidities, or preoperative aneurysm size (suprarenal, 6.0 cm; infrarenal, 5.7 cm) between the suprarenal and infrarenal groups. However, the suprarenal group had less favorable aortic necks with a shorter length (13 vs 25 mm; P < .0001), a larger diameter (27 vs 24 mm; P < .0001), and greater angulation (19 degrees vs 11 degrees; P =.007) compared with the infrarenal group. The proximal aortic fixation length was greater in the suprarenal than in the infrarenal group (22 vs 16 mm; P < .0001), with the top of the device closer to the superior mesenteric artery (8 vs 21 mm; P < .0001) as a result of the 15-mm uncovered suprarenal stent. There was no difference in iliac fixation length between the suprarenal and infrarenal groups (26 vs 25 mm; P =.8). Longitudinal centerline stent graft movement at 1 year was similar in the suprarenal and infrarenal groups (4.3 +/- 4.4 mm vs 4.8 +/- 4.3 mm; P = .6). Patients with longitudinal centerline movement of more than 5 mm at 1 year or clinical evidence of migration at any time during the follow-up period comprised the respective migrator groups. Suprarenal migrators had a shorter iliac fixation length (17 vs 29 mm; P = .006) and a similar aortic fixation length (23 vs 22 mm; P > .999) compared with suprarenal nonmigrators. Infrarenal migrators had a shorter iliac fixation length (18 vs 30 mm; P < .0001) and a similar aortic fixation length (14 vs 17 mm; P = .1) compared with infrarenal nonmigrators. Nonmigrators had closer device proximity to the hypogastric arteries in both the suprarenal (7 vs 17 mm; P = .009) and infrarenal (8 vs 24 mm; P < .0001) groups. No migration occurred in either group in patients with good iliac fixation. Multivariate logistic regression analysis revealed that iliac fixation, as evidenced by iliac fixation length (P = .004) and the device to hypogastric artery distance (P = .002), was a significant independent predictor of migration, whereas suprarenal or infrarenal treatment was not a significant predictor of migration. During a clinical follow-up period of 45 22 months (range, 12-70 months), there have been no aneurysm ruptures, abdominal aortic aneurysm-related deaths, or surgical conversions in either group.Conclusions: Distal iliac fixation is important in preventing migration of both suprarenal and infrarenal aortic endografts that have longitudinal columnar support. Secure iliac fixation minimizes the risk of migration despite suboptimal proximal aortic neck anatomy. Extension of both iliac limbs to cover the entire common iliac artery to the iliac bifurcation seems to prevent endograft migration.