Fenestrated and branched endovascular aortic repair for chronic type B aortic dissection with thoracoabdominal aneurysms
Fenestrated and branched endovascular aortic repair for chronic type B aortic dissection with thoracoabdominal aneurysms
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DOI：
10.1016/j.jvs.2013.01.049
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发表时间：
2013-09-01
影响因子：
4.3
通讯作者：
Roselli, Eric E.
中科院分区：
文献类型：
--
作者：
Kitagawa, Atsushi;Greenberg, Roy K.;Roselli, Eric E.
目的：主动脉弓和胸腹主动脉瘤（TAAA）和慢性夹层患者的治疗具有挑战性。我们报告开窗和分支血管内修复术（FEVAR）的结果，这样的aneurysms.Methods：单中心前瞻性FEVAR试验纳入356例患者（2006年至2011年），其中30例慢性夹层动脉瘤弓或TAAA，或两者兼而有之。患者分为A组，15例患者（平均年龄58岁），广泛夹层从弓延伸到内脏段，和B组，15例患者（平均年龄74岁），局灶性夹层，没有延伸到胸主动脉。入选标准为动脉瘤直径>5.5 cm。将定制移植物植入真腔内，并将分支延伸至主动脉上干（弓分支器械）和内脏血管的真腔内。每年通过临床、影像学和实验室研究对患者进行监测。结果分析包括生存率，破裂，脊髓缺血，内漏，发病率（心脏，肾脏或肺），再干预，夹层，和动脉瘤growth.Results：平均时间从夹层发病到FEVAR进行A组为10.4年。平均最大动脉瘤直径为60 mm。平均随访1.7年。无围手术期死亡。由于既存的未经治疗的主动脉弓夹层进展，在第87天时发生了1例与动脉粥样硬化相关的死亡。未发生破裂、心脏、肾脏、肺或脊髓缺血并发症。尽管最初真腔尺寸狭窄，但覆膜支架在植入后扩张至其标称直径，分支内脏血管和远端主动脉无任何血流干扰。未发生移植物压缩。在2例患者中观察到FEVAR后生长，与II型内漏相关。囊袋消退相似（-6.8 vs -11.4 mm; P = 0.43），但早期血管内再介入在A组中更常见（8例患者）。广泛夹层的患者更年轻，夹层更可能与明确的结缔组织疾病相关（马凡综合征或Loeys-Dietz突变，40% vs 0%; P = 0.006）。结论：FEVAR对慢性夹层和TAAA患者是可行的。在我们的经验中，对真腔直径狭窄导致的内脏血管通路和移植物压缩的担忧并不相关。有利的囊和腔形态学变化，加上低死亡率和并发症风险，使其成为处理该临床问题的有吸引力的方法。
Objective: The treatment of patients with arch and thoracoabdominal aortic aneurysms (TAAAs) and chronic dissections is challenging. We report the results of fenestrated and branched endovascular aortic repair (FEVAR) of such aneurysms.Methods: A single-center prospective FEVAR trial enrolled 356 patients (2006 to 2011), of whom 30 had chronic dissections with arch aneurysm or TAAAs, or both. Patients were divided into group A, 15 patients (mean age, 58 years) with extensive dissections extending from the arch through the visceral segment, and group B, 15 patients (mean age, 74 years old) with focal dissections and no extension into the thoracic aorta. Inclusion criterion was aneurysm size >5.5 cm in diameter. Customized grafts were implanted into the true lumen, and branches were extended into the true lumen of the supra-aortic trunk (arch branch devices) and visceral vessels. Patients were monitored annually with clinical, imaging, and laboratory studies. Outcome analyses included survival, rupture, spinal cord ischemia, endoleak, morbidity (cardiac, renal or pulmonary), reinterventions, dissection, and aneurysm growth.Results: The mean time from the onset of dissection to the FEVAR performed in group A was 10.4 years. The mean maximum aneurysm diameter was 60 mm. Follow-up averaged 1.7 years. There were no perioperative deaths. One aortic-related death occurred at 87 days due to progression of a pre-existing untreated arch dissection. No ruptures, cardiac, renal, pulmonary, or spinal cord ischemia complications occurred. Despite the initially narrow true lumen dimensions, stent grafts expanded to their nominal diameters after implantation without any blood flow disturbance of branched visceral vessels and distal aorta. No graft compression occurred. Post-FEVAR growth was noted in two patients, related to type II endoleaks. Sac regression was similar (-6.8 vs -11.4 mm; P = .43), but early endovascular reinterventions were more common in group A (8 patients). Patients with extensive dissection were younger, and the dissection more likely to be associated with a defined connective tissue disease (Marfan syndrome or Loeys-Dietz mutations, 40% vs 0%; P = .006).Conclusions: FEVAR is feasible for patients with chronic dissections and TAAA. Concerns regarding visceral vessel access and graft compression resulting from narrow true lumen diameters were not relevant in our experience. Favorable sac and lumen morphologic changes, coupled with a low mortality and complication risk, makes this an attractive means of handling this clinical problem.