The importance of iliac fixation in prevention of stent graft migration
The importance of iliac fixation in prevention of stent graft migration
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髂骨固定对防止支架移位的重要性
DOI：
10.1016/j.jvs.2006.01.031
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发表时间：
2006-06-01
影响因子：
4.3
通讯作者：
Zarins, Christopher K.
中科院分区：
文献类型：
--
作者：
Heikkinen, Maarit A.;Alsac, Jean Marc;Zarins, Christopher K.
目标：将覆膜支架近端牢固固定在肾下主动脉瘤颈上对于动脉瘤腔内修复术的短期和长期成功非常重要。我们试图确定髂动脉远端固定在预防动脉瘤腔内修复术后覆膜支架移位和不良临床事件方面的相对重要性。我们回顾了1996年至2003年在斯坦福大学医学中心接受外部支持覆膜支架治疗的173例患者的结局。对植入后计算机断层扫描进行定量图像分析，以确定近端主动脉和远端髂动脉固定长度以及覆膜支架远端与髂动脉分叉的接近度。审查后续随访计算机断层扫描是否存在覆膜支架移位的证据。根据主动脉固定良好（> 15 mm）、中等或不良（< 10 mm）和髂动脉固定良好（髂动脉固定长度>= 25 mm且髂动脉分支距离髂动脉分叉< 10 mm）、中等或不良（固定长度< 25 mm）对患者进行分组。在23 +/-19个月随访期间，在17例患者（10%）中观察到10 mm或以上的覆膜支架移位。无移位患者的髂动脉固定长度（30 +/- 12 mm）大于移位患者（22 8 mm; P = .01），髂动脉分支远端（15 +/- 12 mm）比移位患者（25 +/- 10 mm; P < .001）更靠近髂动脉分叉。无移位患者的近端主动脉固定长度（23 +/- 12 mm）也大于移位患者（13 7 mm; P = .001）。髂动脉固定良好的患者中无移位，无论主动脉固定良好、中等或不良（0/63; 0%）。在髂动脉固定不良/中度和主动脉固定良好的患者中，58例患者中有5例（9%）发生移位。髂动脉和主动脉固定不良/中度的患者迁移率最高（12/52; 23%）。考克斯比例风险回归模型显示，预测移位的重要因素是远端邻近度差。髂动脉分支末端至髂动脉分叉（比值比17.2; P = 0.01）和主动脉固定长度（比值比2.0;每厘米p = 0.007）。在9例髂动脉固定不良和移位的患者中放置了髂动脉延长器模块，在平均12个月的随访期间没有进一步移位。髂动脉和主动脉固定良好且术后首次计算机断层扫描无内漏的患者（n = 43）在2年随访期内无移位、二次手术或不良临床事件。髂动脉固定，沿着近端主动脉固定，是防止具有纵向柱状支撑的覆膜支架移位的重要因素。髂动脉固定良好的患者即使在近端主动脉固定欠佳的情况下也未发生移位。覆膜支架远端与髂动脉分叉的紧密接近似乎提供了抗移位的稳定性。
Objective: Secure proximal fixation of endografts to the infrarenal aortic neck is known to be important in the short- and long-term success of endovascular aneurysm repair. We sought to determine the relative importance of distal iliac fixation in preventing endograft migration and adverse clinical events after endovascular aneurysm repair.Methods. We reviewed the outcome of 173 patients treated from 1996 to 2003 at Stanford University Medical Center with an externally supported stent graft. Quantitative image analysis of the postimplantation computed tomography scan was performed to determine the proximal aortic and distal iliac fixation lengths and the proximity the distal end of the stent graft to the iliac bifurcation. Subsequent follow-up computed tomography scans were reviewed for evidence of stent graft migration. Patients were grouped according to good (> 15 mm), intermediate, or bad (< 10 mm) aortic fixation and good (iliac fixation length >= 25 rum and iliac limbs < 10 mm from iliac bifurcation), intermediate, or bad (< 25-mm fixation length) iliac fixation.Results. Stent graft migration of 10 mm or more was seen in 17 patients (10%) during the 23 +/- 19-month follow-up period. Patients with no migration had a greater iliac fixation length (30 +/- 12 nun) than those with migration (22 8 mm; P = .01), and the distal ends of the iliac limbs were closer to the iliac bifurcation (15 +/- 12 mm) than in patients with migration (25 +/- 10 mm; P < .001). Patients with no migration also had a greater proximal aortic fixation length (23 +/- 12 mm) than migration patients (13 7 mm; P = .001). There were no migrations among patients with good iliac fixation whether aortic fixation was good, intermediate, or bad (0/63; 0%). Among patients with bad/intermediate iliac and good aortic fixation, there were 5 (9%) of 58 patients had migrations. Patients with both bad/intermediate iliac and bad/intermediate aortic fixation had the highest migration rate (12/52; 23%). Cox proportional hazards regression modeling revealed that the significant factors predicting migration were poor proximity of the distal. end of the iliac limbs to the iliac bifurcation (odds ratio 17.2; P = .01) and aortic fixation length (odds ratio 2.0; p = 0.007 for each centimeter). Iliac extender modules were placed in 9 patients with bad iliac fixation and migration, with no further migration during a mean follow-up of 12 months. Patients with good iliac and aortic fixation and no endoleak on the initial postprocedure computed tomography scan (n = 43) had no migrations, secondary procedures, or adverse clinical events over a 2-year follow-up period.Conclusions. Iliac fixation, along with proximal aortic fixation, is an important factor in preventing the migration of stent grafts that have longitudinal columnar support. Patients with good iliac fixation did not experience migration even in the presence of suboptimal proximal aortic fixation. Close proximity of the distal end of the stent graft to the iliac bifurcation seems to provide stability against migration.