Branched endografts for thoracoabdominal aneurysms
Branched endografts for thoracoabdominal aneurysms
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DOI：
10.1016/j.jtcvs.2010.07.061
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发表时间：
2010-12-01
影响因子：
6
通讯作者：
Mastracci, Tara
中科院分区：
文献类型：
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作者：
Greenberg, Roy;Eagleton, Matthew;Mastracci, Tara
目的：自2001年以来，已对胸腹部动脉瘤的血管内治疗进行了研究，取得了显著进展，允许治疗复杂的解剖情况，包括慢性主动脉夹层、迂曲的解剖结构和累及内脏段、主动脉弓和髂动脉的广泛动脉瘤。然而，该技术并没有广泛传播，工程原理，成像技术和设备的透彻理解是requirement.Methods：加强开窗分支加上球囊扩张支架移植物，和侧臂分支设计交配自膨式支架移植物已被使用。纯开孔型设计用于近肾动脉瘤，而胸腹动脉瘤采用加强型开孔型分支或混合器械（包括侧臂分支和加强型开孔型分支）治疗。术中融合技术自2009年开始使用，术前计算机断层扫描数据与术中荧光透视融合。根据疾病程度的长期生存率用寿命表分析技术进行评估，差异用对数秩检验进行分析。中期数据有关通畅性的两种类型的分支和截瘫进行了评估，以前published.Results：共406例胸腹动脉瘤和227例肾旁动脉瘤患者已被纳入一项前瞻性研究。围手术期和2年生存率与初始疾病的程度最密切相关，在24个月时，估计肾旁动脉瘤分别为1.8%和82%，IV型动脉瘤为2.3%和82%，II型和III型胸腹动脉瘤分别为5.2%和74%。当接受血管内修复术（ER组）的患者与接受同期手术修复术（SR组）的患者在解剖学病变程度方面相匹配时，30天（5.7% ER vs 8.3% SR; P = .2）和12个月（15.6% ER vs 15.9% SR; P = .9）时的死亡率相似。两组的截瘫风险也相似（分别为4.3% ER和7.5% SR; P = 0.08）。在633例患者中，有5例（0.8%）在治疗后平均18个月发生晚期破裂，其中4例为致死性。其归因于组件分离（n = 3）、血管内修复术近端远端动脉瘤破裂和修复术远端外科聚酯移植物失效。平均随访15个月时，与球囊扩张型覆膜支架结合使用时，加强型开孔型分支通畅率为97.8%。仅1例在手术后24小时内发生侧臂分支闭塞。新的成像工具导致平均造影剂剂量显著降低（>50%）。结论：胸腹动脉瘤腔内修复术多种方法的中期结果表明该手术的技术可行性，并在开放手术高风险患者中显示出巨大的前景。中期通畅率和生存率都很好，破裂非常罕见。然而，这种技术的死亡率和脊髓缺血风险仍然相当大。（《胸血管外科杂志》2010; 140：S171-8）
Purpose: Endovascular management of thoracoabdominal aneurysms has been studied since 2001, with marked advances allowing for the treatment of complex anatomic situations including chronic aortic dissections, tortuous anatomy, and extensive aneurysms that involve the visceral segment, aortic arch, and iliacs as well. However, the technology is not widely disseminated, and a thorough understanding of the engineering principles, imaging techniques, and devices available is required.Methods: Reinforced fenestrated branches coupled with balloon expandable stent grafts, and side-arm branch designs mated with self-expanding stent grafts have been used. Pure fenestrated designs were used for juxtarenal aneurysms, whereas thoracoabdominal aneurysms were treated with reinforced fenestrated branches or hybrid devices including side-arm branches and reinforced fenestrated branches. Intraoperative fusion techniques have been used since 2009, whereby preoperative computed tomographic data are fused with intraoperative fluoroscopy. Long-term survival in accordance with extent of disease was assessed with life table analysis techniques, and differences were analyzed using the log rank test. Intermediate-term data pertaining to patency related to both types of branches and paraplegia have been evaluated and previously published.Results: A total of 406 patients with thoracoabdominal aneurysms and 227 patients with juxtarenal aneurysms have been enrolled in a prospective study. Perioperative and 2-year survival were most closely related to extent of initial disease and were estimated to be 1.8% and 82% for juxtarenal aneurysms, 2.3% and 82% for type IV, and 5.2% and 74% for type II and III thoracoabdominal aneurysms at 24 months, respectively. When patients undergoing endovascular repair (ER group) were matched with those having contemporary surgical repair (SR group) for anatomic disease extent, mortality was similar at 30 days (5.7% ER vs 8.3% SR; P = .2) and at 12 months (15.6% ER vs 15.9% SR; P = .9). Paraplegia risk was also similar between the 2 groups (4.3% ER vs 7.5% SR, respectively; P = .08). Among the 633 patients, there were 5 (0.8%) late ruptures at a mean of 18 months after treatment, of which 4 were fatal. They were attributed to component separation (n = 3), a remote aneurysm rupture proximal to the endovascular repair, and a failed surgical polyester graft distal to the repair. Reinforced fenestrated branch patency, when coupled with balloon-expandable stent grafts, was 97.8% at a mean follow-up of 15 months. Side-arm branch occlusion occurred in only 1 case, within 24 hours of the procedure. New imaging tools resulted in a marked reduction in the average contrast dose (>50%).Conclusions: Intermediate-term results with multiple methods of endovascular repair of thoracoabdominal aneurysm indicate the technical feasibility of the procedure and show great promise in patients considered at high risk for open surgery. The intermediate-term patency and survival are excellent, and ruptures are exceedingly uncommon. However, mortality and spinal cord ischemia risks are still considerable with this technique. (J Thorac Cardiovasc Surg 2010; 140:S171-8)