Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology.
Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology.
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DOI：
10.1016/j.jvs.2015.06.133
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发表时间：
2015-11
影响因子：
4.3
通讯作者：
Beck AW
中科院分区：
文献类型：
--
作者：
Scali ST;Neal D;Sollanek V;Martin T;Sablik J;Huber TS;Beck AW
对涉及内脏血管的急性主动脉病变进行开放性手术修复，其发病率和死亡率分别为40% ~ 70%和30% ~ 60%。由于这些不良的结果，在这种情况下，开窗/分支血管内主动脉修复（F/B-EVAR）的应用已经扩大；然而，其耐久性仍不得而知。本分析的目的是描述急性主动脉疾病F/B-EVAR后的结果。完成了对急性主动脉疾病的所有F/B-EVARs的单中心回顾性评价。主要终点包括死亡率和无再干预生存期。次要终点是通畅和无内漏，以及动脉瘤直径的变化和估计的肾小球滤过率。生命表用于估计终点，而混合统计模型用于确定动脉瘤直径的变化。37例患者（平均年龄±标准差，67±10岁，男性75%）因急性主动脉疾病行F/B-EVAR，中位随访时间为10.3个月（范围0.5 ~ 31.4个月）。适应症包括胸腹动脉瘤（65%,n = 24）、肾旁动脉瘤（17%,n = 6）、术后吻合口假性动脉瘤（8%,n = 3）、夹层（5%,n = 2）、穿透性溃疡（5%,n = 2）。术前平均动脉瘤直径7.3±1.8 cm。所有患者均为美国麻醉医师学会IV级或IV- e级，38% （n = 14）有主动脉修复史。105例内脏血管重建（腹腔26例；肠系膜上动脉29例；肾脏50例），24例（65%）患者接受了三或四血管修复。技术成功率为92% (n = 34)，无术中死亡和一例转归（3%）。中位住院时间为6天（范围2-60天），术后发病率为41% (n = 15；脊髓缺血14%[永久性]8%；肺部14%；肾脏14%；四肢缺血8%；中风5%；心脏3%；出血3%)，30天死亡率为19% （n = 7；住院8%；n = 3）。27% （n = 10）的患者在随访的某个时间点检测到Endoleak，大多数为II型（n = 7）。6例（16%）患者接受了再干预，未发生晚期转化。术后成像27例（73%），1例腹腔开窗在12个月时失去通畅。一年内分支血管通畅率为98%±6%，再介入率为70%±9%。估计1年和4年生存率分别为70%±8%和67%±8%。随访期间，主动脉直径下降0.5 cm(95%可信区间1.1-0.2;P = 0.1)，肾小球滤过率下降2 mL/min/1.73 m2。F/B-EVAR可用于治疗各种症状性和/或破裂的内脏旁主动脉病变。围手术期的发病率和死亡率可以显著；然而，这比基于文献的开放式修复的结果要少。短期开窗/支状移植物通畅良好，但再次介入频繁，需要认真随访。急性主动脉疾病F/B-EVAR首次住院存活的患者可以预期良好的长期生存率。
Open surgical repair for acute aortic pathologies involving the visceral vessels is associated with morbidity and mortality rates of 40% to 70% and 30% to 60%, respectively. Due to these poor outcomes, the application of fenestrated/branched endovascular aortic repair (F/B-EVAR) has been expanded in this setting; however, durability remains unknown. The purpose of this analysis was to describe outcomes after F/B-EVAR for acute aortic disease. A single center retrospective review of all F/B-EVARs for acute aortic disease was completed. Primary end points included mortality and reintervention-free survival. Secondary end points were patency and freedom from endoleak, as well as change in aneurysm diameter and estimated glomerular filtration rate. Life-tables were used to estimate end points, while mixed statistical models were used to determine aneurysm diameter change. Thirty-seven patients (mean age ± standard deviation, 67 ± 10 years; 75% male) underwent F/B-EVAR for acute aortic disease, and median follow-up time was 10.3 months (range, 0.5–31.4 months). Indications included thoracoabdominal aneurysm (65%; n = 24), pararenal aneurysm (17%; n = 6), postsurgical anastomotic pseudoaneurysm (8%; n = 3), dissection (5%; n = 2), and penetrating ulcer (5%; n = 2). Mean preoperative aneurysm diameter was 7.3 ±1.8 cm. All patients were American Society of Anesthesiologists class IV or IV-E, and 38% (n = 14) had history of aortic repair. There were 105 visceral vessels revascularized (celiac, 26; superior mesenteric artery, 29; renal, 50) and 24 (65%) patients underwent three- or four-vessel repair. Technical success was 92% (n = 34), with no intraoperative deaths and one conversion (3%). Median length of stay was 6 days (range, 2–60 days), and postoperative morbidity was 41% (n = 15; spinal cord ischemia, 14% [8% permanent]; pulmonary, 14%; renal, 14%; extremity ischemia, 8%; stroke, 5%; cardiac, 3%; bleeding, 3%) with 30-day mortality of 19% (n = 7; in-hospital, 8%; n = 3). Endoleak was detected at some point in follow-up in 27% (n = 10), and a majority were type II (n = 7). Six (16%) patients underwent reintervention, and no late conversions occurred. Postoperative imaging was available in 27 (73%), and one celiac fenestration lost patency at 12 months. One-year branch vessel patency and freedom from reintervention was 98% ± 6% and 70% ± 9%, respectively. Estimated 1- and 4-year survival were 70% ± 8% and 67% ± 8%, respectively. During follow-up, aortic diameter decreased 0.5 cm (95% confidence interval, 1.1–0.2; P = .1) while estimated glomerular filtration rate decreased by 2 mL/min/1.73 m2. F/B-EVAR can be performed to treat a variety of symptomatic and/or ruptured paravisceral aortic pathologies. Perioperative morbidity and mortality can be significant; however, it is less than literature-based outcomes of open repair. Short-term fenestrated/branched graft patency is excellent, but reintervention is frequent, highlighting the need for diligent follow-up. Patients surviving the initial hospitalization for F/B-EVAR of acute aortic disease can anticipate good long-term survival.
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影响因子：
4.3
作者：
DeSart, Kenneth;Scali, Salvatore T.;Feezor, Robert J.;Hong, Michael;Hess, Philip J., Jr.;Beaver, Thomas M.;Huber, Thomas S.;Beck, Adam W.
通讯作者：
Beck, Adam W.
影响因子：
4.3
作者：
Glebova, Natalia O.;Selvarajah, Shalini;Abularrage, Christopher J.
通讯作者：
Abularrage, Christopher J.
DOI：
10.1016/s0022-5223(99)70185-6
发表时间：
1999-09-01
影响因子：
6
作者：
Mastroroberto, P;Chello, M
通讯作者：
Chello, M
影响因子：
4.3
作者：
Fillinger, Mark F.;Greenberg, Roy K.;Chaikof, Elliot L.
通讯作者：
Chaikof, Elliot L.
影响因子：
4.3
作者：
Chaikof, EL;Blankensteijn, JD;Kent, KC
通讯作者：
Kent, KC