复杂主动脉病变的腔内血管外科治疗

目的 探讨复杂主动脉病变的腔内血管外科治疗方法。方法 对21例合并有内脏动脉缺血等复杂的主动脉病变,双球管定位下经锁骨上动脉到股动脉交换导丝以确保真腔内植入带膜支架,对真腔完全被假腔压闭的患者采取真腔内加压推进以通过导丝,用超长带膜支架来封堵大破口治疗夹层合并巨大假性动脉瘤形成,对夹层合并腹主动脉瘤患者采取血管腔内技术联合开腹手术等方法。结果 术后内漏3例,其中2例7 d后停止,1例漏血持续存在。3例主动脉创伤术后完全康复,余18例复杂主动脉夹层术后即时造影示瘘口已被完整覆盖,假腔无血漏入,内脏动脉等恢复真腔供血。18例中6例合并肠管缺血,3例合并肾动脉缺血,3例肠管缺血、肾动脉缺血,2例腹主动脉真腔完全被假腔压迫,以及2例合并下肢缺血术后均逐渐恢复,无脏器及肢体缺血坏死发生。2例合并腹主动脉瘤夹层行支架型人工血管封闭夹层破口后行开腹手术切除腹主动脉瘤、人工血管置换。16例随访5～36个月,平均22.3月,1例内漏持续存在,但假腔未继续加大,其余患者存活良好。结论 对复杂的主动脉病变的治疗,通过对腔内血管外科技术进行改进,并适当结合传统手术方法,使某些过去被认为不能够治疗的复杂主动脉病变可得以成功治疗。     

延伸移植物后撤式释放法治疗胸主动脉夹层动脉瘤腔内隔绝术中近端内漏

目的 总结腔内隔绝术治疗Stanford B型胸主动脉夹层动脉瘤某些特殊情况下近端内漏的治疗方法，比较延伸移植物(cuff)延伸释放法和后撤释放法的价值。方法 2001年以来，stanford B型胸主动脉夹层动脉瘤腔内隔绝术中发生近端内漏6例，分别采用向近端延伸法和后撤法植入cuff封闭内漏。结果 3例采用延伸法，其中1倒采用1枚cuff，1例采用5枚cuff，均完全封闭内漏；1例采用1枚cuff封闭不完全，带漏返回。3例采用后撤法，各用l枚cuff一次性将近端内漏消除。结论 主动脉弓远端或降主动脉近端成角明显时，如腔内隔绝术治疗Stanford B型主动脉夹层动脉瘤术中发生近端内漏，采用后撤法植入cuff是一种效果满意的方法。     

Immediate and 1-year success rate of type 2 endoleak treatment using three-dimensional image fusion guidance

PurposeTo retrospectively assess immediate and 1-year success rate of type 2 endoleak (T2E) treatment with ethylene-vinyl-alcohol-polymer using three-dimensional (3D) image fusion guidance with cone beam computed tomography via trans-arterial embolization (TAE) or direct percutaneous sac injection (DPSI).Materials and methodsA total of 37 patients with T2E who were treated either using TAE (34/37; 92%) or DPSI (9/37; 8%) were included. There were 34 men and 3 women with a mean age of 86 ± 9 (SD) years (range: 67–104 years). Mean aneurysm diameter was 67 ± 14 (SD) mm (range: 42–101 mm) at pre-procedure evaluation. Immediate success was complete embolization of the sac and feeding artery. 1-year success was reduction or stability of the aneurysmal sac diameter based on pre-procedure and 12-month follow-up examinations. Safety (treatment-related complications), patient demographics, duration of procedure and contrast volume were reported.ResultsImmediate and 1-year successful outcomes were reported in 94% (n = 32) and 88% (n = 28) of patients after TAE and 100% (n = 9) and 89% (n = 8) after DPSI. T2E treatments were immediately successful for 95% of the procedures (41/43) and for 88% (36/41) at 1 year. Overall, T2E treatment was effective in 33 patients (89%). No major complications occurred. Mean procedure time and contrast volume were significantly different between the 2 techniques with respectively 87 ± 16 (SD) min (range: 65–120 min) and 75 ± 26 (SD) mL (range: 40–130 mL) for TAE and 32 ± 10 (SD) min (range: 20–50 min) (P < 0.01) and 6 ± 6 (SD) mL (range: 2–22 mL) (P < 0.01) for DPSI. Mean aneurysm diameter at 1-year was 68 ± 17 (SD) mm (range: 43–101 mm). No significant differences in the pre-procedure sac diameter were found at long-term follow-up between patients without T2E and those with persistent T2E (P = 0.1) in the successful embolization group (n = 33).ConclusionTAE or DPSI treatments of T2E with ethylene-vinyl-alcohol-polymer using 3D-image fusion guidance were immediately successful for 95% of the procedures and remained effective for 88%. Longer follow-up is necessary to assess sac stability in the case of persistent endoleak.     

Contrast-enhanced ultrasound (CEUS) versus computed tomography angiography (CTA) in detection of endoleaks in post-EVAR patients. Are delayed type II endoleaks being missed? A systematic review and meta-analysis

Purpose

The purpose of this systematic review is to assess the accuracy of contrast-enhanced ultrasound (CEUS) to computed tomography angiography (CTA) for the detection of endoleaks within EVAR surveillance program.

Material and methods

A systematic review in Pubmed, Embase and Cochrane database was performed. Articles assessing diagnostic accuracy and comparative modality (CTA vs. CEUS) for endoleaks in adult patients within surveillance programs were retrieved. Methodological assessment was performed, using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tools. The sensitivity and specificity of data were extracted and statistical analysis was performed using MetaDiSc version 1.4.

Results

Eight articles were found eligible (n = 454 patients). The pooled sensitivity of CEUS at detecting endoleak is 0.914 (CI 0.866–0.949) and pooled specificity is 0.782 (CI 0.741–0.820).

Conclusion

The CEUS with its dynamic nature and longer scanning window demonstrated to be a highly sensitive modality for endoleak detection in comparison to CTA in delayed endoleaks type II.     

Long-term freedom from aneurysm-related mortality remains favorable after endovascular abdominal aortic aneurysm repair in a 15-year multicenter registry

ObjectiveEndovascular aneurysm repair (EVAR) has become the preferred approach to abdominal aortic aneurysm (AAA) because of lower early morbidity and mortality than open repair. However, the ability of EVAR to prevent long-term aneurysm-related mortality (ARM) has been questioned in light of recent trial data. We have updated our long-term EVAR experience in a large multicenter registry to further examine this issue.MethodsBetween 2000 and 2010, 1736 patients with AAA underwent EVAR in a large integrated regional healthcare system. We extended follow-up in this previously reported cohort through 2015 and identified predictors associated with ARM and need for major reintervention. The primary outcome was ARM. Secondary outcomes were all-cause mortality, delayed aneurysm rupture, major adverse event, major reintervention, sac growth of more than 5 mm, and type I or III endoleak. End points were analyzed for the whole cohort and compared for patients who underwent EVAR during the earlier (2000-2005) and latter (2006-2010) halves of the enrollment period to assess for changes in outcomes over time of repair.ResultsThe overall follow-up rate was 96.3%, and median follow-up was 5.5 years (interquartile range, 2.8-7.7 years). During the study period, 958 patients died, of whom 63 experienced ARM (6.6%). Overall crude rate of freedom from ARM was 96.4%. Delayed aneurysm rupture was seen in 1.3% (n = 23), with a median time to event of 4.1 years (interquartile range, 1.7-7.2 years). Major adverse events occurred in 12.4% of patients, and major reintervention was performed in 10.3%. Overall freedom from major adverse event or major reintervention was seen in 84.0%. Significant predictors of ARM included female sex, age 80 to 89 years, urgent EVAR, and any major reintervention. The unadjusted cumulative probability of all-cause survival was significantly higher in the late group than the early group at 5 years (66.8% vs 59.8%; P = .01, log-rank test); however, freedom from ARM at 5 years was not significantly different (96.5% and 97.1%, respectively; P = .67, log-rank test).ConclusionsOur results demonstrate favorable long-term freedom from major adverse event or major reintervention after EVAR and extremely low rates of ARM and delayed rupture. Our findings support EVAR as a safe, long-term solution for managing patients with AAA and provide insight into clinical parameters that can be used to stratify patients' post-EVAR surveillance and need for reintervention.     

Prophylactic Residual Aneurysmal Sac Embolization with Expandable Hydrogel Embolic Devices for Endoleak Prevention: Preliminary Study in Dogs

Objective To explore the feasibility and efficacy of residual aneurysmal sac (RAS) embolization with the expandable hydrogel embolic device (EHED) in prevention of endoleaks in a surgically created and endoluminally treated abdominal aortic aneurysm (AAA).Methods In eight dogs, an AAA was created by means of side-to-side anastomosis between the infrarenal abdominal aorta and inferior vena cava (IVC) with ligation of the IVC above and below the anastomotic end, followed by deployment of an endograft with holes. The RAS was then embolized with the EHED. One animal was killed immediately after RAS embolization and one animal died 12 hr after the procedure. Follow-up aortograms were obtained in six animals after 1 day (1 animal), 2 weeks and 6 months (1 animal), and 8 weeks (4 animals).Results Four animals had no endoleaks on the follow-up aortograms. The remaining two animals with incomplete RAS embolization had moderate type III endoleaks. Type I or II endoleaks were not seen in any animals. Complications included RAS wall penetration by the devices with platinum wires in two animals (nos. 1 and 2), device migration into an aortic circulation through the endograft holes in two animals (nos. 2 and 3) or through distal interstices between the aortic wall and endograft in one animal (no. 8), aortic occlusion in three animals (nos. 3, 7, and 8), and RAS rupture in one animal (no. 7). Histologic examination showed expanded hydrogels occupying the RAS with associated mature or immature organized thrombus, fibrinous thrombus, or degenerate blood cells.Conclusion RAS embolization was feasible with the EHED, although additional modifications to the device are required to avoid complications. Angiographic and histologic results suggested that RAS embolization with the EHED may help in the prevention of endoleaks.     

Tube Stent-Grafts for Infrarenal Aortic Aneurysm: A Matched-Paired Analysis Based on EUROSTAR Data

Objective Tube stent-grafts for treatment of infrarenal aortic aneurysms (AAAs) are a nearly forgotten concept. For focal aortic pathologies tube stent-grafts may be a treatment option. We have performed a retrospective matched-paired analysis of the EUROSTAR registry regarding the outcome of tube vs. bifurcated stent-grafts for AAA. Tapered aortomonoiliac stent-grafts were not the objective of this study. Materials and methods From July 1997 to June 2006, 7581 patients who underwent an endovascular AAA repair were entered in the EUROSTAR registry by 164 centers. One hundred fifty-three patients were treated with tube stent-grafts. For each of these 153 patients we selected one patient from a bifurcated stent-graft group (BGG-original, 7428 patients) matched according to gender, ASA, age, AAA diameter, and type of anesthesia. Differences in preoperative details between the two study groups were analyzed using chi-square test for discrete variables and Wilcoxon rank-sum test for continuous variables. Multivariate logistic regression analysis was performed on early complications. Midterm outcomes (>30 days) were analyzed by Kaplan-Meier and multivariate Cox proportional hazard model. Results The duration of the procedure was shorter in the tube stent-graft group (TGG; 102.3 ± 52.2) than in BGG (128.3 ± 55.0; p = 0.0002). Type II endoleak was less frequent in TGG (4.0%; mean follow-up, 23.12 ± 23.9 months) than in BGG (14.3%; mean follow-up, 20.77 ± 20.0 months; p = 0.0394). Type I endoleaks and migration were distributed equally, without significant differences between the groups. Combined 30-day and late mortality was higher for TGG (p = 0.0346) and was obviously not aneurysm related. Conclusions We conclude that after selection of patients, tube stent-grafts for infrarenal aortic repair can be performed with great safety regarding endoleaks and migration. The combined higher 30-day mortality and non-aneurysm-related mortality during follow-up were mainly caused by cardiac failures in our sample. On Behalf of the EUROSTAR Collaborators