胸主动脉腔内修复术后截瘫危险因素分析

【摘要】 目的 探讨胸主动脉腔内修复术（TEVAR）后发生截瘫的危险因素。方法 回顾性分析2015年12月至2021年2月在苏州大学附属第一医院接受TEVAR治疗的307例Stanford B型主动脉夹层或胸主动脉瘤患者临床和影像资料。根据术后有无截瘫发生将患者分为截瘫组（8例）和无截瘫组（299例）。观察患者临床指标及围手术期主动脉CTA检查结果。对两组间差异有统计学意义的临床指标进行单因素和多因素logistic 回归分析。 结果 术后截瘫总发生率为2.61%。两组患者间伴冠心病、假腔血栓、围手术期低血压、支架远端距腹腔干开口长度、支架远端真腔狭窄率参数差异有统计学意义（均P＜0.05）。单因素 logistic回归分析显示,围手术期低血压、支架远端距腹腔干开口长度、真腔狭窄率是截瘫发生的危险因素（均P＜0.05）。多因素logistic回归分析显示,围手术期低血压、支架远端距腹腔干开口长度、真腔狭窄率是截瘫发生的独立危险因素（均P＜0.05）。结论 围手术期低血压、支架远端距腹腔干开口长度、真腔狭窄率是TEVAR术后并发截瘫的预测因子。对于主动脉破口较低患者仍需寻找更优化方案封堵破口,保护脊髓供血,避免截瘫发生。     

Complications following endovascular abdominal aortic aneurysm repair

There is a growing population of patients who have undergone endovascular abdominal aortic aneurysm repair (EVAR) and thus there is an increasing likelihood that radiologists who are unfamiliar with this technique and its complications will have to report radiological investigations on one of these patients. The purpose of this review is to describe and illustrate the normal and abnormal radiological appearances after EVAR on plain radiography, ultrasound and CT.     

Low-dose multidetector-row CT-angiography of abdominal aortic aneurysm after endovascular repair

Purpose

To investigate the possibility of reducing radiation dose exposure while maintaining image quality using multidetector computed tomography angiography (MDCTA) with high-concentration contrast media in patients undergoing follow-up after endovascular aortic repair (EVAR) to treat abdominal aortic aneurysm.

Materials and methods

In this prospective, single center, intra-individual study, patients underwent two consecutive MDCTA scans 6 months apart, one with a standard acquisition protocol (130 mAs/120 kV) and 120 mL of iomeprol 300, and one using a low dose protocol (100 mAs/80 kV) and 90 mL of iomeprol 400. Images acquired during the arterial phase of contrast enhancement were evaluated both qualitatively and quantitatively for image noise and intraluminal contrast enhancement.

Results

Thirty adult patients were prospectively enrolled. Statistically significantly higher attenuation values were measured in the low-dose acquisition protocol compared to the standard protocol, from the suprarenal abdominal aorta to the common femoral artery (p < 0.0001; all vascular segments). Qualitatively, image quality was judged significantly (p = 0.0002) better with the standard protocol than with the low-dose protocol. However, no significant differences were found between the two protocols in terms of contrast-to-noise ratio (CNR) (13.63 ± 6.97 vs. 11.48 ± 8.13; p = 0.1058). An overall dose reduction of up to 74% was observed for the low-dose protocol compared with the standard protocol.

Conclusion

In repeat follow-up examinations of patients undergoing EVAR for abdominal aortic aneurysm, a low-dose radiation exposure acquisition protocol provides substantially reduced radiation exposure while maintaining a constant CNR and good image quality.     

Risk factors associated with late aneurysmal sac expansion after endovascular abdominal aortic aneurysm repair

PURPOSE

We aimed to identify the risk factors associated with late aneurysmal sac expansion after endovascular abdominal aortic aneurysm repair (EVAR).

METHODS

We retrospectively reviewed contrast-enhanced computed tomography (CT) images of 143 patients who were followed for ≥6 months after EVAR. Sac expansion was defined as an increase in sac diameter of 5 mm relative to the preoperative diameter. Univariate and multivariate analyses were performed to identify associated risk factors for late sac expansion after EVAR from the following variables: age, gender, device, endoleak, antiplatelet therapy, internal iliac artery embolization, and preprocedural variables (aneurysm diameter, proximal neck diameter, proximal neck length, suprarenal neck angulation, and infrarenal neck angulation).

RESULTS

Univariate analysis revealed female gender, endoleak, aneurysm diameter ≥60 mm, suprarenal neck angulation >45°, and infrarenal neck angulation >60° as factors associated with sac expansion. Multivariate analysis revealed endoleak, aneurysm diameter ≥60 mm, and infrarenal neck angulation >60° as independent predictors of sac expansion (P < 0.05, for all).

CONCLUSION

Our results suggest that patients with small abdominal aortic aneurysms (<60 mm) and infrarenal neck angulation ≤60° are more favorable candidates for EVAR. Intraprocedural treatments, such as prophylactic embolization of aortic branches or intrasac embolization, may reduce the risk of sac expansion in patients with larger abdominal aortic aneurysms or greater infrarenal neck angulation.The aim of endovascular abdominal aortic aneurysm repair (EVAR) is to prevent rupture of an abdominal aortic aneurysm (AAA) by depressurizing the aneurysm and excluding it from the systemic circulation using a stent-graft. Aneurysmal sac reduction is a reliable marker for the long-term prognosis after EVAR. Although most aneurysmal sacs shrink after EVAR, some sacs continue to expand. A relationship between aneurysm size and endoleaks was previously reported (1, 2). Most type II endoleaks spontaneously disappear over time, but 10%–25% persist for more than six months after EVAR (3–6). Persistent endoleaks with aneurysmal sac expansion are at high risk of rupture because of the continuously elevated intra-aneurysmal pressure and require a second intervention, such as embolization (7–11). However, it is difficult to predict sac expansion and persistent endoleak before performing EVAR. Although intraoperative intrasac thrombin injection and prophylactic embolization of aortic branches such as the inferior mesenteric artery and lumbar artery are reported to reduce the incidence of type II endoleak, the efficacy and clinical benefit of these procedures in terms of late postoperative aneurysm shrinkage have not been fully evaluated (12–15). Therefore, the purpose of this study was to identify the risk factors associated with late aneurysmal sac expansion after EVAR to determine possible indications for intrasac embolization and prophylactic embolization of aortic branches.     

Renal perfusion defects after endovascular repair of abdominal aortic aneurysms

PURPOSE: To determine the prevalence of new renal perfusion defects and the association of these events with aneurysm neck atheroma during endovascular stent-graft repair of abdominal aortic aneurysm (AAA). MATERIALS AND METHODS: A retrospective review was performed of 50 patients who underwent AAA repair with bifurcated endovascular stent-grafts without suprarenal components between June 1998 and May 1999. Pre- and postprocedural computed tomographic (CT) angiograms were reviewed to determine the prevalence of new renal perfusion defects. The percent volume of atheroma of the aneurysm neck was determined by three-dimensional volumetric reformation and correlated with prevalence of new postprocedural renal perfusion defects. Follow-up CT angiography was performed between 6 months and 2 years after the procedure and used to evaluate the presence of residual defects and interval changes. RESULTS: Of 50 subjects, 18% (n = 9) had new perfusion defects presumed to be embolic in origin. Follow-up was available for four patients: scarring and cortical thinning consistent with infarction developed in two, whereas the defects resolved in the other two. Analysis of aneurysm neck revealed an average percentage of atheroma of 32% and a range of 0%-73%. In subjects with >/=40% neck atheroma, the prevalence of new renal perfusion defects was 45.4% (five of 11), compared to 10.3% (four of 39) in subjects with <40% neck atheroma. This difference was significant (P =.0170). CONCLUSIONS: In this series, the frequency of renal embolic events associated with AAA endovascular repair was 18%. Prevalence of renal embolic perfusion defects was shown to correlate with volume of aneurysm neck atheroma.     

Complications of endovascular repair for thoracic and abdominal aortic aneurysm: an imaging spectrum.

Endovascular stent-graft implantation is an alternative to conventional open surgery for the treatment of aortic aneurysm. Forty-nine consecutive patients with aortic aneurysm (thoracic, n = 17; infrarenal, n = 32) were treated with endovascular stent-graft implantation. Complications occurred in 25 patients (two patients had two complications): endoleak (n = 13), graft thrombosis (n = 5), graft kinking (n = 2), pseudoaneurysm caused by graft infection (n = 1), graft occlusion (n = 1), shower embolism (n = 1), perforation of mural thrombus by means of inadvertent penetration of delivery system (n = 1), colon necrosis (n = 1), aortic dissection (n = 1), and hematoma at the arteriotomy site (n = 1). Imaging findings were analyzed for spiral computed tomography, plain abdominal radiography, transesophageal echocardiography, and digital subtraction angiography. Since some of these complications are fatal, radiologists need to instantly and accurately recognize them. Awareness and understanding of possible complications should help ensure a safe, successful procedure.     

腹主动脉瘤腔内修复术22例围手术期处理回顾性总结

目的 总结腹主动脉瘤腔内修复术(EVAR)围手术期处理的临床经验.方法 回顾分析22例腹主动脉瘤患者EVAR临床经过,通过术前对主要脏器功能进行评估和保护,CTA测量近远侧瘤颈长度、直径、角度和构型,瘤体与分支动脉的关系,最低肾动脉开口至腹主动脉分叉的距离,导入途径的直径、扭曲和钙化程度.根据CTA测量结果,选择覆膜支架和手术方式.术时采用局麻20例,中转全麻l例,1例通过髂总动脉重建导人途径采用硬膜外麻醉,1例合并Stanf.0rd A型主动脉夹层,术时采用全麻.在支架释放前准确定位最低肾动脉位置,至少保留一侧通畅的髂内动脉,若双侧需要覆盖,分期覆盖或髂内动脉重建.支架植入后复查造影,有无内漏.正确判断内漏类型并进行相应处理.支架近端Ⅰ内漏2例,球囊扩张1例,植入Cuff 1例;支架远端Ⅰ内漏1例,球囊扩张时,动脉破裂,行人工血管补片修补术;Ⅲ型内漏3例,球囊扩张后支架植入1例.1例合并Starford A型主动脉夹层先行胸主动脉腔内修复术,后行EVAR.术后7一10 d复查CTA,以后每年复查1次.结果 EVAR手术全获成功.主要并发症为单侧髂肢扭结继发血栓形成,Fogarty导管取栓并支架植人1例;腹壁切口裂开1例,清创缝合;无手术死亡,随访6个月～5年,患者均存活.结论 CTA图像质量高、测量准确,是EVAR术前评估和术后随访的金标准.EVAR是高危、高龄腹主动脉瘤患者有效的治疗方法.     

Endovascular treatment of endoleaks after endovascular abdominal aortic aneurysm repair: personal experience

PURPOSE: This paper describes the different endovascular treatments (cuffs, endografts and embolisation) available for types I, II and III endoleaks occurring after endovascular abdominal aortic aneurysm repair (EVAR). MATERIALS AND METHODS: From January 2000 to June 2006, 134 patients (118 men, 16 women; mean age 75.1 years) underwent EVAR. Ten patients (7%) developed significant endoleaks requiring endovascular treatment. RESULTS: Five endoleaks were type I, two were type II and three were type III. Of the five type I endoleaks, four were proximal and one was distal. The proximal endoleaks were treated by cuff deployment, whereas the distal endoleak was treated with a bifurcated graft. Of the two patients with type II endoleak, one was treated by translumbar puncture and coil embolisation, and the other was treated by superselective embolisation of the lumbar feeding vessel with nonresorbable particles. Of the three patients with type III endoleak, two were treated by deploying an aortouniiliac endograft inside the bifurcated graft and the other by implanting a cuff to restore continuity between the graft body and the contralateral limb. Endovascular treatment was successful in 6/10 cases, whereas three cases required surgical conversion. One patient did not undergo surgery owing to poor general condition. CONCLUSIONS: The reported incidence of endoleaks after EVAR is 10%-20%. Significant endoleaks should be treated promptly. Endovascular treatment can be done with different techniques, but success in not constant due to adverse anatomical conditions and technical difficulties.     

Follow-up of abdominal aortic aneurysm after endovascular aortic repair: comparison of volumetric and diametric measurement

Purpose

To determine the correlation of maximal diameter measurements with volumetric evaluation of size after endovascular aortic repair (EVAR) of abdominal aortic aneurysms (AAA) using computed tomography angiography (CTA) and to survey its applicability for clinical follow-up.

Materials and methods

73 consecutive patients (2 females, 71 males; age 38–84 years; mean age, 69.1 ± 8 years) with AAA were treated with percutaneous EVAR in a single institution. For follow-up, CTA was performed periodically after EVAR. Images were evaluated for maximal diameter in consensus by two experienced radiologists. Using OsirixTM, volumetric measurements were done by one radiologist, including the entire infrarenal abdominal aorta.

Results

In 73 patients 220 CTA examinations were performed after EVAR with a mean follow-up of 17.3 months (range, 1.8–42.7 months). The mean postinterventional volume of aneurysm was 165.63 ml ± 93.29 ml (range, 47.94–565.67 ml). The mean maximal postinterventional diameter was 5.91 ± 1.52 cm (range, 3.72–13.82 cm). At large over the entire observation period a slight, non-significant decrease of 1.6% (2.58 ml ± 69.05 ml, range 82.82–201.92 ml) in volumes and a 9.3% (mean 0.55 cm ± 1.22 cm, range 2.85–1.93 cm) in diameters were observed. For all examinations a high correlation of volume and diameter was calculated (r = 0.813–0.905; α < 0.01).

Conclusion

For follow-up of abdominal EVAR using CTA there is a high correlation between volumetric and diametric measurements of aneurysm. Based on a daily clinical routine setting, measurements of maximal diameters in cross sectional imaging of AAA after EVAR seems to be sufficient to exclude post interventional enlargement.     

Renewed endovascular repair for recurrent acute abdominal aortic aneurysm

The aim of the study was to describe the successful endovascular management of a patient who was admitted urgently with a second episode of acute abdominal aortic aneurysm (AAA) 30 months after emergency endovascular abdominal aortic aneurysm repair (eEVAR) for a ruptured AAA. The patient, an 84 year-old male physician, presented with severe acute abdominal and back pain. Contrast-enhanced computer tomography scanning showed type III endoleak owing to complete disconnection of both graft limbs and the prosthetic main body. Treatment consisted of acute stent-grafting with two bridging stent-grafts to seal the endoleak and reline the graft. The patient is alive and well 6 months postoperatively. This case indicates the need for follow-up after eEVAR, but also that complications can be managed endovascularly.     

Endovascular occlusion of an aortic coarctation after thoracic endovascular aortic repair of an anastomotic aneurysm

A 58-year-old man with a history of aortic and mitral mechanical valve replacement was referred to our hospital for symptomatic chronic heart failure. In 1988, he had undergone open surgical correction of an isthmic aortic coarctation (CoA), with the creation of an extra-anatomic bypass from the left subclavian artery to the descending thoracic aorta. The following findings were found: severe mitral valve failure with perivalvular leakage, severe aortic valve stenosis, pulmonary hypertension, distal anastomotic aneurysm with the apparent occlusion of the CoA. A thoracic endovascular aneurysm repair was performed. A postoperative high-pressure leak with no evident signs of ineffective sealing was observed. Computed tomography angiography (CTA) 3D reconstruction demonstrated the recanalization of the CoA. A second procedure was planned. The CoA was anterogradely cannulated. Three coils were deployed into the aneurysmal sac, followed by a vascular plug, positioned on the coarctation conduit, but it failed to anchor and dislocated into the sac. A second plug was deployed, but it also partially dislocated. Finally, a patent foramen ovale occluder device was deployed to occlude the communication. The final angiogram showed the complete occlusion of the coarctation and correction of the leak, which was confirmed by a 6-month post-operative CTA.

For patients who undergo surgical repair of aortic coarctation (CoA), lifelong follow-up should be mandatory, due to the risk of long-term complications. Up-to-date guidelines suggest surgical correction of the CoA in infants, in order to maintain the aortic flow, while an endovascular approach is preferred in adults (1, 2). We describe a case of CoA catheter-based occlusion with a patent foramen ovale (PFO) closure device.A 58-year-old man with a history of aortic and mitral mechanical valve replacement was referred to our hospital for symptomatic chronic heart failure. In 1988, he had undergone open surgical correction of an isthmic aortic coarctation, with the creation of an extra-anatomic bypass from the left subclavian artery to the descending thoracic aorta.Transesophageal and transthoracic ultrasound evaluations showed severe mitral valve failure with perivalvular leakage, severe aortic valve stenosis, and pulmonary hypertension. Computed tomography angiography (CTA) confirmed the aforementioned findings and showed enlargement of the anastomotic aneurysm (from 47 mm to 58 mm) with the apparent occlusion of the CoA (Fig. 1a). Progressive worsening of the symptoms required prompt surgical substitution of the mechanic valves. However, after consultation with the cardiac surgery team, it was decided to postpone the procedure to perform thoracic endovascular aneurysm repair (TEVAR) first, in order to reduce the risk of aneurysm rupture during open heart surgery.Open in a separate windowFigure 1. a, bComputed tomography angiography (CTA) image (a) confirms enlargement of the anastomotic aneurysm with apparent occlusion of the aortic coarctation. Standard thoracic endovascular aortic repair was performed with a Conformable C-TAG (b, 31/150 mm, W. L. Gore and Associates). LSA, left subclavian artery; DTA, descending thoracic aorta.     

Device migration after endovascular abdominal aortic aneurysm repair: experience with a talent stent-graft

PURPOSE: Device migration (DM) may cause late failure after endovascular aortic aneurysm repair (EVAR). Computed tomography (CT) scans following EVAR were reviewed to establish the frequency of DM and whether it can be predicted. MATERIALS AND METHODS: Fifty-five patients underwent EVAR with a Talent stent-graft with suprarenal fixation. CT with a fixed protocol was performed at regular intervals. Patient demographics, risk factors, procedure details, and follow-up events were reviewed. Two observers, blinded to each other, reviewed axial images and mutliplanar reformats of the CT scans. DM was defined as a change of > or = 10 mm in the distance between a reference vessel (celiac axis/superior mesenteric artery) and the proximal device. Follow-up was performed for a minimum of 2 years (mean, 3 years; range, 2-5 years). RESULTS: DM was detected in six of 38 patients (15.8%) by 2 years. There were no new cases of migration in the 19 patients at 3 years but one new case in the six patients at 4 years (16.6%). Mean migration over 2 years was 4.8 mm +/- 4.2 mm. One patient with DM developed a type I endoleak that required reintervention. This patient developed a further endoleak and died following surgery for rupture. Top neck enlargement was the only predictive factor identified, present in 71% of patients with DM (P = .056). CONCLUSION: DM occurred in a small proportion of patients; closer follow-up intervals may be necessary in patients with short/enlarging proximal necks.     

Complete ten-year follow-up after endovascular abdominal aortic aneurysm repair: survival and causes of death

Purpose

To analyze the hazard and causes of death after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms during a complete ten year follow-up.

Methods

This is a retrospective clinical study of 130 consecutive patients undergoing EVAR between 1995 and 1998. One-hundred twenty-one patients (93.1%) were treated with first-generation stentgrafts and nine patients (6.9%) received second-generation devices. All patients completed a follow-up of at least 10 years, unless death occurred before then. Time and causes of death were provided by the Austrian central register of deaths.

Results

The median follow-up was 7.6 years, and the 130 patients had 968.5 person-years of follow-up. The ten-year mortality rate was 62.3%. Cardiovascular events were the most frequent causes of death, with a 3.9 incidence rate per 100 person-years. Cancer death and death due to other causes occurred in 2.1 and 1.8 cases per 100 person-years, respectively. Lethal late aneurysm rupture happened in 4.6% (n = 6), which corresponds to an annual incidence rate of 0.6 per 100 person-years. All of those patients had been treated with first-generation devices.

Conclusions

Cardiovascular events were the most frequent cause of death after EVAR, followed by malignancy and other diseases. The risk of dying from secondary rupture was clearly lower than that of death due to other reasons during ten years after EVAR, even in patients with first-generation stentgrafts.     

采用血管缝合器治疗复杂型腹主动脉瘤腔内隔绝术一例

腹主动脉瘤腔内修复术(TEVAR)常规采用双侧股动脉切开途径置入.我们采用血管缝合器顺利完成1例复杂型TEVAR,现报道如下.患者男,56岁.既往有10年高血压、糖尿病及糖尿病肾病史,行口服药物治疗.3年前发现腹部搏动性包块,CT确诊断为肾下型腹主动脉瘤,当时测得瘤体最大径约35 mm.