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1.
Konstantinos P. Donas Gergana T. Taneva Georgios A. Pitoulias Giovanni Torsello Frank J. Veith 《Journal of vascular surgery》2019,69(4):1072-1079.e1
Objective
Hypogastric aneurysms (HAs) frequently coexist with aortoiliac aneurysms (AIAs). However, the presence of an HA is a contraindication to endovascular aneurysm treatment by iliac branch devices (IBDs) because of the risk of distal sealing-related endoleaks. No robust evidence exists in the published literature, and therefore we sought to evaluate the performance of IBDs in the presence of HAs within a multicenter registry of nine vascular centers.Methods
Clinical and radiographic information of 804 patients with AIAs treated by IBDs was retrospectively reviewed and analyzed using prearranged, defined, and documented protocols. The treatment period was between January 2005 and April 2017.Results
HA was present in 315 (32.6%) of the overall 910 deployed IBDs. Mean radiologic follow-up was 32 months. The incidence of incomplete aneurysm exclusion and type I endoleak was 3% in the HA group vs 0.7% in the non-HA group (P = .019). The 5-year freedom from IBD-related type I endoleak was 93% vs 98% in the HA group vs the non-HA group, respectively (P = .006). Subgroup analysis of the HA group revealed that use of a single distal bridging stent graft vs multiple bridging devices led to higher rate of type I endoleak (9.6% vs 2.8%; P = .031), branch occlusions (8.3% vs 0.9%; P = .009), and buttock claudication (7.6% vs 1.9%; P = .038).Conclusions
This series of AIAs with HAs is the largest reported. It shows that HAs coexisting with AIAs, when treated with IBDs, have significantly worse outcomes. Lengthening the distal landing zone with more than one bridging stent graft into the distal healthy hypogastric artery or one of its main branches improves outcomes. 相似文献2.
Gustavo S. Oderich Mauricio Ribeiro Jan Hofer Jean Wigham Stephen Cha Julia Chini Thanila A. Macedo Peter Gloviczki 《Journal of vascular surgery》2017,65(5):1249-1259.e10
Purpose
To investigate outcomes of manufactured fenestrated and branched endovascular aortic repair (F-BEVAR) endografts based on supraceliac sealing zones to treat pararenal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs).Methods
A total of 127 patients (91 male; mean age, 75 ± 10 years old) were enrolled in a prospective, nonrandomized single-center study using manufactured F-BEVAR (November 2013-March 2015). Stent design was based on supraceliac sealing zone in all patients with ≥ four vessels in 111 (89%). Follow-up included clinical examination, laboratory studies, duplex ultrasound, and computed tomography imaging at discharge, 1 month, 6 months, and yearly. End points adjudicated by independent clinical event committee included mortality, major adverse events (any mortality, myocardial infarction, stroke, paraplegia, acute kidney injury, respiratory failure, bowel ischemia, blood loss >1 L), freedom from reintervention, and branch-related instability (occlusion, stenosis, endoleak or disconnection requiring reintervention), target vessel patency, sac aneurysm enlargement, and aneurysm rupture.Results
There were 47 pararenal, 42 type IV, and 38 type I-III TAAAs with mean diameter of 59 ± 17 mm. A total of 496 renal-mesenteric arteries were incorporated by 352 fenestrations, 125 directional branches, and 19 celiac scallops, with a mean of 3.9 ± 0.5 vessels per patient. Technical success of target vessel incorporation was 99.6% (n = 493/496). There were no 30-day or in-hospital deaths, dialysis, ruptures or conversions to open surgical repair. Major adverse events occurred in 27 patients (21%). Paraplegia occurred in two patients (one type IV, one type II TAAAs). Follow-up was >30 days in all patients, >6 months in 79, and >12 months in 34. No patients were lost to follow-up. After a mean follow-up of 9.2 ± 7 months, 23 patients (18%) had reinterventions (15 aortic, 8 nonaortic), 4 renal artery stents were occluded, five patients had type Ia or III endoleaks, and none had aneurysm sac enlargement. Primary and secondary target vessel patency was 96% ± 1% and 98% ± 0.7% at 1 year. Freedom from any branch instability and any reintervention was 93% ± 2% and 93% ± 2% at 1 year, respectively. Patient survival was 96% ± 2% at 1 year for the entire cohort.Conclusions
Endovascular repair of pararenal aortic aneurysms and TAAAs, using manufactured F-BEVAR with supraceliac sealing zones, is safe and efficacious. Long-term follow-up is needed to assess the impact of four-vessel designs on device-related complications and progression of aortic disease. 相似文献3.
Hector W.L. de Beaufort Elena Cellitti Quirina M.B. de Ruiter Michele Conti Santi Trimarchi Frans L. Moll Constantijn E.V.B. Hazenberg Joost A. van Herwaarden 《Journal of vascular surgery》2018,67(1):104-112.e3
Objective
The objective of this study was to describe our experience with endovascular aneurysm repair (EVAR) with the use of chimney grafts for branch vessel preservation.Methods
Patients treated with a chimney graft procedure between October 2009 and May 2015 were included for analysis. Patients who were not considered eligible for open surgical repair or for conventional, branched, or fenestrated endovascular repair were selected. A standardized operating procedure with left brachial or axillary artery cutdown access for the chimney grafts and bilateral femoral artery cutdown access for the aortic main device was used. Outcomes were noted according to the Society for Vascular Surgery reporting standards. In addition, evolution of gutter area over time was determined. Estimated rates of survival, freedom from aneurysm growth, and clinical success at 24 months of follow-up were calculated.Results
Thirty-three patients (mean age, 77.6 ± 6.8 years; 87.9% male) with a mean preoperative maximum aneurysm diameter of 71.7 ± 13.5 mm were included. A total of 54 of an intended 54 chimney grafts were deployed. Primary technical success and 30-day secondary clinical success rates were 87.9% and 84.8%, respectively. The early mortality rate was 6.1% (n = 2). The early type IA endoleak rate was 6.1% (n = 2), and the chimney graft occlusion rate was 6.1% (n = 2). Median follow-up duration was 26 months (interquartile range, 14.8-37.3 months). The estimated 2-year actuarial survival rate was 78.1% (standard error, ±7.4%). Late complications included type IA endoleak (n = 1), chimney graft occlusion (n = 2), type II endoleak with aneurysm growth (n = 4), and distal stent graft limb kinking and occlusion (n = 1). Late reinterventions included coil or glue embolization (n = 3), distal limb extension (n = 2), open endoleak ligation (n = 2), Palmaz stent placement (n = 1), repeated EVAR (n = 1), and femorofemoral bypass graft (n = 1). At 2 years, the estimated secondary clinical success and freedom from aneurysm growth rates were 80.5% (±7.2%) and 84.4% (±7.2%). Gutter size showed a small but significant decrease over time at the level of the proximal markers and at 10 mm distal from the markers.Conclusions
Midterm results show that a standardized procedure for EVAR using chimney grafts for branch vessel preservation is an acceptable option for high-risk patients with large, complex aneurysms who are unfit for open repair and who have been excluded from fenestrated EVAR. Gutter size decreases over time, but the rate of branch vessel loss and reinterventions demonstrate that this approach should remain reserved for those who are at truly prohibitive risk for open or fenestrated stent graft repair. 相似文献4.
Theodoros Kratimenos Constantine N. Antonopoulos Dimitrios Tomais Panagiotis Dedeilias Vasileios Patris Ilias Samiotis John Kokotsakis Dimosthenis Farsaris Michalis Argiriou 《Journal of vascular surgery》2019,69(4):996-1002.e3
Objective
The aim of the study was to present the results for patients with atherosclerotic aneurysm of the descending thoracic aorta (DTA) treated with a novel thoracic stent graft.Methods
A single-center retrospective review of prospectively collected data was performed. We extracted demographic variables as well as atherosclerotic comorbidities and operation-related and imaging-related data from patients' medical records. We estimated technical success rate, in-hospital and 30-day mortality, and mortality at the end of follow-up as well as complication and reintervention rate in our study cohort. Follow-up computed tomography angiography was performed after 1 month and 6 months and yearly thereafter.Results
A total of 30 patients (80% male; mean age, 73.7 ± 6.33 years) were treated with Ankura Thoracic Stent Graft (Lifetech, Shenzhen, China) for DTA aneurysm from February 2014 until June 2017. Technical success of the thoracic endovascular aortic repair (TEVAR) was 97% (29/30 patients). A surgical conduit was required in one patient; in three patients, we intentionally covered the left subclavian artery because of insufficient proximal landing zone. No aorta-related deaths were recorded during follow-up. During the early postoperative period, two patients (7%) with long DTA coverage developed paralysis or paraparesis, which immediately resolved after lumbar drainage. No renal complications requiring dialysis were observed. One patient (3%) developed postoperative pulmonary infection, whereas access site complications were 7%. Two symptomatic patients treated outside instructions for use (7%) developed early type IA endoleak and one patient (3%) developed type IB endoleak; type II endoleak was recorded in 3% of the study cohort. During the 30-day postoperative period, two patients died of non-TEVAR-related causes, one of gastrointestinal bleeding and the other of pulmonary infection. During a median follow-up of 31.7 (range, 38.4) months, two more patients also died of non-TEVAR-related causes, one of stroke from carotid artery disease and the other of motor vehicle trauma. In the rest of the cohort, no other adverse events were noted.Conclusions
This novel endograft showed early evidence of a safe, effective, and durable endoprosthesis for the treatment of DTA aneurysms. 相似文献5.
Bruno Gossetti Ombretta Martinelli Michelangelo Ferri Roberto Silingardi Fabio Verzini 《Journal of vascular surgery》2018,67(5):1397-1403
Objective
Because of advances in technology and experience of the operator, endovascular aneurysm repair (EVAR) has supplanted open repair to treat abdominal aortic aneurysm (AAA). The low 30-day mortality and morbidity of EVAR make the endovascular approach particularly suitable for patients at high surgical risk. However, endoleak or endograft migration requiring secondary intervention or open surgical conversion is a limitation of EVAR. The Nellix system (Endologix, Inc, Irvine, Calif) has been designed to seal the entire AAA to overcome these limitations with EVAR. We report the results of a retrospective, multicenter study with endovascular aneurysm sealing (EVAS) aimed to assess technical success, procedure-related mortality, complications, and reinterventions.Methods
This study included patients selected for elective treatment with the Nellix device per the endovascular repair protocol at 16 Italian vascular centers. All patients were enrolled in a postoperative surveillance imaging program including duplex ultrasound investigations, computed tomography, and magnetic resonance controls following local standards of care.Results
From 2013 to 2015, there were 335 patients (age, 75.5 ± 7.4 years; 316 men) who underwent elective EVAS. In 295 cases (88.0%), EVAS was performed under standard instructions for use of the Nellix system. Preoperative aneurysm diameter was 55.5 ± 9.4 mm (range, 46-65 mm). The inferior mesenteric artery and lumbar arteries emerging from the AAA were patent in 61.8% and 81.3% of cases, respectively. Chimney grafts were electively carried out in eight cases (2.4%). One (0.3%) intraprocedural type IB endoleak was observed and promptly corrected. Device deployment was successful in all patients, with no perioperative mortality. Early (≤30 days) complications included 1 (0.3%) type IA endoleak, 2 (0.6%) type II endoleaks (0.6%), 2 (0.6%) stent occlusions (0.6%), 3 (0.9%) distal embolizations, and 2 (0.2%) femoral artery dissections. Six (2.9%) patients underwent reinterventions. At 1-year follow-up, complications included 3 (1.1%) type II endoleaks, 4 (1.4%) type IA endoleaks, 1 (0.3%) type IB endoleak, 2 (0.7%) distal stent migrations, 5 (1.8%) distal embolizations, and 1 (0.3%) stent occlusion. Twelve patients (3.7%) underwent reinterventions, including four (1.4%) surgical conversions due to aortoduodenal fistula (1), endograft infection (1), and type IA endoleak that was unsuccessfully treated percutaneously (2). Two AAA-related deaths occurred. Freedom from aneurysm-related reintervention was 98.3% at 1-month and 94.7% at 12-month follow-up.Conclusions
The preliminary results of this real-world multicenter study showed that EVAS with Nellix for the management of AAAs appears feasible. This device platform is associated with acceptable procedure-related mortality and low overall complication and reintervention rates. Definitive conclusions on the value of this novel device await long-term follow-up data. 相似文献6.
Michael C. Madigan Michael J. Singh Rabih A. Chaer Georges E. Al-Khoury Michel S. Makaroun 《Journal of vascular surgery》2019,69(2):432-439
Objective
Most type II endoleaks have a benign natural history, but 6% to 8% are associated with sac enlargement and respond poorly to treatment. Our aim was to evaluate whether these enlargements are associated with delayed or occult type I and III endoleaks.Methods
Patients with interventions for endoleak after endovascular aortic repair from 2000 to 2016 were reviewed retrospectively. Patient demographics, comorbidities, endoleak type, secondary procedures, aortic sac growth (≥5 mm), and mortality were collected. Successful treatment was defined as endoleak resolution with no further aortic sac growth. Secondary procedures, ruptures, endograft explant, and death were captured.Results
There were 130 patients diagnosed with a primary type II endoleak after endovascular aortic repair at a median of 1.3 months (interquartile range, 1.0-13.3 months). One hundred eighteen had their initial treatment for a primary type II. Twelve of the 130 were initially stable and observed, but were treated for a delayed type I or III endoleak. The 130 patients underwent 279 procedures for endoleaks (mean of 2.2 ± 1.3) over 6.9 ± 3.8 years of follow-up. Of the 118 patients treated for primary type II endoleaks, 26 (22.0%) later required interventions for delayed type I and III endoleaks. The mean time to intervention for a delayed type I or III endoleak was 5.4 ± 2.8 years. Overall, there were 16 type IA, 11 type IB, 2 type III, 7 combined type IA/IB, and 2 type IA/III delayed endoleaks. The odds of harboring a delayed type I or III endoleak was 22.0% before the first attempt at type II endoleak treatment, 35.1% before the second, 44.8% before the third, and 66.6% before the fourth attempts. Rapid aortic sac growth of ≥5 mm/y before initial endoleak treatment was associated with increased risk for delayed type I or III endoleak (47.8 vs 14.1%; P = .003). Patients with delayed type I or III endoleaks had a lower successful treatment rate (8.3% vs 52.3%; P = .001) than those with only type II endoleaks. Late rupture was increased with delayed type I or III endoleak (P = .002), whereas mortality (P = .96) and aortic-related mortality (P = .46) were similar. Graft explant (P = .06) trended toward an increase with a delayed type I or III endoleak, but was not statistically significant.Conclusions
Failed attempts treating type II endoleaks and/or a rapid aortic sac growth of 5 mm/y or greater should raise the suspicion of a delayed or occult type I or III endoleak. Occult endoleaks are associated with decreased chance of endoleak resolution. 相似文献7.
Yuk Law Tilo Kölbel Fiona Rohlffs Christian Behrendt Franziska Heidemann Eike Sebastian Debus Nikolaos Tsilimparis 《Journal of vascular surgery》2019,69(2):334-340
Objective
Manufacturers often recommend the iliac arteries as the distal landing zone in fenestrated or branched endovascular aortic repair (FB-EVAR) for thoracoabdominal aneurysm. It is not uncommon to choose distal landing at the infrarenal aorta for preservation of lumbar arteries or the inferior mesenteric artery (IMA); however, the safety and durability of this procedure have not been verified in the literature.Methods
Consecutive patients who underwent FB-EVAR with distal landing at the infrarenal aorta were reviewed retrospectively. The primary outcome measured any type IB endoleak over time. Secondary outcomes measured perioperative complications of paraplegia and bowel ischemia, preservation of lumbar artery and IMA, and degeneration of infrarenal aorta (diameter of infrarenal aorta at landing zone) and common iliac arteries (maximum diameters) over time.Results
Between August 2011 and August 2017, 40 patients (40% male with a mean age of 72 ± 8 years) affected by types I (37.5%), II (25.0%), III (20.0%), and V (17.5%) thoracoabdominal aneurysms were included. The mean aneurysm diameter was 6.4 ± 1.5 cm. There was no immediate or delayed type IB endoleak with mean follow-up period of 15 ± 18 months (range, 0-72 months). Postoperative complications included six (15%) spinal cord ischemia (five temporary and one permanent) and no mesenteric ischemia. There were three deaths (7.5%) within 30 days. Follow-up with computed tomography arteriography showed that 37 patients (92.5%) had at least one lumbar artery preserved. Out of the 31 preoperatively patent IMA, 23 (74.2%) were preserved. There was one incidental finding of new focal dissection distal to the stent graft end. Mean infrarenal aorta diameters were 24.8, 27.7, 27.7, and 29.4 mm immediately preoperatively, and at 1 and 2 years postoperatively, respectively. The mean maximal right common iliac diameters were stable and measured 15.8, 15.9, and 14.8 mm preoperatively, immediately postoperatively, and 1 year postoperatively, respectively. Mean maximal left common iliac diameters were also stable and measured 15.7, 15.9, and 14.7 mm preoperatively, immediately postoperatively, and at 1 year postoperatively, respectively.Conclusions
Our early experience showed that distal landing at the infrarenal aorta was secure in FB-EVAR with no type IB endoleak, although the observation of gradual infrarenal aortic degeneration mandates regular surveillance. 相似文献8.
Shinichi Iwakoshi Shigeo Ichihashi Takeshi Inoue Takashi Inoue Futoshi Sakuragi Shoji Sakaguchi Kimihiko Kichikawa 《Journal of vascular surgery》2019,69(4):1021-1027
Objective
The objective of this study was to assess the accuracy of predicting stent graft position for thoracic endovascular aortic repair by measuring three lengths of the virtual stent graft: smaller curvature (SC), center lumen line (CL), and greater curvature (GC).Methods
From January 2012 to December 2016, patients treated at our institution were analyzed retrospectively. Patients who were treated with more than two devices, patients treated for aortic dissection, and cases without complete preoperative or postoperative computed tomography (CT) data were excluded. From the preoperative CT data, the virtual stent graft image based on the SC (SCVS) was created so that its SC length matched that of the stent graft actually used. In the same manner, virtual stent graft images based on the CL (CLVS) and GC (GCVS) were created. These virtual stent graft images were created using SYNAPSE VINCENT software (Fujifilm Co, Tokyo, Japan) and superimposed on the postoperative CT image to measure the misalignment between these virtual stent graft images and the actual stent graft. These misalignments were compared using Wilcoxon signed rank sum test. In addition, the actual length (AL) of the stent graft was measured on the basis of the CL from postoperative CT data and compared with its original length (OL).Results
A total of 35 cases were analyzed. Twenty-six patients were men. The average age of the patients was 72.4 ± 13.0 years. The proximal landing zone were located at the descending aorta (n = 11) and the aortic arch (n = 24). The misalignment between SCVS, CLVS, and GCVS and actual stent graft position was ?47.8 ± 18.1 mm, ?21.5 ± 9.4 mm, and 5.3 ± 7.4 mm, respectively. The difference in means between the three groups was significant (P < .001). The relationship between the AL based on CL and OL was represented by the formula AL = OL * 0.92 ? 0.05 (in the descending aorta) and AL = OL * 0.77 + 9.85 (in the aortic arch).Conclusions
Compared with CLVS and SCVS, GCVS was the most accurate predictor of stent graft position for thoracic endovascular aortic repair. 相似文献9.
Background
Endovascular aneurysm repair is a minimally-invasive method for the treatment of abdominal aortic aneurysms. For aneurysms that involve the visceral arteries, a custom-made stent graft with fenestrations for the branch arteries is required. The purpose of the current study is to evaluate the structural impact of misaligned fenestrations with respect to luminal patency and proximal aortic neck apposition in an in vitro model.Methods
A custom apparatus was used to evaluate seven Anaconda and three Zenith fenestrated stent grafts. All stent grafts were evaluated at 10° increments of stent/fenestration misalignment up to 80°. Images were captured at each interval and the luminal cross-sectional area and wall apposition were measured.Results
The Anaconda stent graft, which has an unsupported main body, demonstrated a linear reduction in luminal patency at increasing angles of misalignment (P < 0.0001). Stent/fenestration misalignments of 20° and 80° resulted in decreases in mean luminal patency of 14% and 54% respectively. The Zenith stent graft demonstrated a similar decrease in luminal patency, starting at misalignments of ≥40° (P < 0.0001). However, with stent/fenestration misalignments of ≥30°, apposition between the Zenith stent graft and the simulated aortic neck was compromised suggesting the creation of a type Ia endoleak.Conclusions
Both the Anaconda and Zenith devices behave adversely at extreme angles of misalignment with luminal narrowing in the Anaconda device and loss of wall apposition in the Zenith device; however, both stent grafts appear to be equivalent at low angles of misalignment. 相似文献10.
Adam Tanious Mathew Wooster Paul A. Armstrong Bruce Zwiebel Shane Grundy Martin R. Back Murray L. Shames 《Journal of vascular surgery》2018,67(5):1353-1359
Objective
A number of adjunctive “off-the-shelf” procedures have been described to treat complex aortic diseases. Our goal was to evaluate parallel stent graft configurations and to determine an optimal formula for these procedures.Methods
This is a retrospective review of all patients at a single medical center treated with parallel stent grafts from January 2010 to September 2015. Outcomes were evaluated on the basis of parallel graft orientation, type, and main body device. Primary end points included parallel stent graft compromise and overall endovascular aneurysm repair (EVAR) compromise.Results
There were 78 patients treated with a total of 144 parallel stents for a variety of pathologic processes. There was a significant correlation between main body oversizing and snorkel compromise (P = .0195) and overall procedural complication (P = .0019) but not with endoleak rates. Patients were organized into the following oversizing groups for further analysis: 0% to 10%, 10% to 20%, and >20%. Those oversized into the 0% to 10% group had the highest rate of overall EVAR complication (73%; P = .0003). There were no significant correlations between any one particular configuration and overall procedural complication. There was also no significant correlation between total number of parallel stents employed and overall complication. Composite EVAR configuration had no significant correlation with individual snorkel compromise, endoleak, or overall EVAR or procedural complication. The configuration most prone to individual snorkel compromise and overall EVAR complication was a four-stent configuration with two stents in an antegrade position and two stents in a retrograde position (60% complication rate). The configuration most prone to endoleak was one or two stents in retrograde position (33% endoleak rate), followed by three stents in an all-antegrade position (25%). There was a significant correlation between individual stent configuration and stent compromise (P = .0385), with 31.25% of retrograde stents having any complication.Conclusions
Parallel stent grafting offers an off-the-shelf option to treat a variety of aortic diseases. There is an increased risk of parallel stent and overall EVAR compromise with <10% main body oversizing. Thirty-day mortality is increased when more than one parallel stent is placed. Antegrade configurations are preferred to any retrograde configuration, with optimal oversizing >20%. 相似文献11.
Alexander Kulik Amy M. Abreu Viviana Boronat Marc Ruel 《The Journal of thoracic and cardiovascular surgery》2019,157(1):151-161.e1
Objective
Statins prevent saphenous vein graft (SVG) disease and improve outcomes after coronary artery bypass graft surgery. However, the optimal postoperative statin dose remains unclear. The Aggressive Cholesterol Therapy to Inhibit Vein Graft Events trial was undertaken to evaluate whether early postoperative high-dose statin therapy reduces SVG occlusion compared with conventional moderate-dose therapy.Methods
In this pilot, multicenter, double-blind randomized trial, 173 patients who had coronary artery bypass graft surgery with SVG were randomized to receive 10 mg or 80 mg atorvastatin daily for 1 year. The primary outcome was SVG occlusion at 1 year. Secondary outcomes were SVG stenosis and major adverse cardiovascular events.Results
During trial enrollment, patients randomized to 80 mg atorvastatin achieved significantly lower low-density lipoprotein cholesterol levels (P < .00001). One-year graft assessment was performed in 145 patients (83.8%). The primary outcome, SVG occlusion at 1 year, did not significantly differ between the 2 groups (12.9% vs 11.4% for 10 mg atorvastatin vs 80 mg atorvastatin; P = .85). The incidence of vein graft stenosis also did not significantly differ between the groups (P = .54). However, there was a trend toward fewer patients developing vein graft disease (either occlusion or stenosis) in the 80 mg atorvastatin group (29.2% vs 19.2%, 10 mg atorvastatin vs 80 mg atorvastatin; P = .18). Freedom from major adverse cardiovascular events at 1 year was similar between the groups (P = .27).Conclusions
Compared with 10 mg atorvastatin, 80 mg atorvastatin did not significantly reduce vein graft occlusion 1 year after coronary artery bypass graft surgery in this pilot trial. 相似文献12.
Christopher A. Latz Virendra I. Patel Richard P. Cambria Emel A. Ergul R. Todd Lancaster Glenn M. LaMuraglia Mark F. Conrad W. Darrin Clouse 《Journal of vascular surgery》2019,69(3):661-670
Objective
Perioperative outcomes and late mortality after open type IV thoracoabdominal aortic aneurysm (TAAA) repair are known, yet risk of late graft and subsequent aortic events is infrequently described. Such data are increasingly important as endovascular repair becomes an option and are the subject of this study.Methods
During a 27-year interval, 233 patients underwent open surgical repair of type IV TAAA. Surviving patients were monitored for late aortic or graft-related events. Late aortic events were defined as native aortic disease unrelated to the prior reconstruction leading to death or further intervention. Graft-related complications included anastomotic aneurysm, graft infection, and branch occlusion. Variables were assessed for association with study end points using univariate log-rank methods and Cox proportional hazards regression. Time-to-event analysis was performed using Kaplan-Meier techniques.Results
In-hospital mortality occurred in 7 patients (3%), leaving 226 available for surveillance. Mean age was 72 ± 9 years; 50 patients (21%) had 52 synchronous, noncontiguous aortic aneurysms at time of repair (n = 11 ascending aorta/arch; n = 41 descending thoracic aorta). Mean follow-up was 4.3 ± 3.7 years (median, 3.5 years; interquartile range, 5 years). Aortic events (n = 19 [8%]) included elective aortic repair (n = 15), emergent repair (n = 2), and atheroembolic embolization (n = 2) at a mean of 2.6 ± 2.2 years after type IV TAAA repair. There were 17 patients (8%) who experienced graft-related events (renovisceral occlusion [n = 10; 4% of cohort], anastomotic aneurysm repair [n = 5], graft infection [n = 1], and graft-caval fistula [n = 1]) occurring at 1.7 ± 1.9 years after repair. Variables independently predictive of an aortic event were initial rupture (hazard ratio, 5.6; P = .02) and native aortic expansion during surveillance (hazard ratio, 3.9; P = .04). No independent predictors of graft-related complication were identified. Freedom from an aortic or graft-related event was 93% at 1 year and 66% at 5 years. Freedom from graft or aortic reintervention was 86% at 5 years. Aortic-related mortality in follow-up was 2% and estimated to be 5% at 5 years after type IV TAAA repair. Overall survival was 92% and 66% at 1 year and 5 years, respectively.Conclusions
After open type IV TAAA repair, late aortic and graft-related events are uncommon. Native aortic disease sequelae and graft complications occur with equal frequency and with similar temporal relation to repair. Need for reintervention is infrequent, and aortic-related mortality is low. These findings verify durability of open type IV TAAA repair and serve as long-term comparative results for endovascular repair. 相似文献13.
Konstantinos Spanos Tilo Kölbel Jens C. Kubitz Sabine Wipper Nikolaos Konstantinou Franziska Heidemann Fiona Rohlffs Sebastian E. Debus Nikolaos Tsilimparis 《Journal of vascular surgery》2019,69(2):357-366
Objective
The aim of our study was to analyze the incidence of spinal cord ischemia (SCI) in patients presenting with complex aortic aneurysms treated with endovascular aneurysm repair (EVAR) and to identify risk factors associated with this complication.Methods
A retrospective study was undertaken of prospectively collected data including patients presenting with complex aortic aneurysm (pararenal abdominal aortic aneurysm and thoracoabdominal aortic aneurysm) treated with fenestrated EVAR (F-EVAR) or branched EVAR (B-EVAR). The primary end point was the incidence of SCI and the assessment of any associated factors.Results
Between January 2011 and August 2017, a total of 243 patients (mean aneurysm diameter, 65.2 ± 15.3 mm; mean age, 72.4 ± 7.5 years; 73% male) were treated with F-EVAR or B-EVAR. Asymptomatic patients were treated in 73% of the cases (177/243, in contrast to 27% urgent), and 52% (126/243) were treated for thoracoabdominal aortic aneurysm (in contrast to 48% for pararenal abdominal aortic aneurysm). F-EVAR (mean number of fenestrations, 3.3/case) and B-EVAR (mean number of branches, 3.7/case) were undertaken in 67% (164/243) and 33% (79/243), respectively. The total incidence of SCI was 17.7% [43/243; paraplegia in 4% (10/243) and paraparesis in 13.7% (33/243)]. Most of the patients with SCI presented with immediate postoperative symptoms (72% [31/43]). A spinal drain was preoperatively placed in 53% (130/243) and was associated with the prevention of SCI (SCI with spinal drainage, 12% [16/130]; SCI without spinal drainage, 24% [27/113]; P = .018). The 30-day mortality rate was 9% (21/243). After multiple logistic regression analysis, SCI was associated with preoperative renal function (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: odds ratio [OR], 2.43; 95% confidence interval [CI], 1.18-4.99; P = .016) and the number of vertebral segments covered (SCI with higher position of proximal stent in terms of vertebra: OR, 1.2; 95% CI, 1.1-1.3; P = .000). A similar outcome was derived when the height of the proximal end of the stent graft was replaced by the total length of aortic coverage (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: OR, 2.36 [95% CI, 1.11-5.00; P = .025]; SCI with longer length of aortic coverage: OR, 1.01 [95% CI, 1.003-1.009; P = .000]).Conclusions
The majority of SCI incidence after F-EVAR or B-EVAR of complex aortic aneurysms is manifested immediately postoperatively. The use of preoperative spinal drainage may prevent SCI. Patients with GRF <60 mL/min/1.73 m2 and with longer aortic stent graft coverage are at higher risk of SCI. 相似文献14.
Emanuel R. Tenorio Gustavo S. Oderich Giuliano A. Sandri Pinar Ozbek Jussi M. Kärkkäinen Thanila A. Macedo Terri Vrtiska Stephen Cha 《Journal of vascular surgery》2019,69(4):1045-1058.e3
Objective
The objective of this study was to analyze the impact of advanced imaging applications and cone beam computed tomography (CBCT) on radiation exposure of the patient and operator and detection of technical problems during fenestrated-branched endovascular aortic repair (F-BEVAR) for treatment of pararenal aneurysms and thoracoabdominal aortic aneurysms (TAAAs).Methods
We reviewed the clinical data of 386 consecutives patients (289 male; mean age, 75 ± 8 years) treated by F-BEVAR for 196 pararenal aneurysms and 190 TAAAs (mean, 3.4 ± 0.9 targeted vessels/patient) between 2007 and 2017. Radiation exposure (cumulative air kerma) was analyzed in three fixed imaging systems used between 2007 and 2011 (system 1), 2012 and 2016 (system 2), and 2016 and 2017 (system 3). Onlay fusion and CBCT were available with systems 2 and 3, whereas digital zoom with fusion overlay was used with system 3. Operator effective dose was measured per month using a radiation dosimeter badge. Computed tomography angiography and CBCT were analyzed for findings requiring immediate revision or secondary interventions. End points were patient radiation exposure; operator effective dose; procedure technical success; and 30-day rates of mortality, major adverse events, and secondary interventions.Results
F-BEVAR was performed using system 1 in 98 patients, system 2 in 198 patients, and system 3 in 90 patients. Use of onlay fusion/CBCT was 0% with system 1, 42% with system 2, and 98% with system 3. Procedures performed with onlay fusion/CBCT had significantly (P < .05) higher technical success (99.4% vs 98.8%) and lower contrast material volume (155 ± 58 mL vs 172 ± 80 mL), fluoroscopy time (83 ± 34 minutes vs 94 ± 49 minutes), and cumulative air kerma (2561 ± 1920 mGy vs 3767 ± 2307 mGy). Despite higher case volume and increasing complexity during the experience, operator effective dose decreased to 9 ± 4 × 10?2 mSv/case with system 3 compared with 26 ± 3 × 10?2 mSv/case with system 1 and 20 ± 2 × 10?2 mSv/case with system 2 (P = .001). Among 219 patients who had no CBCT, 18 (8%) had computed tomography angiography findings that prompted secondary interventions before dismissal. Conversely, among 167 patients who had CBCT, 14 patients (8%) had intraoperative CBCT findings requiring immediate revision, with no additional secondary interventions. Patients treated with onlay fusion/CBCT had significantly (P < .05) lower mortality (4% vs 1%), major adverse events (43% vs 19%), and secondary interventions (10% vs 4%) at 30 days.Conclusions
Radiation exposure and operator effective dose significantly decreased with evolution of F-BEVAR experience and use of advanced imaging applications such as onlay fusion and CBCT. CBCT allowed immediate assessment and identified intraoperative technical problems, leading to immediate revision and avoiding early secondary interventions. 相似文献15.
Kiattisak Hongku Björn Sonesson Katarina Björses Jan Holst Timothy Resch Nuno V. Dias 《European journal of vascular and endovascular surgery》2018,55(3):377-384
Objective
To assess the mid-term outcomes and feasibility of branched endovascular repair (b-EVAR) of ruptured thoracoabdominal aortic aneurysms (rTAAAs).Methods
All patients undergoing b-EVAR of rTAAAs between 2011 and 2016 were included. Pre-, intra and postoperative imaging was reviewed to assess technical success, outcomes, and feasibility of b-EVAR in the emergent setting.Results
Eleven emergency b-EVAR of rTAAAs (10 aneurysms and 1 chronic dissection) were performed using off-the-shelf (OTS) branched stentgrafts. Only 18% of patients complied to the anatomical instruction-for-use of the OTS device; a small aortic lumen and occluded target vessels were the main violations. Median operative time was 430 (IQR 395-629) minutes. Technical failure was 36% including one intraoperative death, one target vessel catheterization failure, one type Ia and one type III endoleak. Thirty-day mortality was 27%. Only early re-intervention was for the type Ia endoleak. Spinal cord ischemia occurred in 4 patients (30%), of which 2 recovered completely. Median clinical follow-up were 15 (IQR 7-39) months respectively. The median clinical follow-up index (FUI) was 0.65 (0.32–0.95). Overall survival was 75 ± 21.7% at 18 months. Four branch occlusions occurred; one renal stent occlusion led to permanent hemodialysis. Branch patency was 87.5 ± 8.3% and 72.2 ± 12% at 1 and 2 years, respectively. One stentgraft migrated but no late major endoleak occurred.Conclusion
Emergency b-EVAR of rTAAA with OTS device is feasible despite a low anatomical suitability. With proper adjunctive procedures, it can be offered to most hemodynamically stable patients. These time-consuming complex procedures are not suitable for unstable patients. Often the procedure is done as life-saving in the emergency setting and reinterventions may be needed later. Consequently, the success rates are lower than in the elective setting. These results need to be confirmed by larger studies and longer follow-up. 相似文献16.
Katherine M. Stenson Benjamin O. Patterson Matthew Joe Grima Jorg L. De Bruin Peter J.E. Holt Ian Loftus 《Journal of vascular surgery》2019,69(1):53-62.e1
Background
Endovascular aneurysm sealing (EVAS) represents a novel approach to the treatment of abdominal aortic aneurysms. It uses polymer technology to achieve an anatomic seal within the sac of the aneurysm. This cohort study reports the early clinical outcomes, technical refinements, and learning curve during the initial EVAS experience at a single institution.Methods
Results from 150 consecutive EVAS cases for intact, infrarenal abdominal aortic aneurysms are reported here. These cases were undertaken between March 2013 and July 2015. Preoperative, perioperative, and postoperative data were collected for each patient prospectively.Results
The median age of the cohort was 76.6 years (interquartile range, 70.2-80.9 years), and 87.3% were male. Median aneurysm diameter was 62.0 mm (IQR, 58.0-69.0 mm). Adverse neck morphology was seen in 69 (46.0%) patients, including aneurysm neck length <10 mm (17.3%), neck diameter >32 mm or <18 mm (8.7%), and neck angulation >60 degrees (15.3%). Median follow-up was 687 days (IQR, 463-897 days); 37 patients (24.7%) underwent reintervention. The rates of unresolved endoleak are 1.3% type IA, 0.7% type IB, and 2.7% type I. There were no type III endoleaks. There have been seven secondary ruptures in this cohort; all but one of these patients survived after reintervention. Only one rupture occurred in an aneurysm that had been treated within the manufacturer's instructions for use (IFU).Conclusions
The rate of unresolved endoleaks is satisfactorily low. The incidence of secondary rupture is of concern; however, when the IFU are adhered to, the rate is very low. The results of this study suggest that working within the IFU yields better clinical results. 相似文献17.
Nelson F.G. Oliveira Frederico M. Bastos Gonçalves Marie Josee Van Rijn Quirina de Ruiter Sanne Hoeks Jean-Paul P.M. de Vries Joost A. van Herwaarden Hence J.M. Verhagen 《Journal of vascular surgery》2017,65(6):1608-1616
Objective
Endovascular aneurysm repair (EVAR) has progressively expanded to treat more challenging anatomies. Although EVAR in patients with wide infrarenal necks has been reported with acceptable results, there is still controversy regarding the longer-term outcomes. Our aim is to determine the impact of infrarenal neck diameter on midterm outcome following EVAR with a single endograft with suprarenal fixation.Methods
A retrospective case-control study was designed using data from a prospective multicenter database. Patients who electively underwent standard EVAR with an Endurant stent graft (Medtronic Ave, Santa Rosa, Calif) for a degenerative abdominal aortic aneurysm from January 2008 to December 2012 in three high-volume centers in The Netherlands were included. All measurements were obtained using dedicated reconstruction software and center-lumen line reconstruction. Patients with an infrarenal neck diameter of ≥30 mm were compared with patients with a neck diameter of <30 mm. The primary end point was freedom from neck-related adverse events (a composite of type Ia endoleak, neck-related secondary intervention, and endograft migration). Secondary end points were primary clinical success, type Ia endoleak, neck-related reinterventions, endoleaks, and aneurysm-related secondary interventions.Results
Four-hundred twenty-seven patients were included. Seventy-four patients (17.3%) with a neck diameter of ≥30 mm were compared with a control group of 353 patients. There were no significant differences at baseline between groups including demographics, comorbidities, baseline aneurysm diameter, infrarenal neck length, suprarenal angulation, or infrarenal neck angulation. Median stent graft oversizing was 12.5% (7.9-16.1) and 16.6% (12.0-23.1) in the ≥30-mm neck-diameter and control groups, respectively (P < .001). Median follow-up was 3.1 years (1.2-4.7) and 4.1 years (2.7-5.6) for the large neck and control groups, respectively (P < .001). Type Ia endoleaks occurred in 17 patients (4.0%) and were significantly more frequent in patients with ≥30-mm neck diameter (9.5% vs 2.8%; P = .005). Neck-related secondary interventions were performed in 20 patients (4.7%) and were also more common among patients with neck diameters of ≥30 mm (9.5% vs 3.7%; P = .04). The 4-year freedom from neck-related adverse events were 75% and 95% for the large neck and control groups, respectively (P < .001). On multivariable regression analysis, infrarenal neck diameter of ≥30 mm was an independent risk factor for neck-related adverse events (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.6-9.1), type Ia endoleak (OR, 2.7; 95% CI, 1.0-8.3), and neck-related secondary interventions (OR, 3.2, 95% CI, 1.1-9.2).Conclusions
EVAR in patients with large diameter necks is associated with an increased risk of neck-related adverse events in midterm follow-up. This may influence the clinical decision regarding choice of repair and toward a more intensive surveillance following EVAR in these patients in the long term. 相似文献18.
Sabin J. Bozso Jeevan Nagendran Roderick G.G. MacArthur Michael W.A. Chu Bob Kiaii Ismail El-Hamamsy Raymond Cartier Ali Shahriari Michael C. Moon 《The Journal of thoracic and cardiovascular surgery》2019,157(5):1763-1771
Objectives
We describe the Canadian results of the Ascyrus Medical Dissection Stent (AMDS), a novel partially uncovered aortic arch hybrid graft implanted antegrade during hypothermic circulatory arrest to promote true lumen expansion and enhance aortic remodeling.Methods
From March 2017 to February 2018, 16 consecutive patients (66 ± 12 years; 38% female) presented with acute type A aortic dissections and underwent emergent surgical aortic repair with AMDS implantation. All patients presented with DeBakey I aortic dissection, with evidence of malperfusion in 50% (n = 8) of patients. All cases were performed under hypothermic circulatory arrest with an additional average duration for AMDS implantation time of 2.1 minutes.Results
All 16 device implantations were successful. Overall 30-day mortality was 6.3% (n = 1) and stroke occurred in 6.3% (n = 1) of cases. There was no incidence of device-related aortic injury or aortic arch branch vessel occlusion. During the follow-up period, 12 patients had completed at least 1 postoperative computed tomography scan. At initial follow-up computed tomography scan, complete or partial thrombosis, and remodeling of the aortic arch occurred in 91.7% of cases (n = 11/12) and in the proximal descending thoracic aorta, complete or partial thrombosis, and remodeling occurred in 91.7% (n = 11/12).Conclusions
Preliminary results suggest that the AMDS is a safe, feasible and reproducible adjunct to current surgical approaches for acute DeBakey I aortic dissection repair. Further, the AMDS manages malperfusion and promotes early positive remodeling in the aortic arch and distal dissected segments, with favorable FL closure rates at follow-up. Ongoing follow-up will provide additional insight into the long-term effects of the AMDS. 相似文献19.
Nikolaos Tsilimparis Christian Detter Yuk Law Fiona Rohlffs Franziska Heidemann Jens Brickwedel Yskert von Kodolitsch E. Sebastian Debus Tilo Kölbel 《Journal of vascular surgery》2019,69(4):977-985.e1
Objective
Whereas open repair is the “gold standard” for most aortic arch diseases, a subgroup of patients might benefit from an endovascular approach. The introduction of branched stent grafts with dedicated design to address the challenges of the ascending aorta and the aortic arch has opened an entirely new area of treatment for these patients. We investigated the early outcomes of branched thoracic endovascular aortic repair (b-TEVAR) in various types of disease of the aortic arch.Methods
A retrospective analysis was conducted of prospectively collected data from a single center of all consecutive patients treated with b-TEVAR. The indication for elective endovascular repair was consented in an interdisciplinary case conference. All patients were treated with a custom-made inner branched arch endograft with two internal branches (Cook Medical, Bloomington, Ind) and left-sided carotid-subclavian bypass. Study end points were technical success, 30-day mortality, and complications as well as late complications and reinterventions.Results
Between 2012 and 2017, there were 54 patients (38 male; median age, 71 years) treated with diseases of the aortic arch. Indications for therapy involved degenerative aortic arch or proximal descending aortic aneurysms requiring arch repair (n = 24), dissection with or without false lumen aneurysms (n = 26), and penetrating aortic ulcers (n = 4). Forty-three cases (80%) were performed electively and 11 urgently for contained ruptures (n = 3) or symptomatic aneurysms (n = 8) with endografts already available for the patient or with grafts of other patients with similar anatomy. Technical success was achieved in 53 cases (98%). The 30-day mortality and major stroke incidence were 5.5% (3/54) and 5.5% (3/54), respectively; in-hospital mortality was 7.4% (n = 4), and minor strokes (including asymptomatic new cerebral lesions) occurred in 5.5% (n = 3). There were two cases of transient spinal cord ischemia with complete recovery and one of paraplegia. No retrograde type A dissections or cardiac injuries were observed. Three early stent graft-related reinterventions were necessary to correct proximal endograft kinking with type IA endoleak in one patient, a bridging stent graft stenosis in another patient, and false lumen persistent perfusion from dissected supra-aortic vessels in the last patient. Mean in-hospital stay was 14 ± 8 days. During a mean follow-up of 12 ± 9 months, three nonaorta-related deaths and one aorta-related death distal to the arch repair were observed.Conclusions
Treatment of aortic arch diseases with b-TEVAR is feasible and safe with acceptable mortality and stroke rates. 相似文献20.
Yuki Ikeno Koki Yokawa Takashi Matsueda Katsuhiro Yamanaka Takeshi Inoue Hiroshi Tanaka Yutaka Okita 《The Journal of thoracic and cardiovascular surgery》2019,157(1):75-85.e3