Type IA Endoleak Correction With Fenestrated Devices After EVAR: Outcomes and Predictors of Secondary Failure.

IF 1.7 2区 医学 Q3 PERIPHERAL VASCULAR DISEASE
Thomas Mesnard, Michel Daher, Benjamin O Patterson, Maxime Lebaz-Dubosq, Richard Azzaoui, Louis Pruvot, Stéphan Haulon, Jonathan Sobocinski
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引用次数: 0

Abstract

Purpose: The aim of this study was to review the results of fenestrated stent-graft (Fenestrated Endovascular Aortic Repair [FEVAR]) implantation to treat patients with type IA endoleaks after prior infrarenal endovascular aortic repair (EVAR).

Methods: A retrospective single-center analysis of prospectively collected data was conducted, including consecutive patients who underwent FEVAR to correct a type IA endoleak between November 2009 and April 2021. All devices were manufactured by Cook Medical (INC, Bloomington, Indiana). Demographic details, anatomical features, fenestrated stent-graft configuration, technical success, and major adverse events (MAEs) were recorded according to current SVS standards. The primary endpoint was freedom-from-significant aneurysm sac expansion (≥5 mm) and survival according to the Kaplan-Meier analysis. Secondary endpoints included 30-day outcomes, freedom-from-all-cause mortality, and aortic-related secondary interventions. Multivariate Cox regression was performed to identify factors associated with the study endpoints.

Results: Overall, 47 patients (89% male, median age 80) were included. Median time from initial EVAR was 60 months [41-72]. Median pre-FEVAR maximal aneurysm diameter was 68mm [62-79]. Median fluoroscopy time and dose area product were, respectively, 49 min [36-63] and 66 Gy.cm2 [38-101]. Technical success rate was 96% with no 30-day deaths reported. Two (4.3%) renal MAE occurred. Median follow-up was 22 months [12-36]. Two-year freedom-from-aneurysm sac expansion and aortic-related secondary intervention were 80% [66-96] and 69% [55-87], respectively. From the multivariate analysis, the configuration of the fenestrated device was not predictive of aneurysm sac expansion, whereas only the preoperative aneurysm maximal diameter was an independent predictor (hazard ratio [HR] [per 1 mm increment]=1.05 [1.01-1.10]; p=0.016) and was associated with a higher risk of aortic-related secondary intervention (HR [per 1 mm increment]=1.07 [1.02-1.12]; p=0.006). Other predictors of aortic-related secondary intervention were pre-existing type IB or III endoleak (HR=7.89 [1.39-44.8]; p=0.020) and aortic degeneration above the primary EVAR (HR=16.6 [1.88-147], p=0.011).

Conclusion: Late type IA endoleak after EVAR can be treated safely with a fenestrated stent-graft; preoperative maximum aneurysm diameter is associated with an increased risk of later aneurysm sac growth. Close follow-up is mandatory in this subgroup of patients given the high reintervention rate.

Clinical impact: Type IA endoleak following endovascular aneurysm repair (EVAR) can be treated using a fenestrated stent-graft (FEVAR). Treatment options include the addition of a fenestrated cuff alone or complete relining of the previous graft with either a 3-component device or a unibody bifurcated FEVAR. Regardless of the device configuration the treatment appears to be safe but remains associated with high rates of reintervention and aneurysm growth. Although no significant differences have been observed in long-term outcomes, a complete relining with a bifurcated FEVAR may be preferred as a first-line approach, as it offers the advantage of addressing occult associated Type III endoleaks and reducing the risk of component disconnection.

EVAR后使用开窗装置进行IA型内漏矫正:继发性失效的结果和预测因素。
目的:本研究的目的是回顾开窗支架移植物(开窗血管内主动脉修复[FEVAR])植入术治疗先前肾下血管内主动脉修复(EVAR)后IA型内漏患者的结果。方法:回顾性单中心分析前瞻性收集的数据,包括2009年11月至2021年4月期间接受FEVAR纠正IA型内漏的连续患者。所有设备均由Cook Medical (INC, Bloomington, Indiana)制造。根据当前的SVS标准记录人口统计学细节、解剖特征、开窗支架配置、技术成功和主要不良事件(MAEs)。根据Kaplan-Meier分析,主要终点是无明显动脉瘤囊扩张(≥5mm)和生存。次要终点包括30天结局、无全因死亡率和与主动脉相关的次要干预。采用多变量Cox回归来确定与研究终点相关的因素。结果:总共纳入47例患者(89%为男性,中位年龄80岁)。从首次EVAR开始的中位时间为60个月[41-72]。fevar前最大动脉瘤直径中位数为68mm[62-79]。中位透视时间为49 min[36-63],剂量面积积为66 Gy。cm2(38 - 101)。技术成功率为96%,无30天死亡报告。2例(4.3%)发生肾性MAE。中位随访时间为22个月[12-36]。两年无动脉瘤囊扩张和主动脉相关二次干预分别为80%[66-96]和69%[55-87]。从多因素分析来看,开窗装置的配置不能预测动脉瘤囊扩张,而术前动脉瘤最大直径是一个独立的预测因素(风险比[HR][每增加1毫米]=1.05 [1.01-1.10];p=0.016),并与主动脉相关继发性干预的高风险相关(HR[每增加1毫米]=1.07 [1.02-1.12];p = 0.006)。其他与主动脉相关的二次干预的预测因素包括:先前存在的IB型或III型内皮渗漏(HR=7.89 [1.39-44.8];p=0.020)和原发EVAR以上的主动脉变性(HR=16.6 [1.88-147], p=0.011)。结论:经开窗支架移植治疗EVAR后晚期IA型内漏是安全的;术前最大动脉瘤直径与后期动脉瘤囊生长的风险增加有关。由于再干预率高,该亚组患者必须密切随访。临床影响:血管内动脉瘤修复(EVAR)后的IA型内漏可以使用开窗支架移植(FEVAR)治疗。治疗方案包括单独添加开窗袖带或使用3组件装置或单体分叉FEVAR对先前的移植物进行完全修补。无论设备配置如何,治疗似乎是安全的,但仍然与高再干预率和动脉瘤生长有关。虽然在长期结果上没有观察到显著的差异,但采用分岔FEVAR完全复位可能是首选的一线方法,因为它具有解决隐匿性相关III型内漏和降低部件断开风险的优势。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
5.30
自引率
15.40%
发文量
203
审稿时长
6-12 weeks
期刊介绍: The Journal of Endovascular Therapy (formerly the Journal of Endovascular Surgery) was established in 1994 as a forum for all physicians, scientists, and allied healthcare professionals who are engaged or interested in peripheral endovascular techniques and technology. An official publication of the International Society of Endovascular Specialists (ISEVS), the Journal of Endovascular Therapy publishes peer-reviewed articles of interest to clinicians and researchers in the field of peripheral endovascular interventions.
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