Objective

To determine the optimal and safest proximal sealing length (PSL) during thoracic endovascular aortic repair (TEVAR), depending on anatomical aortic arch types and proximal landing zones (LZs).

Methods

This was a single centre retrospective observational study of consecutive TEVAR patients (2008–2020). All aortic pathologies requiring Ishimaru landing zone (LZ) 0 – 3 were included; results were stratified by aortic arch type. The PSL was measured as the length of complete aortic wall to endograft apposition at the level of the proximal neck. The primary endpoint was proximal failure (type 1A endoleak, endograft migration, or re-intervention requiring proximal graft extension). Freedom from proximal failure was estimated with Kaplan–Meier curves. An “optimal” sealing length (PSL cutoff maximising sensitivity + specificity for proximal failure) and “safest length” (PSL cutoff determining ≥ 90% sensitivity) were identified using receiver operating characteristic curve analysis.

Results

One hundred and forty patients received TEVAR; mean ± standard deviation PSL was 29 ± 9 mm. Freedom from proximal endograft failure at five years (median 31 months) was 82.4% (95% confidence interval [CI] 72 – 95); the shorter the PSL, the greater was the risk of failure (hazard ratio 0.90, 95% CI 0.84 – 0.97; p = .004). Overall optimal and safest PSL were 25 mm (sensitivity 78%, specificity 66%) and 30 mm (sensitivity 92%, specificity 30%), respectively. In type I arch, the optimal PSL was 22 mm (sensitivity 50%, specificity 87%). In type II, the optimal PSL was 25 mm (sensitivity 89%, specificity 59%) overall and 27 mm for type II/LZ 2 – 3 (sensitivity 31%, specificity 68%). For type III, the optimal PSL was 27 mm (sensitivity 80%, specificity 87%); the safest was 30 mm (sensitivity 100%, specificity 61%) In type III/LZ 2 – 3, the optimal PSL was 27 mm (sensitivity 31%, specificity 68%) and safest was 30 mm (sensitivity 100%, specificity 55%).

Conclusion

A 20 mm PSL may be acceptable only for type I arches. For types II/III, that represent the majority of cases, a 25 – 30 mm PSL may be required for a safe and durable TEVAR.

中文翻译：

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胸主动脉腔内修复术中最佳和最安全的近端封闭长度的确定

客观的

根据解剖主动脉弓类型和近端着陆区 (LZ)，确定胸主动脉腔内修复 (TEVAR) 期间最佳和最安全的近端密封长度 (PSL)。

方法

这是一项针对连续 TEVAR 患者（2008-2020 年）的单中心回顾性观察研究。包括所有需要 Ishimaru 着陆区 (LZ) 0 – 3 的主动脉病变；结果按主动脉弓类型分层。PSL 测量为完整主动脉壁到近端颈水平内移植物附着的长度。主要终点是近端失败（1A 型内漏、内移植物迁移或需要近端移植物延伸的重新干预）。用 Kaplan-Meier 曲线估计近端失败的自由度。使用受试者工作特征曲线分析确定了“最佳”密封长度（PSL 截止值最大化灵敏度 + 对近端故障的特异性）和“最安全长度”（PSL 截止值确定 ≥ 90% 灵敏度）。

结果

一百四十名患者接受了 TEVAR；均值 ± 标准偏差 PSL 为 29 ± 9 毫米。5 年（中位 31 个月）无近端移植失败率为 82.4%（95% 置信区间 [CI] 72 – 95）；PSL 越短，失败的风险就越大（风险比 0.90，95% CI 0.84 – 0.97；p = .004)。总体最佳和最安全的 PSL 分别为 25 mm（敏感性 78%，特异性 66%）和 30 mm（敏感性 92%，特异性 30%）。在 I 型弓中，最佳 PSL 为 22 mm（敏感性 50%，特异性 87%）。在 II 型中，最佳 PSL 总体为 25 mm（敏感性 89%，特异性 59%），II/LZ 2-3 型的最佳 PSL 为 27 mm（敏感性 31%，特异性 68%）。对于 III 型，最佳 PSL 为 27 mm（敏感性 80%，特异性 87%）；最安全的是 30 mm（敏感性 100%，特异性 61%） 在 III/LZ 2-3 型中，最佳 PSL 为 27 mm（敏感性 31%，特异性 68%），最安全的是 30 mm（敏感性 100%，特异性 55 %）。

结论

20 mm PSL 可能仅适用于 I 型拱门。对于代表大多数病例的 II/III 型，安全耐用的 TEVAR 可能需要 25 – 30 mm PSL。