Objective

To report the outcome of fenestrated and branch endovascular aortic repair (FEVAR–BEVAR) for asymptomatic and acute symptomatic proximal aortic pathology in patients with prior open (OSR) or endovascular (EVAR) abdominal aortic aneurysm (AAA) repair.

Methods

This was a single centre retrospective study of consecutive patients with non-ruptured (asymptomatic and acute symptomatic) proximal aortic pathology after prior OSR or EVAR treated between December 2007 and February 2020. The primary endpoint was 30 day/in hospital mortality. Secondary endpoints were technical success, primary clinical success, and Kaplan–Meier estimates of medium term survival and freedom from re-intervention. Data are presented as median (interquartile range [IQR]). The effect of covariates on medium term survival was estimated using multivariable (Cox proportional hazards model) analysis. A p value < .05 was considered to be statistically significant.

Results

Ninety-two patients (83 men; median age 75 years [IQR 71 – 80 years]; median diameter 73 mm [IQR 64 – 89 mm]; 82 elective, 10 acute) underwent FEVAR–BEVAR after prior OSR (n = 47) or EVAR (n = 45). Indications for intervention were aneurysmal degeneration with or without type 1a endoleak (n = 57; four juxtarenal [JR] AAA, 21 extent II/III, 32 extent IV thoraco-abdominal aortic aneurysms); type 1a endoleak alone (n = 27) and to create a more durable repair after acute infrarenal EVAR (n = 8; JRAAA). In total, 348 renovisceral vessels were targeted for preservation and 324 were stent grafted. Twenty-four unstented vessels comprised one bypass, 11 scallops and six fenestrations intentionally not stent grafted, two vessels occluded before graft implantation, and four vessels occluded intra-operatively. Primary technical success was 95.6%. The thirty day mortality rate was 1.1% and one patient each (1.1%) required permanent dialysis or developed temporary spinal cord ischaemia. Early primary clinical success was 94.6%. Median follow up was 36 months (IQR 23 – 64 months). Estimated overall survival (± standard error) at one, two, and three years was 86% ± 4%, 85% ± 4%, and 70% ± 5%, respectively. Multivariable analysis did not demonstrate any independent predictors of survival. Four target vessels occluded during follow up. Nineteen patients underwent 28 late re-interventions, with almost half performed for issues arising distal to the FEVAR–BEVAR. Patients treated with a cuff were statistically significantly more likely to require distal re-intervention compared with those treated by relining (9/49 vs. 1/43, p = .018 [odds ratio 9.3, 95% confidence interval 1.2 – 423]). In patients with prior EVAR alone, this did not reach statistical significance (cuff 7/25 vs. relining 1/20, p = .059 [odds ratio 7.1, 95% confidence interval 0.8 – 350]). Estimated freedom from re-intervention at one, two, and three years was 88% ± 3%, 81% ± 4%, and 81% ± 4%, respectively.

Conclusion

FEVAR–BEVAR after prior OSR or EVAR is associated with low peri-operative morbidity and mortality, and acceptable medium term survival and freedom from re-intervention. Treatment with a FEVAR–BEVAR cuff is associated with a higher requirement for distal re-intervention than relining of the original repair.

中文翻译：

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先前腹主动脉瘤修复后的有孔分支血管内修复

客观的

报告开窗和分支血管内主动脉修复术 (FEVAR-BEVAR) 对既往开放 (OSR) 或血管内 (EVAR) 腹主动脉瘤 (AAA) 修复术患者的无症状和急性有症状近端主动脉病变的结果。

方法

这是一项单中心回顾性研究，对 2007 年 12 月至 2020 年 2 月期间接受过 OSR 或 EVAR 治疗后未破裂（无症状和急性症状）近端主动脉病变的连续患者进行了单中心回顾性研究。主要终点是 30 天/住院死亡率。次要终点是技术成功、主要临床成功和 Kaplan-Meier 对中期生存率和免于再干预的估计。数据表示为中位数（四分位距 [IQR]）。使用多变量（Cox 比例风险模型）分析估计协变量对中期生存的影响。甲p值<0.05被认为是统计学上显著。

结果

92 名患者（83 名男性；中位年龄 75 岁 [IQR 71 – 80 岁]；中位直径 73 毫米 [IQR 64 – 89 毫米]；82 名选择性患者，10 名急性患者）在既往 OSR 后接受了 FEVAR-BEVAR（n  = 47）或 EVAR（n  = 45）。干预的适应症是伴有或不伴有 1a 型内漏的动脉瘤变性（n  = 57；4 个近肾 [JR] AAA，21 度 II/III，32 度 IV 胸腹主动脉瘤）；单独的 1a 型内漏 ( n  = 27) 并在急性肾下 EVAR 后产生更持久的修复 ( n = 8; JRAAA）。总共有 348 根肾内脏血管进行了保存，324 根进行了支架移植。24 条无支架血管包括 1 个旁路、11 个扇贝和 6 个有意未植入支架的开窗、2 条植入前闭塞的血管和 4 条术中闭塞的血管。初级技术成功率为 95.6%。30 天死亡率为 1.1%，每人一名 (1.1%) 需要永久性透析或出现暂时性脊髓缺血。早期初级临床成功率为 94.6%。中位随访时间为 36 个月（IQR 23 – 64 个月）。一年、两年和三年的估计总生存率（± 标准误差）分别为 86% ± 4%、85% ± 4% 和 70% ± 5%。多变量分析没有证明任何独立的生存预测因素。四个目标血管在随访期间闭塞。19 名患者接受了 28 次晚期再干预，其中几乎一半是针对 FEVAR-BEVAR 远端出现的问题进行的。与重新衬里治疗的患者相比，使用袖带治疗的患者在统计学上更可能需要远端再干预 (9/49与 1/ 43，p  = .018 [优势比 9.3，95% 置信区间 1.2 – 423]）。在先前单独使用 EVAR 的患者中，这没有达到统计学显着性（袖带 7/25与换衬 1/20，p  = .059 [优势比 7.1，95% 置信区间 0.8 – 350]）。估计在一年、两年和三年内免于再次干预的概率分别为 88% ± 3%、81% ± 4% 和 81% ± 4%。

结论

既往 OSR 或 EVAR 后的 FEVAR-BEVAR 与围手术期的低发病率和死亡率、可接受的中期生存率和免于再次干预相关。使用 FEVAR-BEVAR 袖带进行治疗与重新修复原始修复的内衬相比，需要更高的远端再介入治疗。