腹主动脉瘤腔内修复术后内漏的发生及转归：单中心10年随访结果分析.pdf

叶中国血管外科杂志渊电子版冤曳圆园23 年 9 月第 15 卷第 3 期 悦澡蚤灶 允 灾葬泽糟 杂怎则早 渊耘造藻糟贼则燥灶蚤糟 灾藻则泽蚤燥灶冤袁September 圆园23袁灾燥造援15袁 晕燥援3窑窑腹主动脉瘤腔内修复术后内漏的发生及转归:单中心 10 年随访结果分析宁俊杰袁王冕袁李梓伦袁姚陈袁武日东袁王斯文袁吴伟滨袁秦原森袁汪睿袁崔进袁石毅袁常光其渊血管疾病诊治技术国家地方 渊广东冤 联合工程实验室 中山大学附属第一医院 血管外科袁广东 广州 510080冤揖摘要铱目的研究腹主动脉瘤渊abdominal aortic aneurysm袁AAA冤患者行腹主动脉腔内修复术渊endovascular aortic repair袁EVAR冤后内漏的发生情况及转归的趋势与规律遥 方法回顾性收集中山大学附属第一医院 20132022 年 195 例行常规 EVAR 术及 EVAR+烟囱技术重建内脏动脉渊chimneyendovascular aortic repair袁Ch-EVAR冤 后发生内漏的真性 AAA 患者临床资料袁 比较各型内漏的发生率袁比较不同处理方式对内漏的预后有无影响遥 结果Ch-EVAR 术后内漏发生率显著高于常规EVAR 渊46.4%vs 23.0%袁P0.05冤遥EVAR 术后 30d 内死亡 4 例袁其中 1 例为术后动脉瘤破裂曰术后 30d 后死亡 40 例袁其中 4 例与内漏相关遥 结论针对不同类型的内漏采取不同的处理方式袁对瘤体持续增大和/或患者有症状的内漏进行积极干预袁均能取得较为满意的结果遥揖关键词铱腹主动脉瘤曰腹主动脉腔内修复术曰内漏曰发生曰转归Incidence and outcomes of endoleaks after endovascular aortic repair for abdominal aortic aneurysm:A single-center experience for 10 yearsNing Junjie,Wang Mian,Li Zilun,Yao Chen,Wu Ridong,WangSiwen,Wu Weibin,Qin Yuansen,Wang Rui,Cui Jin,Shi Yi,Chang Guangqi.Department of VascularSurgery,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases,The First Affiliated Hospital of Sun Yat-sen University,Guangzhou 510080,ChinaCorresponding author:Chang Guangqi,E-mail:揖粤遭泽贼则葬糟贼铱韵遭躁藻糟贼蚤增藻To investigate the trends and patterns in the incidence and outcomes of endoleaksin patients who underwent endovascular aortic repair 渊EVAR冤 for abdominal aortic aneurysm 渊AAA冤.MethodsThe clinical data of 195 cases who had endoleaks after EVAR or chimney endovascular aortic repair 渊Ch-EVAR冤between 2013 and 2022 in the First Affiliated Hospital of Sun Yat-sen University were analyzedretrospectively.Incidence of various types of endoleaks were calculated and compared,and the effects ofdifferent management on the prognosis of endoleaks were also compared.ResultsThe incidence rate ofendoleak after Ch-EVAR was significantly higher than that after conventional EVAR 渊46.4%vs 23.0%,P0.05冤.Four cases died within 30days after EVAR,one of which was due to postoperative aneurysm rupture.40 cases died after 30 post-operative days of EVAR,four of which were related to endoleaks.ConclusionAdopting different treatmentmethods for different types of endoleaks and actively intervening in cases of continued aneurysm growth and/窑 论著 窑DOI:10.3969/j.issn.1674-7429.2023.03.005基金项目院国家自然科学基金面上项目渊82170510冤通讯作者院常光其袁电子邮箱院215叶中国血管外科杂志渊电子版冤曳圆园23 年 9 月第 15 卷第 3 期 悦澡蚤灶 允 灾葬泽糟 杂怎则早 渊耘造藻糟贼则燥灶蚤糟 灾藻则泽蚤燥灶冤袁September 圆园23袁灾燥造援15袁 晕燥援3窑窑or symptomatic endoleaks can achieve satisfactory results.揖运藻赠 憎燥则凿泽铱 Abdominal aortic aneurysm;Endovascular aortic repair;Endoleak;Incidence;Outcome腹主动脉腔内修复术渊endovascular aortic repair袁EVAR冤已逐渐取代传统开放手术袁成为腹主动脉瘤渊abdominal aortic aneurysm袁AAA冤的主要治疗方法遥 多项研究证实 EVAR 在术后近中期的无事件生存率和总生存率方面具有优势咱1-4暂袁但内漏等并发症仍可能对患者构成重大威胁袁需要腔内甚至开放手术进行再干预咱5,6暂遥 内漏是支架和动脉瘤壁之间的瘤囊内持续存在血流袁 可能导致动脉瘤持续增大袁甚至瘤囊破裂咱7,8暂遥 据统计袁EVAR 术后内漏的发生率约为 20%咱9暂遥 因此袁患者术后需长期规律随访袁终身监测袁以便尽早发现并处理内漏袁避免动脉瘤破裂咱9-11暂遥 目前袁各种内漏类型的临床意义尚存争议咱12,13暂袁本文总结中山大学附属第一医院血管外科 20132022 年 EVAR 术后发生内漏患者的随访结果并进行分析袁探究各型内漏发生及转归的趋势与规律袁现报告如下遥1资料与方法1.1一般资料共 819 例实施 EVAR 的 AAA 患者袁其中 195 例渊23.8%冤术后出现内漏遥 内漏患者中袁男性 156 例袁女性 39 例袁平均年龄为渊71.0依7.2冤岁遥 患者为行常规 EVAR 术及 EVAR+烟囱技术 重 建 内 脏 动 脉 渊chimney endovascular aorticrepair袁Ch-EVAR冤的真性 AAA 患者袁不包括腹主动脉夹层动脉瘤或假性 AAA尧 使用开窗技术或分支支架重建内脏动脉的胸腹主动脉瘤尧使用多层裸支架或对吻覆膜支架技术修复动脉瘤以及外院行EVAR 术后在本院处理内漏问题的患者遥1.2资料收集临床资料包括性别尧年龄尧入院日期尧手术日期尧手术方式尧内漏类型尧内漏处理方式和处理效果等遥 所有内漏根据造影尧CT 和/或彩超结果进行分型遥 随访过程中袁若有瘤囊持续增大和/或出现内漏引起的症状袁则有干预的指征遥 内漏干预方式包括植入主动脉延支渊Cuff冤尧植入髂动脉延长支覆膜支架尧弹簧圈栓塞瘤腔尧向瘤腔内注射纤维蛋白黏合剂以及栓塞反流分支血管等遥内漏是否符合干预指征以及使用何种方案干预由主诊医师决定袁所有主诊医师均具有副主任医师以上资质遥随访资料包括每一次随访的时间及其结果遥患者在 EVAR 术后 1尧3尧6尧12 个月复查 CTA 或血管彩超袁此后每年复查 1 次遥 对未在本院行影像学复查的患者袁通过电话或微信等形式获取其在外院复查结果和影像学检查结果遥内漏转归包括内漏消失或内漏持续存在遥 对死亡患者袁收集其死亡时间及死亡原因遥1.3统计学方法数据使用 SPSS 20.0 软件进行统计分析遥 连续型数据以均值依标准差表示袁组间比较使用 t 检验曰离散型数据以例数渊%冤表示袁组间比较使用 字2检验或 Fisher 精确检验遥 P0.05 表示差异有统计学意义遥2结果患者术后平均随访时间为渊35.5依25.8冤个月遥常规 EVAR 术后发生内漏 182 例 渊23.0%袁182/791冤袁Ch-EVAR 术后发生内漏 13 例 渊46.4%袁13/28冤袁Ch-EVAR 术后内漏发生率显著高于常规EVAR渊字2=8.18袁P0.05冤遥3讨论内漏是 EVAR 术后的常见并发症袁 存在内漏是 EVAR 术后远期预后不良的危险因素袁 可能导致动脉瘤瘤囊扩张和破裂咱14-17暂遥 在不同研究中袁内漏的总发生率因研究标准不同而有差异袁从 10%50%不等咱18-23暂曰而 Ch-EVAR 的内漏发生率未见大规模研究报道袁 其玉a 型内漏的发生率可能高达13.0%咱24-26暂遥本研究结果显示袁EVAR 治疗真性 AAA的术后内漏总发生率为 23.8%袁与上述文献报道相符曰其中袁Ch-EVAR 术后内漏发生率显著高于常规EVAR袁可能与其玉a 型内漏的发生率较高相关袁但由于 Ch-EVAR 的总例数较少袁仍需更大样本量的研究进一步验证遥 此外袁各种分型内漏的发生率不同袁其中玉a 型最高袁约占所有内漏病例的一半袁而郁型最低袁不足 2%遥内漏是否有干预指征需结合内漏分型尧瘤体是否持续增大及患者有无症状进行考虑咱9,27暂遥 对有干预指征的内漏病例袁本中心使用植入 Cuff尧植入肾动脉烟囱支架尧弹簧圈栓塞瘤腔尧向瘤腔内注射纤维蛋白黏合剂尧植入髂动脉延支尧栓塞反流分支血管及开放手术等措施干预遥 经干预后的内漏与无干预指征的内漏在转归及预后方面差异无统计学意义袁提示上述干预措施效果良好遥玉a 型内漏多见于瘤颈短尧 瘤颈扭曲成角严重尧瘤颈呈倒梯形尧瘤颈存在附壁血栓或钙化斑的病例袁持续性玉a 型内漏的发生率为2.511.4%咱28-30暂遥由于玉a 型内漏被认为与瘤囊内压力升高及动脉瘤破裂风险增大有关咱31暂袁美国血管外科学会指南建议应积极干预咱9暂遥 本研究玉a 型内漏的发生率为13.3%袁与文献报道类似遥73 例渊67.0%冤患者在随访过程中瘤囊无增大袁且无腹痛尧腰痛等症状而予以观察随访袁最终有 51 例内漏自行消失袁提示近半数表 1各类型内漏的发生与转归情况渊例冤玉a 型玉b 型域型芋型郁型10923451915观察干预观察干预观察干预观察干预观察干预733611123312190105消失511871018511-92持续存在1513311566-12失访或未复查7511012-010.090.310.60-0.18与内漏相关3100100-00死因不明0102200-00与内漏明确无关131131612-000.610.400.78-内漏类型处理例数例数例数内漏转归死亡P值P值217叶中国血管外科杂志渊电子版冤曳圆园23 年 9 月第 15 卷第 3 期 悦澡蚤灶 允 灾葬泽糟 杂怎则早 渊耘造藻糟贼则燥灶蚤糟 灾藻则泽蚤燥灶冤袁September 圆园23袁灾燥造援15袁 晕燥援3窑窑玉a 型内漏无需干预即可消失遥 对在随访过程中瘤囊增大或出现腹痛尧腰痛症状的 36 例玉a 型内漏袁本中心根据实际情况采用多种方法干预袁 最终有18 例内漏消失袁但仍有 13 例内漏持续存在遥 随访期内共有 29 例玉a 型内漏患者死亡袁4 例死于动脉瘤破裂遥 干预后与未干预的玉a 型内漏患者的死亡率及死亡原因差异无统计学意义遥 血管内固定锚钉可将支架锚定区固定在血管壁袁并降低支架移位风险袁可能是预防或治疗玉a 型内漏的有效方法袁但其长期效果仍有待研究咱32,33暂遥当腔内手术无法处理玉a 型内漏时袁开放手术是再干预的有效手段遥 南京鼓楼医院采用开放手术治疗 9 例玉a 型内漏袁随访显示患者的内漏均消失袁瘤腔未进一步增大咱34暂遥EVAR 术后玉b 型内漏的发生率为 08%袁常见于髂总动脉较粗尧髂动脉锚定区较短或髂动脉扭曲的病例咱35暂遥 本研究玉b 型内漏发生率为 2.8%袁与文献报道相符遥 美国血管外科学会指南建议应积极干预玉b 型内漏咱9暂遥 本中心通过植入髂支渊根据延长支位置确定是否行髂内动脉栓塞冤 干预 12 例渊52.2%冤 瘤囊增大或有症状的玉b 型内漏患者袁取得良好的效果曰除该方法外袁亦可使用髂动脉分支支架修复内漏袁或行开放手术进行治疗遥 12 例患者随访期未有与动脉瘤明确相关的死亡病例遥 另 11例渊47.8%冤玉b 型内漏仅予观察随访袁最终有 7 例自行消失袁3 例仍持续存在遥 ZUCCON 等咱35暂对 27 篇文献进行综述袁指出未干预的玉b 型内漏发生动脉瘤破裂的可能性高达 40%遥 因此袁对本研究 3 例玉b 型内漏持续存在的患者应密切随访袁未来仍可能需要积极干预遥域型内漏在 EVAR 结束时的发生率可能高达25%袁但至少一半可自行消失袁术后 6 个月时仅有10%15%的病例仍有内漏咱36-38暂遥 因此袁美国血管外科学会指南建议仅需对瘤囊增大逸5 mm 或有症状的域型内漏进行干预咱27暂遥 本研究对域型内漏干预指征的判断与指南一致袁最终对 26.7%的域型内漏病例进行干预遥 除本研究使用的干预措施外袁研究提示琢-氰基丙烯酸正丁酯渊N-butyl 2-cyanoacrylate袁NBCA冤 栓塞亦可降低 AAA 患者 EVAR 术后内漏的发生率袁但目前对 NBCA 栓塞用于域型内漏的研究仍相对较少咱39暂遥若域型内漏无法行腔内手术修复或腔内手术失败袁 亦可考虑行腹腔镜下反流血管渊主要是肠系膜下动脉及腰动脉冤结扎术尧机器人手术结扎和开放手术动脉结扎治疗咱18,40,41暂遥 文献报道经干预后的域型内漏复发率仍可能高达 60%咱42暂袁本研究经干预后有 50%仍持续存在遥 因此袁有学者认为对域型内漏进行干预并不能改善其预后咱43,44暂遥本研究随访期有 10 例患者渊22.2%冤死亡袁其中1 例在 EVAR 术后 27.6 个月死于主动脉-消化道瘘袁另有 2 例死因不明袁均为观察随访未干预的患者遥EVAR术后芋型内漏的发生率为2.1%3.5%咱19,45,46暂袁本研究发生率为 2.3%袁与文献报道相符遥因内漏量均较小袁随访过程未见瘤囊增大袁且患者均无症状袁故所有病例均未行干预遥 随访过程中有 11 例渊57.9%冤芋型内漏自行消失袁6 例渊31.6%冤仍持续存在遥 此外袁有 2 例患者死亡袁但均与动脉瘤明确无关遥由于芋型内漏被认为可增加动脉瘤的破裂风险咱31,36暂袁故美国血管外科学会指南建议积极干预袁通过植入覆膜支架修复咱9暂遥 本研究芋型内漏持续存在的 6 例患者仍在密切随访中遥郁型内漏非常罕见袁发生率可能不足 1%咱47,48暂遥本研究郁型内漏发生率为 1.8%袁 可能与选用的支架品牌相关遥美国血管外科学会指南建议无需干预咱9暂袁但也有郁型内漏导致动脉瘤迟发性破裂的个案报道咱49暂遥 本中心对 5 例内漏量大的病例进行干预袁分别植入髂支及向瘤腔内注射纤维蛋白黏合剂遥15 例郁型内漏患者中有 12 例消失曰3 例在末次随访时仍有内漏袁但流量小尧流速低袁考虑到郁型内漏导致动脉瘤破裂风险低咱50暂袁继续予以观察随访遥 所有郁型内漏患者在随访期间均无死亡遥总之袁 本研究对本中心在过去 10 年对 EVAR治疗真性 AAA 术后内漏的处理经验进行总结袁对不同类型的内漏采取不同的处理方式袁对瘤体持续增大和/或患者有症状的内漏进行积极干预袁 均能取得较为满意的结果遥参考文献GREENHALGHRM,BROWNLC,KWONGGP,etal.Comparison of endovascular aneurysm repair with open repairin patients with 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