Clinical Efficacy Evaluation Of Key Technologies Of Endovascular Aortic Repair And Study On The Impact Of Postoperative Endolea

Part 1 Midterm outcomes for self-radiopaque marker-guided single fenestrated arch repairObjectives:To provide the midterm outcomes for self-radiopaque marker-guided single fenestrated arch repair and test the necessity of bridging stent on the preservation of the left subclavian artery(LSA).Methods:Information for consecutive patients who received single fenestrated arch repair using physician modified stent-graft(PMSG)in three centers from January 1,2016,to December 31,2019,were retrospectively reviewed.30 days and follow-up outcomes were provided,Cox regression and linear regression were performed to explore the independent predictors for left subclavian artery occlusion and perfusion respectively.Results:We included 309 patients for analysis.The technical success rate was 90.6%.The 30 days mortality and complication rate were 1.6%and 6.4%,respectively.The 4 years survival rate and free-from aortic reoperation rate were 94.9%and 95.9%,respectively.In 296 patients included for left subclavian artery patency analysis,a bridging stent was placed in 160 cases,and branch artery occlusion was observed in 6 patients(all had no bridging stent).The 1,3 years free-from LSA occlusion rates were 98.6%and 97.5%,respectively.Multivariate analysis revealed no independent predictor.In 217 patients included for left subclavian artery perfusion analysis,bridging stent group had a lower average pressure difference(1 vs 3mmHg,p<0.001),lower proportion of average pressure difference≥10mmHg(5.5%vs 29.2%,p<0.001),and lower proportion of average pressure difference≥20mmHg(0.7%vs 8.3%,p=0.006).The presence of a bridging stent was associated with a 5.8 mmHg lower average pressure difference.Conclusions:Self-radiopaque marker-guided single fenestrated aortic arch repair is safe and effective,and bridging stent is associated with better preservation of LSA perfusion.Part 2 Standardized endovascular repair of abdominal aortic aneurysm(standardized EVAR):two-center experience,protocol,and technical notesObjective:Endovascular repair of abdominal aortic aneurysm(EVAR)has become the most commonly used treatment of abdominal aortic aneurysm.Although EVAR is a minimally invasive procedure,it may also lead to related complications and long-term effects.This study introduces the experience,scheme and technical description of standardized EVAR surgery.The results show that standardized EVAR has good long-term results and low incidence of complications.It is hoped that the surgical experience and technical details presented in this study will help to improve the clinical results of EVAR surgery,especially for young doctors who are in the early stage of EVAR surgery.Methods:A total of 968 patients from two vascular surgery centers in China from January 1,2015 to December 31,2020 were retrospectively analyzed,and a standardized EVAR procedure was introduced,which was based on the experience of an EVAR surgery leader shared by the two centers.After the follow-up of the patients who used the standardized EVAR procedure in the past 6 years,it was found that the standardized EVAR treatment had a low incidence of complications and better long-term effect.Results:There was no significant difference in aortic-related mortality,reintervention rate or internal leakage rate between the two centers,but there was a significant difference in overall survival rate between the two centers(P=0.0002).The longest follow-up time between the two vascular surgical centers was 96 months(the median follow-up time was 50 months).The results showed that there was no significant difference in follow-up rate,survival rate of non-aortic-related death,risk of internal leakage and risk of re-intervention.Conclusion:Standardized EVAR surgery uses standard technical methods and routes for endovascular repair of AAA.Improper operation or lack of standardized techniques during the operation may lead to adverse results or complications in the follow-up diagnosis and treatment.The standardized EVAR procedure proposed in this study is based on the practical experience of two vascular surgery centers for many years.The operation time is relatively short,the recovery speed of patients is fast,and the long-term follow-up effect is good.Part 3 Outcomes of endovascular true descending thoracic aortic aneurysm repair with or without endoleak from intercostal or bronchial arteriesObjective:The impact of endoleak from intercostal or bronchial arteries after thoracic endovascular aortic repair(TEVAR)for true descending thoracic aortic aneurysm(TAA)had not been reported.This study was focused on the impact of this type of endoleak on the follow-up outcomes and aortic remodeling after TEVAR.Methods:Data from consecutive patients with endovascular true descending TAA repair from January 1,2010,to December 31,2020,was retrospectively reviewed.We used the Kaplan-Meier curve to calculate the survival and aortic reintervention-free survival rate.30-day and follow-up outcomes were compared in patients with or without endoleak from intercostal or bronchial arteries.Cox and Logistic regression were used to confirm the independent predictors for a composite of aortic-related death or reintervention and significant aneurysm growth(≥5mm)respectively.Results:63 patients were included,the mean age was 59(±13)years old.6 patients had endoleak from intercostal or bronchial arteries(endoleak group),the other 57 all had thrombosed aneurysm sac(no endoleak group).The 30-day mortality and complication rates were 0%and 10%respectively.At a median follow-up time of 38[14,58]months,all-cause mortality and aortic reintervention rate were 6%and 2%respectively.The 5-year survival and aortic reintervention-free survival rates were 92.8%and 100%respectively.There was no statistically significant difference in 30-day mortality,complication rate,follow-up all-cause mortality,and aortic reintervention rate between the two groups.For the composite of aortic-related death or reintervention,cox regression revealed no parameters with a statistically significant difference.However,patients in the endoleak group had a higher aneurysm growth rate(0.3 vs-0.1mm/month,p=0.013)and a higher proportion of significant aneurysm growth(50%vs 5%,p=0.013).Endoleak from intercostal or bronchial arteries was positively associated with significant aneurysm growth(Odds ratio=18,95%confident interval:2-196,p=0.008).Conclusion:Endoleak from intercostal or bronchial arteries after TEVAR for true descending TAA was not associated with the composite of aortic-related death or reintervention,but with a higher rate of significant aneurysm growth.The slow but persistent aortic growth may render patients to develop late aortic-related events,life-long surveillance is needed for them.Part 4 Type R entry flow is an independent predictor for abdominal aortic growth in repaired type B aortic dissectionObjective:To study the impact of type R entry flow on long-term outcomes(survival and aortic reoperation)and aortic remodeling(aorctic growth and false lumen regression)in patients with repaired type B aortic dissection.Methods:We performed a retrospective study on 188 patients with repaired type B aortic dissection.The total aortic diameter was measured at four levels:diaphragm,celiac,renal,and aortic bifurcation,and compared between the first and last computed tomography angiography after the operation.Aortic growth was defined as an increase≥5mm in total aortic diameter in any of the four measured levels,and false lumen regression was defined as the maximal diameter of false lumen<5mm.Logistic regression was used to reveal the independent predictor of aortic growth and false lumen regression at the stent segment.Results:The mean age of the 188 patients was 52.3 years old and the female proportion was 13%,30 of the 188 patients had type R entry flow.The 6-year survival rate was 92.9%with no significant difference between patients with or without type R entry flow.The 6years endovascular aortic reoperation-free survival rate was 97.7%and was higher in patients with type R entry flow(p=0.001).130 patients were included in the aortic remodeling analysis,25 of them had type R entry flow.At a median follow-up time of 14 months,type R entry flow still existed in 16 patients.The proportion of aortic growth was higher in patients with type R entry flow(64%vs 25%,p<0.001)，multivariate Logistic regression revealed 3 predictors:iliac involved(OR=3.35,95%CI:1.25-8.97,p=0.016),type R entry flow(OR=3.43,95%CI:1.17-10.06,p=0.025),and number of residual tears(OR=1.55,95%CI:1.03-2.35,p=0.036).The proportion of false lumen regression at the stent segment was lower in patients with type R entry flow(16%vs 75%,p<0.001),multivariate Logistic regression revealed 2 predictors:classification(chronic:OR=0.04,95%CI:0-0.41.p=0.006)and type R entry flow(OR=0.07,95%CI:0.02-0.25,p<0.001).Conclusions:In patients with repaired type B aortic dissection,type R entry flow did not affect the long-term survival but may be associated with a higher endovascular aortic reoperation rate.Type R entry flow positively predicts abdominal aortic growth and negatively predicts false lumen regression at the stent segment,close surveillance with timely intervention may be needed for achieving a favorable aortic remodeling.