| Research objective:The application of fenestrated and branched endovascular aortic repair for the treatment of thoracoabdominal aortic coarctation and thoracoabdominal aortic aneurysms is gradually being used in clinical practice,with a large number of follow-up studies on medium-and long-term outcomes still lacking.In this study,we followed up this group of patients to investigate the high risk factors for death and re-surgical intervention and the relationship between the points of preoperative CT assessment and the occurrence of endoleak affecting aortic remodeling and endoleak.Research methods:A retrospective analysis was performed on patients diagnosed with thoracoabdominal aortic dissection and thoracoabdominal aortic aneurysm and treated with fenestrated and branched endovascular aortic repair at the Vascular Surgery Department of Nanjing Towel Hospital from January 2018 to December 2019.Preoperative general data(including: age,sex,underlying conditions,length of hospitalization,etc.),surgical procedure,and preoperative CT imaging of the thoracoabdominal aorta were collected,and the prognosis of patients was collected by various methods such as outpatient follow-up and telephone follow-up,and statistical analysis was performed on patients who died after surgery and underwent surgical intervention again.Patients who were closely followed up and had available imaging data(mainly thoracoabdominal aortic CT imaging)were screened to determine the occurrence of aortic endoleaks and the results of aortic remodeling and statistically analyzed with the preoperative data.Research result:1.A total of 105 patients were included in the study,including 62 patients with thoracoabdominal aortic dissection and 43 patients with thoracoabdominal aortic aneurysm.A total of 336 branch arteries were reconstructed,and a total of 100 patients were followed up,with a follow-up rate of 95.2%.89 patients(84.5%)were followed up and remained alive,including 54 patients with aortic coarctation and 35 patients with aortic aneurysm;29 patients with leakage occurred within three years after surgery,with an incidence rate of 27.6%.There were 3 patients who died 30 d after surgery,with a mortality rate of 2.86%;11 patients died 3 years after surgery,with a mortality rate of 10.5%,including 6 patients who died from aortarelated causes,with a mortality rate of 5.7%,and 5 patients who died from non-aorta-related causes,with a mortality rate of 4.8%.Fifteen cases of re-intervention with aortic-related surgery were performed during postoperative follow-up,with a re-intervention rate of 14.3%.9patients(8.6%)underwent planned second-stage surgery for treatment of the distal endoleak due to the involvement of a longer extent of the aorta,and 6 patients(5.7%)underwent unplanned reoperations for other interventions.The results of COX survival regression analysis of high risk factors for reintervention in patients with f/b EVAR suggested that a history of preoperative combined renal insufficiency was an independent risk factor for reoperative intervention in patients with thoracoabdominal aortic dissection and thoracoabdominal aortic aneurysm(preoperative renal insufficiency P=0.010,OR=0.17,95% CI: 0.045-0.66).2.All patients underwent preoperative CT revascularization of the thoracoabdominal aorta in our hospital.The true lumen diameter of the aorta was 13.3 mm(7.49-107.0 mm),the maximum diameter of the aorta was 44.6 mm(29.46-107.0 mm),and the diameters of the visceral arteries were 8.17 ± 1.18 mm for the celiac trunk artery,6.81 ± 0.61 mm for the superior mesenteric artery,6.04 ± 1.14 mm for the left renal artery,and 5.53 ± 0.72 mm for the right renal artery.The diameter of the left renal artery was 6.04±1.14 mm,and the diameter of the right renal artery was 5.53±0.72 mm.22 patients(20.9%)had preoperative aortic angulation(>60°),47 patients(44.8%)had aortic calcification in the visceral artery area,42 patients(40%)had visceral arteries originating from false lumen,and 11 patients(10.5%)had visceral artery entrapment..The results of COX survival regression analysis of the above data suggested that the smaller diameter of the celiac trunk artery and the combination of visceral artery entrapment were risk factors for patient death(celiac trunk artery diameter P=0.049,OR=0.60,95% CI: 0.36-0.10;combination of visceral artery entrapment P=0.009,OR=0.19,95% CI: 0.056-0.67)..The area under the working characteristic curve of subjects with abdominal trunk artery diameter AUC=0.69,P=0.039,95% CI 0.56-0.82,critical value=7.37 mm,sensitivity=0.82 and specificity=0.54 of the prediction model at this point.3.A total of 69 patients who were closely followed up and had complete imaging data were screened.The most recent CT angiography of the thoracoabdominal aorta was used as the basis for grouping patients with or without endoleaks,and univariate analysis revealed statistically significant differences in the distribution of left and right renal artery diameters between the different groups(P=0.049 for the left renal artery diameter and P=0.019 for the right renal artery diameter),with patients with endoleaks having larger renal artery diameters.A multifactorial logistic correlation analysis found that the maximum aortic diameter was an independent risk factor for endoleaks(P=0.04,OR=1.043).,OR=1.043,95%CI:1.002-1.085),and subject workup characteristic curve analysis revealed a maximum diameter AUC=0.605,P=0.152,95%CI:46-0.75,threshold=41.5 mm,sensitivity=0.59 and specificity=0.59 of the prediction model at this point.Based on the results of the most recent CT angiography of the thoracoabdominal aorta,and grouped by thoracoabdominal aortic remodeling,single factor analysis revealed statistically significant differences(P < 0.05)in aortic angulation,visceral artery from pseudolumen,aortic calcification in the visceral artery region and the maximum diameter of the aorta and true lumen diameter of the aorta.A multifactorial logistic correlation analysis revealed that aortic calcification in the visceral artery region and larger true aortic lumen were factors influencing positive aortic remodeling(P=0.04,OR=8.18,94% CI:1.10-60.68 for the former;P=0.03,OR=0.90,95%CI:0.81-0.99 for the latter).Subject operating characteristic curve(ROC)analysis revealed: aortic true lumen diameter AUC=0.928,P<0.001,95%CI:0.863-0.993,cut-off value D true lumen=18.95 mm,sensitivity of the prediction model at this point=0.857,specificity=1.Research conclusions:1.The application of Fenestrated and branched endovascular aortic repair for thoracoabdominal aortic coarctation and thoracoabdominal aortic aneurysm at our center has a lower 30-d mortality rate(2.86%),a lower reintervention rate(14.3%),and a satisfactory mid-term follow-up,and control of endoleaks remains the main point of treatment with this technique.2.Factors affecting the prognosis of patients undergoing f/b EVAR include patient baseline characteristics and aortic morphology.TAAA and TAAD patients exhibit significant differences in chest and abdominal aortic CT measurements.Postoperative creatinine increase,smaller diameter of the abdominal aortic aneurysm,and visceral artery involvement with dissection are associated with mortality in f/b EVAR patients.Larger maximum aortic diameter is a risk factor for endoleak during follow-up,whereas larger diameter of the bilateral renal arteries is a potential risk factor for endoleak.Larger true lumen diameter of the aorta and atherosclerotic calcification of the visceral aortic segment are risk factors for aortic remodeling after f/b EVAR. |
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