| Objective: To evaluate the correlation between the anatomical conditions of the proximal neck of abdominal aortic aneurysm(AAA)and the results of endovascular aneurysm repair(EVAR),and to explore the anatomical indications of EVAR for AAA.Methods: The clinical and imaging data of 361 patients with AAA treated by EVAR in the Department of Vascular surgery,General Hospital of Tianjin Medical University from January 2013 to December 2018 were collected.According to the anatomy of the proximal tumor neck before operation,the patients were divided into complex group and non-complex group.The preoperative basic condition,the success rate of technique and surgical,the incidence of intraoperative,perioperative and follow-up complications,aneurysm related mortality and secondary intervention rate of two groups were retrospectively and contrastively analyzed.Results: A total of 323 patients were enrolled in the group,including complex group(n=174)and non-complex group(n=149).The average age of the complex group was older than that of the non-complex group(71.6±7.4vs69.7±8.5,P=0.03).There was no significant difference in sex,comorbidity and the proportion of ruptured AAA were found between the two groups.There were statistically significant differences between the complex group and the non-complex group,such as the average neck length(25.2 ±15.8mm vs 32.5 ±12.3 mm),mural thrombus(20.7% vs 0%),calcification(17.2% vs 0%),irregularity(4.6% vs 0%),the median of superior angle 20°(0°,47.8°)vs5°(0°,10°),the median of infrarenal angle 65°(30°,80°)vs30°(10°,45°),and AAA average diameter(56.3±14.6mm vs 51.1±13.9mm).There was no significant difference in the average diameter of proximal neck,the constituent ratio of the iliac artery calcification and iliac aneurysm.The proportion of untraditional EVAR in the complex group(22.4%,39/174,22 cases of the chEVAR,14 cases of the f EVAR,3 cases of the docking technique EVAR)was significantly higher than that of non-complex group(0%,p<0.05).There was no significant difference in the success rate of device release(99.4%,173/174)and surgical success rate(97.1%,169/174)in the complex group compared with the non-complex group(both 100%).There were 5 cases of proximal neck-related complications in the complex group,including 4 cases of type Ia endoleak,1 case of conversion to open surgery.The incidence rate in the complex group(2.9%)was higher than that in the non-complex group(0%),but there was no significant difference(P=0.102).There was no significant difference in the incidence of type II endoleak between the complex group and the non-complex group(3.4%vs2.7%,P=0.942).There was no intraoperative death in both groups.No significant difference was found in perioperative mortality between complex group(1.1%,)and non-complex group(2%,p=0.861).No new poximal neck-related complications occurred in both groups during the perioperative period.Perioperative secondary surgical intervention included complex group(n = 1)and non-complex group(n = 2),both of which were iliac branch occlusion.305 cases were followed up,the average follow-up was 41.7±19.7 months.There were 3 cases of new proximal neck-related complications in the complex group,including 2 cases of type Ia endoleak and 1 case of pseudoaneurysm at the proximal end of the stent.There was no significant difference in the incidence between the complex group(1.7%)and the non-complex group(0%,P=0.304).The incidence of type II endoleak in complex group(2.3%)was higher than that in non-complex group(1.3%),but the difference was not statistically significant(P=0.825),There were no aneurysm-related deaths in both groups.In the complex group,secondary surgical intervention was performed in 20 cases,there were 3 cases related to proximal aneurysm neck,including 2 cases of new type Ia endoleak,1 case of pseudoaneurysm at the proximal end of the stent.The remaining cases including 2 cases of type Ib,4 cases of type II,1 case of type III and 10 cases of iliac branch occlusion.In the non-complex group,secondary surgical intervention was performed in 13 cases,including 2 cases of type Ib endoleak,2 cases of type II endoleak,2 cases of type III endoleak and 7 cases of iliac branch occlusion.No cases related to proximal neck.No significant difference was found in intervention rate of all-cause secondary surgery between complex group and non-complex group(11.5%vs 8.7%,P=0.413).There were no aneurysm-related deaths in both groups.There was no significant difference between the two groups in the proximal neck-related secondary surgical intervention rate(1.7% vs 0%,P = 0.304).The results of univariate analysis showed that the superior angle and inferior angle are related to the incidence of proximal neck related complications(p<0.05).Multivariate analysis by Logistic regression showed that only the inferior angle and the proximal neck related complications have statistical significance(OR=1.031,95%CI:1.001-1.061,P=0.046).Conclusion: 1.For complex proximal tumor neck problems such as short neck(length 4-15mm),thick neck(diameter 28-32mm),tortuosity,severe calcification,presence of mural thrombus and irregularity of AAA proximal neck,endovascular therapy can be performed by modified EVAR technique:(1)fEVAR are good methods to expand proximal landing zone.It can be used to treat AAA with short proximal neck,but it is not suitable to distort the tortuosity neck AAA.(2)chEVAR can be used as an emergency method for short proximal neck with tortuosity or emergent rupture.(3)Docking technique can be used for AAA with diameter of proximal neck more than 28 mm to 32 mm,mural thrombus and large area calcification.2.Regression analysis showed that the excessive large superior and inferior angle are an important factor in the occurrence of proximal neck-related complications after EVAR.Especially the AAA with both superior angle > 45 °and inferior angle > 60 ° is more likely to occur Ia endoleak after EVAR,so EVAR is not suitable for this type of AAA. |
PDF Full Text Request