Subscribe to RSS
DOI: 10.1055/s-0030-1247468
© Georg Thieme Verlag Stuttgart ˙ New York
Einfluss des Verankerungsmechanismus auf Veränderungen des supra- und infrarenalen Aortensegments nach endovaskulärer Ausschaltung infrarenaler Bauchaortenaneurysmen
Influence of Fixation Mechanism on Changes of the Supra- and Infrarenal Segment of the Aorta after Endovascular Treatment of Infrarenal Aortic AneurysmPublication History
Publication Date:
25 October 2010 (online)
Zusammenfassung
Hintergrund: Die Langzeitergebnisse nach EVAR werden maßgeblich durch Reinterventionen, bedingt durch Endoleaks und Stentgraftmigration, beeinflusst. Ausschlaggebend ist eine korrekte und lang andauernde Abdichtung zwischen Aorta und Stentgraft im infrarenalen Aortensegment. Ziel der Studie war es, die Veränderung der supra- und infrarenalen Durchmesser in Abhängigkeit vom verwendeten Verankerungsmechanismus in einem 10-Jahres-Zeitraum zu erfassen. Patienten: Es wurden alle Patienten, die zwischen 1998 und 2008 in unserer Klinik endovaskulär an einem Bauchaortenaneurysma behandelt wurden, retrospektiv nachuntersucht. Einschlusskriterien waren: Elektiver Eingriff, selbstexpandierbare Stentgrafts der neuesten Generation, 3 unterschiedliche Verankerungsmechanismen (infrarenal, suprarenal und suprarenal mit Widerhaken), mindestens 3 Monate Follow-up in unserer Klinik. Es konnten insgesamt 103 Patienten in die Studie eingeschlossen werden. Diese gliedern sich in 39 Patienten mit infrarenalem (Gore Excluder®, W. L. Gore & Associates, Flagstaff, Ariz, USA), 35 mit einfachem suprarenalen (Medtronic Talent®, Medtronic World Medical, Sunrise, FL, USA) und 29 mit suprarenalen Verankerungsmechanismus mit Widerhaken (Cook Zenith®, Cook Inc. Bloomington, IN, USA). Die einzelnen Durchmesser wurden durch orthogonale Messungen entlang einer center lumen line bestimmt und durch 2 Mitarbeiter ausgewertet. Neben dem infrarenalen Durchmesser wurden der suprarenale und maximale Durchmesser bestimmt. Eine Veränderung von über 2 mm wurde als signifikante Dilatation angesehen. Ergebnisse: Über eine Nachuntersuchungszeit von 39,4 (3–108,8) Monate zeigt sich eine kumulative Dilatationsrate von 28,57 % (Medtronic), 10,26 % (Gore) und 31,03 % (Cook). Für den suprarenalen Bereich entsprechend 17,14 %, 20,51 %, und 17,24 %. Der maximale Durchmesser konnte in 74,3 % (Medtronic), 79,5 % (Gore), und 75,8 % (Cook) reduziert werden. Von 23 Patienten mit einer infrarenalen Aortenhalserweiterung mussten 7 therapiert werden. Hierbei handelte es sich ausschließlich um Stentgrafts mit suprarenaler Verankerung. Es ergab sich kein signifikanter Unterschied zwischen den drei verschiedenen Gruppen bzgl. suprarenaler oder infrarenaler Erweiterung. Schlussfolgerung: Auch wenn der Unterschied zwischen den einzelnen Gruppen nicht signifikant ist, zeigte sich jedoch bei rein infrarenaler Verankerung auch die geringste Rate an infrarenaler Halserweiterung. Ebenso musste in dieser Gruppe kein Patient nachtherapiert werden.
Abstract
Introduction: Dilatation of the infrarenal aortic segment determines the long-term outcome after endovascular repair of abdominal aortic aneurysms. This segment is crucial for sealing and preventing stent-graft migration. The purpose of this study was to evaluate influence of fixation mechanism on changes of supra- and infrarenal aortic diameters over a 10-year period. Methods: We reviewed all our endovascular procedures for abdominal aortic aneurysms and follow-up CT scans between 1998 and 2008. Only patients with the three most frequently implanted self-expandable stent-graft types and a minimal follow-up of three months were included in this study. Further inclusion criteria were elective repair and follow-up at our department to consistent data formats. A total of 103 patients, 35 with suprarenal fixation without hooks (Medtronic Talent®, Medtronic World Medical, Sunrise, FL, USA), 29 with suprarenal fixation with hooks (Cook Zenith®, Cook Inc. Bloomington, IN, USA) and 39 with infrarenal fixation with anchors (Gore Excluder®, W. L. Gore & Associates, Flagstaff, Ariz, USA) met the inclusion criteria. All measurements were performed in duplicate by two different investigators to determine intra- and interobserver errors. Based on this error a minimal change of 2 mm of infrarenal aortic neck diameter was determined as aortic neck dilatation. Results: During a mean follow-up time of 39.4 (3–108.8) months, infrarenal aortic neck dilatation was found in 28.57 % in the Medtronic group, 10.26 % in the Gore group and 31.03 in the Cook group. Suprarenal changes were 17.14 %, 20.51 % and 17.24 %, respectively. Reduction of the maximal diameter could be achieved in 74.3 % (Medtronic), 79.5 % (Gore), and 75.8 % (Cook). Seven of 23 patients with a notable dilatation of the infrarenal neck required reintervention. All of them were stent-grafts with suprarenal fixation. No statistical significance was found between the 3 groups regarding changes of suprarenal or infrarenal diameters or migration rates. Conclusion: Although no statistical significance was found among the groups, infrarenal fixation showed the lowest rate of infrarenal dilatation.
Schlüsselwörter
Aortenaneurysma - endovaskuläre Therapie - Stentprothese - infrarenale Halserweiterung - Verankerungsmechanismus - endovaskulär
Key words
aortic aneurysm - endovascular therapy - stent prosthesis - aortic neck dilatation - fixation mechanism - endovascular
Literatur
- 1 Greenhalgh R M, Brown L C, Kwong G PS et al. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (evar trial 1), 30-day operative mortality results: randomised controlled trial. Lancet. 2004; 364 843-848
- 2 Prinssen M, Verhoeven E LG, Buth J et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004; 351 1607-1618
- 3 Drury D, Michaels J A, Jones L et al. Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm. Br J Surg. 2005; 92 937-946
- 4 Mohan I V, Laheij R J, Harris P L. Risk factors for endoleak and the evidence for stent-graft oversizing in patients undergoing endovascular aneurysm repair. Eur J Vasc Endovasc Surg. 2001; 21 344-349
- 5 Conners M S, Sternbergh W C, Carter G et al. Endograft migration one to four years after endovascular abdominal aortic aneurysm repair with the aneurx device: a cautionary note. J Vasc Surg. 2002; 36 476-484
- 6 Badran M F, Gould D A, Raza I et al. Aneurysm neck diameter after endovascular repair of abdominal aortic aneurysms. J Vasc Interv Radiol. 2002; 13 887-892
- 7 Fillinger M. Three-dimensional analysis of enlarging aneurysms after endovascular abdominal aortic aneurysm repair in the Gore Excluder Pivotal clinical trial. J Vasc Surg. 2006; 43 888-895
- 8 Litwinski R A, Donayre C E, Chow S L et al. The role of aortic neck dilation and elongation in the etiology of stent graft migration after endovascular abdominal aortic aneurysm repair with a passive fixation device. J Vasc Surg. 2006; 44 1176-1181
- 9 Millon A, Deelchand A, Feugier P et al. Conversion to open repair after endovascular aneurysm repair: causes and results. A French multicentric study. Eur J Vasc Endovasc Surg. 2009; 38 429-434
- 10 Sampaio S M, Panneton J M, Mozes G et al. Aneurx device migration: incidence, risk factors, and consequences. Ann Vasc Surg. 2005; 19 178-185
- 11 Sternbergh W C, Money S R, Greenberg R K et al. Influence of endograft oversizing on device migration, endoleak, aneurysm shrinkage, and aortic neck dilation: results from the Zenith Multicenter Trial. J Vasc Surg. 2004; 39 20-26
- 12 May J, White G H, Ly C N et al. Endoluminal repair of abdominal aortic aneurysm prevents enlargement of the proximal neck: a 9-year life-table and 5-year longitudinal study. J Vasc Surg. 2003; 37 86-90
- 13 van Prehn J, van der Wal M BA, Vincken K et al. Intra- and interobserver variability of aortic aneurysm volume measurement with fast cta postprocessing software. J Endovasc Ther. 2008; 15 504-510
- 14 Rodway A D, Powell J T, Brown L C et al. Do abdominal aortic aneurysm necks increase in size faster after endovascular than open repair?. Eur J Vasc Endovasc Surg. 2008; 35 685-693
- 15 Wever J J, Blankensteijn J D, van Rijn J C et al. Inter- and intraobserver variability of ct measurements obtained after endovascular repair of abdominal aortic aneurysms. AJR Am J Roentgenol. 2000; 175 1279-1282
- 16 Dalainas I, Nano G, Bianchi P et al. Aortic neck dilatation and endograft migration are correlated with self-expanding endografts. J Endovasc Ther. 2007; 14 318-323
- 17 Torsello G, Osada N, Florek H et al. Long-term outcome after talent endograft implantation for aneurysms of the abdominal aorta: a multicenter retrospective study. J Vasc Surg. 2006; 43 277-284 discussion 284
- 18 Biebl M, Hakaim A G, Hugl B et al. Endovascular aortic aneurysm repair with the Zenith AAA Endovascular Graft: does gender affect procedural success, postoperative morbidity, or early survival?. Am Surg. 2005; 71 1001-1008
- 19 Bosman W MPF, Steenhoven T JVD, Suarez D R et al. The proximal fixation strength of modern evar grafts in a short aneurysm neck. An in vitro study. Eur J Vasc Endovasc Surg. 2010; 39 187-192
- 20 Mahnken A H, Chalabi K, Jalali F et al. Magnetic resonance-guided placement of aortic stents grafts: feasibility with real-time magnetic resonance fluoroscopy. J Vasc Interv Radiol. 2004; 15 189-195
- 21 Peirano M A, Bertoni H G, Chikiar D S et al. Size of the proximal neck in AAAs treated with balloon-expandable stent-grafts: CTA findings in mid- to long-term follow-up. J Endovasc Ther. 2009; 16 696-707
- 22 Malas M B, Ohki T, Veith F J et al. Absence of proximal neck dilatation and graft migration after endovascular aneurysm repair with balloon-expandable stent-based endografts. J Vasc Surg. 2005; 42 639-644
Dr. A. Oberhuber
Uniklinik Ulm · Klinik für Thorax- und Gefäßchirurgie
Steinhövelstraße 9
89075 Ulm
Deutschland
Phone: +49 / 7 31 / 50 05 40 58
Fax: +49 / 7 31 / 50 05 40 02
Email: alexander.oberhuber@uniklinik-ulm.de