腹主动脉瘤腔内修复术后Ⅱ型内漏的处理

Management of type Ⅱ endoleaks after endovascular abdominal aortic aneurysm repair

背景与目的:Ⅱ型内漏是腹主动脉瘤腔内修复术(EVAR)术后相对常见的并发症,然而目前对其是否需要手术干预及干预时机方面尚无统一的认识。因此,本研究探讨EVAR术后Ⅱ型内漏的手术方法,及其临床效果与安全性,以期为临床提供给参考。方法:回顾中南大学湘雅医院血管外科2016年1月-2020年12月期间行EVAR手术治疗的腹主动脉瘤患者临床与随访资料,分析EVAR术后发生II型内漏的发生率,以及其中行二次手术干预的患者的疗效、并发症及随访情况。结果:期间共282例行EVAR患者,术后随访1~54个月,平均17.9个月。随访过程中,发现单纯Ⅱ型内漏68例(24.1%),其中31例患者(45.6%) Ⅱ型内漏自愈;25例患者(36.8%)瘤体直径无明显增大;12例患者(17.6%)瘤体直径增加>10 mm或表现有相应的临床症状行二次干预。二次干预患者中,10例行经皮动脉栓塞术,其中8例患者行责任动脉栓塞者随诊12个月无内漏复发,瘤体直径缩小;2例栓塞后术后随访24个月Ⅱ型内漏仍存在,但瘤体直径无继续增大;2例行开放手术,其中1例术后出现急性心肌梗死,行急诊PCI,术后顺利恢复出院,另1例术中大出血,住院时间延长至16 d。2例开放手术患者术后随访6个月以上,情况良好,内漏完全消失。结论:大部分EVAR术后Ⅱ型内漏患者预后较好,而对于随访中瘤体直径增长较快及有临床症状者,栓塞责任血管可获得不错的临床效果;开放手术创伤相对较大,严重并发症发生率较高,选择需慎重。

Background and Aims: Type Ⅱ endoleak is a common complication after endovascular aortic aneurysm repair(EVAR). However, there is still no agreement on whether surgical intervention is required or the timing of intervention for this condition. Therefore, this study was conducted to evaluate the safety and efficacy of the surgical methods for type Ⅱ endoleak after EVAR and their efficacy and safety, so as to provide information for clinical decision making.Methods: The clinical and follow-up data of patients undergoing EVAR between January 2016 to December 2020 in Department of Vascular Surgery of Xiangya Hospital, Central South University were reviewed. The incidence of type Ⅱ endoleak after EVAR as well as the efficacy, complications and follow-up results in those undergoing the second surgical intervention were analyzed.Results: A total of 282 patients underwent EVAR during the study period. The follow-up was performed for 1 month to 54 months with an average of 17.9 months. During the follow-up, simple type Ⅱ endoleak occurred in 68 patients(24.1%), in whom, the type Ⅱ endoleak was spontaneously healed in 31 cases(45.6%), the aneurysmal diameter did not significantly increase in 25 cases(36.8%), and 12 cases(17.6%) underwent a second surgical intervention because the aortic aneurysm diameter increased >10 mm or relevant clinical symptoms were noted. In patients undergoing second surgical intervention, 10 patients underwent percutaneous arterial embolization, of whom 8 cases with embolization of the responsible artery were followed-up for 12 months and had no recurrence of endoleak with reduced aneurysmal diameter, and 2 cases undergoing embolization were follow-up 24 months and the type Ⅱ endoleak was still visible, but the aneurysmal diameter did not increase;2 patients underwent open surgery, of whom, 1 case had acute myocardial infarction after surgery, and emergency PCI was performed, and then was uneventfully recovered, and another case had a massive hemorrhage during surgery and the length of hospital was prolonged to 16 d. The 2 patients were followed up after open surgery for more than 6 months, and no further adverse events occurred and the endoleak completely disappeared.Conclusion: Most patients with type Ⅱ endoleak after EVAR have good prognosis. In those with rapid growth of aneurysmal diameter and clinical symptoms, the embolization of the responsible blood vessels can obtain good clinical results. Open surgery is a relatively traumatic procedure, with high incidence of serious complications, so the choice needs to be carefully considered.