目的 总结分析应用原位开窗和烟囱技术重建主动脉弓上分支治疗主动脉扩张性疾病的经验与体会。 方法 回顾性分析2016年2月至2019年8月复旦大学附属中山医院血管外科治疗主动脉扩张性疾病并采用原位开窗或烟囱技术重建弓上分支75例患者的临床资料。根据分支重建方法的不同分为原位开窗组和烟囱支架组，比较两组间的围术期及随访期间并发症情况及弓上分支血管通畅率等，并进一步对弓上单分支和多分支重建进行亚组分析。组间比较采用t检验、秩和检验或卡方检验。 结果 75例患者中，采用原位开窗41例（原位开窗组），烟囱技术34例（烟囱支架组）。原位开窗组中单分支重建30例（73.2%），多分支重建11例（26.8%）。烟囱支架组中，单烟囱和多烟囱重建者各17例。原位开窗组中单分支重建占比明显高于烟囱支架组（73.2% 比 50.0%，χ2=4.265，P=0.039）。原位开窗和烟囱支架的技术成功率分别为97.6%（40/41）和100%（28/28）。住院期间，原位开窗组发生脑卒中2例，Ⅰ型内漏3例，Ⅱ型内漏2例，短暂性截瘫1例；死亡2例，其中1例为原位三开窗术后第3天死亡，考虑为主动脉相关死亡，1例为双开窗术后第4天因脑出血死亡。烟囱支架组脑卒中5例，I型内漏13例，II型内漏3例。烟囱支架组中I型内漏发生率明显高于原位开窗组（38.2% 比 7.3%，χ2=10.587，P=0.001）。原位开窗组37例获得随访，中位随访时间为17.4（13.5，21.7）个月。烟囱支架组31例获得随访，中位随访时间为21.6（17.0，26.7）个月。随访期间，烟囱支架组I型内漏发生率仍高于原位开窗组，差异具有统计学意义（17.6% 比 2.4%，χ2=5.080，P=0.042）。在多分支重建的亚组分析中，住院期间烟囱技术并发症发生率显著高于原位开窗技术（88.2% 比 36.4%，χ2=8.239，P=0.010）。随访期间两种技术的不良事件和死亡发生率差异均无统计学意义（P均>0.05）。 结论 原位开窗和烟囱技术均为重建弓上分支的有效方法，短中期疗效满意。相比开窗技术，烟囱支架组有更高的内漏发生率；原位开窗技术由于破坏了覆膜支架的结构完整性，其远期疗效有待进一步观察。 Objectives To analyse and summarize experiences of applying in situ fenestration or chimney technique to reconstruct supra-aortic branches in the treatment of aortic dilatation. Methods Clinical data of 75 patients with dilated aorta treated in Department of Vascular Surgery, Zhongshan Hospital affiliated to Fudan University from February 2016 to August 2019 were retrospectively analysed. In situ fenestration or chimney technique was used to reconstruct supra-aortic branches. Patients were divided into fenestration group and chimney group according to different branch reconstruction methods. Perioperative and follow-up complications and patency rate of supra-aortic branch vessels between two groups were compared. Subgroup analysis of single and multiple supra-aortic branch reconstruction was further analysed. Comparison between groups was performed using t test, rank sum test, or chi-square test. Results Seventy-five cases were collected for final analysis. In fenestration group (n=41), patients with single and multiple branches were 30 cases (73.2%) and 11 cases (26.8%), respectively. In chimney group(n=34), half of the patients received single branch reconstruction and half multiple. Reconstruction proportion of single branch in fenestration group was significantly higher than that in chimney group (73.2% vs 50.0%,χ2=4.265,P=0.039). Technical success rates were 97.6% (40/41) in fenestration group and 100% (28/28) in chimney group. During hospitalization, complications in fenestration group contained 2 strokes, 3 type Ⅰ endoleak, 2 type Ⅱ endoleak, and 1 transient paraplegia while 5 strokes, 13 type Ⅰ endoleak, and 3 type Ⅱ endoleak were included in chimney group. The incidence of type I endoleak in chimney group was significantly higher than that in fenestration group (38.2% vs 7.3%, χ2=10.587, P=0.001). In fenestration group, 2 patients died during hospitalization. One died on the third day after triple fenestration reconstruction, which was considered as an aortic-related death. The other one died of cerebral hemorrhage on the fourth day after double fenestration reconstruction. 37 cases were followed up with 17.4 (13.5~21.7) months median follow-up in fenestration group, while 31 cases with 21.6 (17.0~26.7) months median follow-up in chimney group. During follow-up, incidence of type I endoleak in chimney group was still higher than that in fenestration group, and difference was statistically significant (17.6% vs 2.4%,χ2=5.080, P=0.042). In a subgroup analysis of multiple branch reconstruction, complication rate of chimney technique during hospitalization was significantly higher than that of fenestration technique (88.2% vs 36.4%,χ2=8.239, P=0.010). There were no statistically significant differences in the incidences of adverse events and mortality between two groups during follow-up(all P>0.05). Conclusion Both in situ fenestration and chimney stent are effective techniques for reconstructing supra-aortic branches, with satisfying efficacy in short and medium-term. Compared with fenestration technique, chimney stent has a higher incidence of endoleak. Since the fenestration technique destroys structural integrity of covered stent-graft, its long-term efficacy remains to be further observed.
Abstract
Objectives To analyse and summarize experiences of applying in situ fenestration or chimney technique to reconstruct supra-aortic branches in the treatment of aortic dilatation. Methods Clinical data of 75 patients with dilated aorta treated in Department of Vascular Surgery, Zhongshan Hospital affiliated to Fudan University from February 2016 to August 2019 were retrospectively analysed. In situ fenestration or chimney technique was used to reconstruct supra-aortic branches. Patients were divided into fenestration group and chimney group according to different branch reconstruction methods. Perioperative and follow-up complications and patency rate of supra-aortic branch vessels between two groups were compared. Subgroup analysis of single and multiple supra-aortic branch reconstruction was further analysed. Comparison between groups was performed using t test, rank sum test, or chi-square test. Results Seventy-five cases were collected for final analysis. In fenestration group (n=41), patients with single and multiple branches were 30 cases (73.2%) and 11 cases (26.8%), respectively. In chimney group(n=34), half of the patients received single branch reconstruction and half multiple. Reconstruction proportion of single branch in fenestration group was significantly higher than that in chimney group (73.2% vs 50.0%,χ2=4.265,P=0.039). Technical success rates were 97.6% (40/41) in fenestration group and 100% (28/28) in chimney group. During hospitalization, complications in fenestration group contained 2 strokes, 3 type Ⅰ endoleak, 2 type Ⅱ endoleak, and 1 transient paraplegia while 5 strokes, 13 type Ⅰ endoleak, and 3 type Ⅱ endoleak were included in chimney group. The incidence of type I endoleak in chimney group was significantly higher than that in fenestration group (38.2% vs 7.3%, χ2=10.587, P=0.001). In fenestration group, 2 patients died during hospitalization. One died on the third day after triple fenestration reconstruction, which was considered as an aortic-related death. The other one died of cerebral hemorrhage on the fourth day after double fenestration reconstruction. 37 cases were followed up with 17.4 (13.5~21.7) months median follow-up in fenestration group, while 31 cases with 21.6 (17.0~26.7) months median follow-up in chimney group. During follow-up, incidence of type I endoleak in chimney group was still higher than that in fenestration group, and difference was statistically significant (17.6% vs 2.4%,χ2=5.080, P=0.042). In a subgroup analysis of multiple branch reconstruction, complication rate of chimney technique during hospitalization was significantly higher than that of fenestration technique (88.2% vs 36.4%,χ2=8.239, P=0.010). There were no statistically significant differences in the incidences of adverse events and mortality between two groups during follow-up(all P>0.05). Conclusion Both in situ fenestration and chimney stent are effective techniques for reconstructing supra-aortic branches, with satisfying efficacy in short and medium-term. Compared with fenestration technique, chimney stent has a higher incidence of endoleak. Since the fenestration technique destroys structural integrity of covered stent-graft, its long-term efficacy remains to be further observed.
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