Kazui Teruhisa, Yamashita Katsushi, Washiyama Naoki, Terada Hitoshi, Bashar Abul Hasan Muhammad, Suzuki Takayasu, Ohkura Kazuhiro
First Department of Surgery, Hamamatsu University School of Medicine, Japan.
Ann Thorac Surg. 2002 Nov;74(5):S1844-7; discussion S1857-63. doi: 10.1016/s0003-4975(02)04155-3.
To evaluate the impact of an aggressive surgical approach on early and late outcome in type A aortic dissection.
From 1983 to 2001, 240 patients underwent operation for acute (n = 138) and chronic (n = 102) type A aortic dissection. The extent of distal aortic resection included the ascending aorta in 39 (16%) patients, hemiarch (HAR) in 47 (20%), and total arch (TAR) in 154 (64%), including 19 patients who also had their descending aorta replaced (DAR).
The in-hospital mortality did not differ between TAR with or without DAR and other more conservative techniques (12.3% versus 16.3%). Actuarial survival at 10 years including in-hospital mortality was 72.4% +/- 3.3% and freedom from reoperation was 77.2% +/- 3.6% for all patients: neither was influenced by the extent of distal aortic resection or acuity of aortic dissection. Multivariate analysis revealed younger age and failure to resect the intimal tear to be independent determinants for late reoperation. However, in contrast to 22 patients who had more conservative operations, none of the patients with TAR required reoperation on the aortic arch through a sternotomy incision.
An aggressive surgical approach did not adversely influence early and late survival following type A aortic dissection; it reduced the necessity of late reoperation and facilitated distal aortic reoperation.
评估积极的手术方式对A型主动脉夹层早期和晚期结局的影响。
1983年至2001年，240例患者接受了急性（n = 138）和慢性（n = 102）A型主动脉夹层手术。远端主动脉切除范围包括升主动脉39例（16%）、半弓（HAR）47例（20%）和全弓（TAR）154例（64%），其中19例还进行了降主动脉置换（DAR）。
全弓置换（无论是否行降主动脉置换）与其他更保守的技术相比，住院死亡率无差异（12.3%对16.3%）。所有患者10年的精算生存率（包括住院死亡率）为72.4%±3.3%，无需再次手术的生存率为77.2%±3.6%：两者均不受远端主动脉切除范围或主动脉夹层急性期的影响。多因素分析显示，年龄较小和未切除内膜破口是晚期再次手术的独立决定因素。然而，与22例接受更保守手术的患者相比，全弓置换的患者中无一例需要通过胸骨切开术切口对主动脉弓进行再次手术。
积极的手术方式对A型主动脉夹层术后的早期和晚期生存无不利影响；它减少了晚期再次手术的必要性，并便于进行远端主动脉再次手术。
