Menard Matthew T, Nguyen Louis L, Chan Rodney K, Conte Michael S, Fahy Lisamarie, Chew David K W, Donaldson Magruder C, Mannick John A, Whittemore Anthony D, Belkin Michael
Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
J Vasc Surg. 2004 Jun;39(6):1163-70. doi: 10.1016/j.jvs.2003.12.019.
Repair of thoracovisceral aortic aneurysms (TVAA) after previous open repair of an infrarenal abdominal aortic aneurysm (AAA) poses significant challenges. We sought to better characterize such recurrent aneurysms and to evaluate their operative outcome.
We reviewed the records and radiographs of 49 patients who underwent repair of TVAAs between 1988 and 2002 after previous repair of an AAA. Visceral artery reconstructions were completed with combinations of beveled anastomoses, inclusion patches, and side arm grafts. In 14 patients visceral endarterectomy was required to treat associated occlusive disease. Sixteen patients had cerebrospinal fluid drainage, and 10 patients had distal perfusion during cross-clamping.
Patient mean age was 72 years, and 80% were men. Fifty-one percent of patients had symptomatic disease, and average TVAA diameter was 6.2 cm. Mean time between AAA and TVAA repair was 77 months. Twenty-six percent of aneurysms were restricted to the lower visceral aortic segment, 35% extended to the diaphragm, another 35% extended to the distal or middle thoracic aorta, and 4% involved the entire remaining visceral and thoracic aorta. The 30-day operative mortality rate was 4.1% in patients with nonruptured aneurysms and 50% in patients with ruptured aneurysms, for an overall mortality rate of 8.2%. Fifteen patients (30.6%) had major morbidity, including paresis in two patients and dialysis-dependent renal failure in five patients. At late follow-up, three patients required further aortic operations to treat additional aneurysms, and four patients had fatal aortic ruptures. Two-year and 5-year cumulative survival rates were 61% (+/-7.5%) and 37% (+/-7.8%), respectively. At univariate analysis, operative blood loss was the sole significant predictor of major morbidity (P <.023), and rupture (P <.030, P <.0001) and aneurysm extent (P <.0007, P <.0001) correlated with both operative death and long-term survival. Only aneurysm extent (P <.010, relative risk 37.3) remained a significant predictor of long-term survival at multivariate analysis.
Elective repair of TVAAs after previous AAA repair can be performed with an acceptable level of operative mortality, though with considerable operative morbidity. Limited long-term survival mandates careful patient selection, and the high mortality associated with ruptured TVAA underscores the need for post-AAA surveillance.
在先前已对肾下腹主动脉瘤（AAA）进行开放修复后，修复胸内脏主动脉瘤（TVAA）面临重大挑战。我们试图更好地描述此类复发性动脉瘤的特征并评估其手术结果。
我们回顾了1988年至2002年间49例在先前AAA修复后接受TVAA修复患者的记录和影像学资料。内脏动脉重建通过斜角吻合、包埋补片和侧臂移植物的组合完成。14例患者需要进行内脏动脉内膜切除术以治疗相关闭塞性疾病。16例患者进行了脑脊液引流，10例患者在交叉钳夹期间进行了远端灌注。
患者平均年龄为72岁，80%为男性。51%的患者有症状性疾病，TVAA平均直径为6.2 cm。AAA修复与TVAA修复之间的平均时间为77个月。26%的动脉瘤局限于下内脏主动脉段，35%延伸至膈肌，另外35%延伸至胸主动脉远端或中段，4%累及整个剩余的内脏和胸主动脉。未破裂动脉瘤患者的30天手术死亡率为4.1%，破裂动脉瘤患者为50%，总体死亡率为8.2%。15例患者（30.6%）发生严重并发症，包括2例患者出现轻瘫，5例患者出现依赖透析的肾衰竭。在晚期随访中，3例患者需要进一步进行主动脉手术以治疗额外的动脉瘤，4例患者发生致命性主动脉破裂。2年和5年累积生存率分别为61%（±7.5%）和37%（±7.8%）。在单因素分析中，手术失血量是严重并发症的唯一显著预测因素（P<.023），破裂（P<.030，P<.0001）和动脉瘤范围（P<.0007，P<.0001）与手术死亡和长期生存均相关。在多因素分析中，只有动脉瘤范围（P<.010，相对风险37.3）仍然是长期生存的显著预测因素。
在先前AAA修复后对TVAA进行择期修复可在可接受的手术死亡率水平下进行，尽管手术并发症较多。有限的长期生存率要求仔细选择患者，与破裂TVAA相关的高死亡率凸显了AAA术后监测的必要性。
