Estrera Anthony L, Miller Charles C, Porat Eyal, Mohamed Shafi, Kincade Robert, Huynh Tam T, Safi Hazim J
Department of Cardiothoracic and Vascular Surgery, The University of Texas at Houston Medical School, Memorial Hermann Hospital, Houston, Texas 77030, USA.
Ann Thorac Surg. 2004 Sep;78(3):837-45; discussion 837-45. doi: 10.1016/j.athoracsur.2004.03.085.
The purpose of this study was to investigate the cause of ascending aorta and aortic arch reoperations and to identify determinants of early and late outcome.
Between January 1991 and March 2003 we repaired aneurysms of the proximal aorta in 597 patients. Of these patients, 104 had reoperations for replacement of the ascending aorta, aortic root, or transverse aortic arch. Previous surgery was defined as any previous cardiac or proximal aortic repair. Median age was 60 years, and 29 of the patients (28%) were female. Indications for reoperation and replacement of the proximal aorta included acute type A dissection in 6 patients (5.8%), aneurysm with chronic dissection in 60 (57.7%), progression of aneurysm in 23 (22.1%), infection in 12 (1.5%), inflammatory disease in 2 (1.9%), and atheromatous disease in 1 (1.0%). Reoperations included aortic root replacement in 20 patients (19.2%), total arch replacement with elephant trunk in 28 (26.7%), ascending and proximal arch in 39 (37.5%), and ascending aorta in 27 (26.0%). The median interval between operations was 69 months. Retrograde cerebral perfusion was used in 80 (77%) cases.
Chronic dissection was the most common indicator for reoperation in our population, followed by progression of aneurysm and infection. Thirty-day and in-hospital mortality was 13.5% (14 of 104) and 15.4% (16 of 104), respectively. Chronic obstructive pulmonary disease, renal dysfunction, and increased pump time were risk factors for mortality. Median follow-up was 5.02 years. Eight patients died during that period. Estimated survival at 1, 5, and 10 years was 83%, 80%, and 62%, respectively. Freedom from second proximal reoperations was 97.1% (10 of 104). Freedom from subsequent distal thoracic aortic repair was 84.6% (8 of 104).
Reoperations of the ascending aorta and aortic arch can be performed safely with good long-term results. Patients with previous proximal aortic dissection repair need long-term surveillance. Renal dysfunction and chronic obstructive pulmonary disease must be carefully considered before reoperations of the proximal aorta.
本研究旨在调查升主动脉和主动脉弓再次手术的原因，并确定早期和晚期结果的决定因素。
1991年1月至2003年3月期间，我们对597例患者的近端主动脉瘤进行了修复。其中，104例患者因升主动脉、主动脉根部或主动脉弓横部置换而接受了再次手术。既往手术定义为任何既往心脏或近端主动脉修复手术。患者的中位年龄为60岁，29例患者（28%）为女性。再次手术和近端主动脉置换的指征包括急性A型夹层6例（5.8%）、伴有慢性夹层的动脉瘤60例（57.7%）、动脉瘤进展23例（22.1%）、感染12例（1.5%）、炎症性疾病2例（1.9%）和动脉粥样硬化疾病1例（1.0%）。再次手术包括20例患者（19.2%）行主动脉根部置换、28例（26.7%）行带象鼻的全弓置换、39例（37.5%）行升主动脉和近端弓置换以及27例（26.0%）行升主动脉置换。两次手术之间的中位间隔时间为69个月。80例（77%）患者采用了逆行脑灌注。
慢性夹层是我们研究人群中再次手术最常见的指征，其次是动脉瘤进展和感染。30天和住院死亡率分别为13.5%（104例中的14例）和15.4%（104例中的16例）。慢性阻塞性肺疾病、肾功能不全和体外循环时间延长是死亡的危险因素。中位随访时间为5.02年。在此期间有8例患者死亡。1年、5年和10年的预计生存率分别为83%、80%和62%。再次近端手术的无复发生存率为97.1%（104例中的10例）。后续胸主动脉远端修复的无复发生存率为84.6%（104例中的8例）。
升主动脉和主动脉弓再次手术可以安全进行，并能取得良好的长期效果。既往近端主动脉夹层修复的患者需要长期监测。在近端主动脉再次手术前，必须仔细考虑肾功能不全和慢性阻塞性肺疾病。
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