Langer Stephan, Mommertz Gottfried, Koeppel Thomas A, Schurink Geert W H, Autschbach Rüdiger, Jacobs Michael J
European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, University Hospital Aachen, Aachen, Germany.
J Vasc Surg. 2008 Jun;47(6):1195-202. doi: 10.1016/j.jvs.2008.01.003.
The number of thoracic aortic endovascular procedures is increasing rapidly, and the clinical outcome largely depends on the underlying aortic pathology. When primary stent grafting is unsuccessful, secondary endovascular solutions are most often feasible. However, in recurrent endovascular failure without further minimally invasive options, conservative treatments or conversion to open surgery are the only remaining therapeutic strategies.
In our experience, 106 patients received thoracic aortic endovascular treatment. Five of these patients and three from other centers underwent conversion to open repair because of 4 type Ia endoleaks (3 thoracic aortic aneurysms, 1 traumatic rupture), 2 retrograde type A dissections, 1 type Ib endoleak with contained rupture, and 1 secondary false aneurysm rupture due to stent graft migration. The latter four were surgical emergencies; the other four were urgent or elective procedures. Three patients underwent supracoronary arch replacement through sternotomy. One patient had arch and proximal descending aortic replacement, three had hemiarch and descending aortic replacement, and one had descending aortic replacement through left thoracotomy. Five stent grafts were totally removed, and three endografts were left in situ. All conversions were performed according to a protocol including total extracorporeal circulation (n = 7) or left heart bypass (n = 1), cerebrospinal fluid drainage and monitoring motor-evoked potentials, transcranial Doppler, and electroencephalography.
All patients survived the surgical procedure. Six patients had an uneventful postoperative course, whereas necrotic cholecystitis developed in one patient who required cholecystectomy and prolonged intensive care stay. One polytrauma patient died from secondary rupture due to prosthesis infection 24 days after stent graft explantation. No stroke, paraplegia, renal failure, or other major complication occurred. With a mean follow-up of 14 months (range, 4-71 months), seven patients are alive without any sign of recurrent aortic problems.
Failure of thoracic endovascular aortic repair comprises a new aortic pathology. Secondary endovascular treatment is feasible in most patients; however, some patients will require open surgery to repair failures of thoracic endovascular aortic treatment. These procedures constitute a large surgical trauma and require an extensive protocol, including extracorporeal circulation, neuromonitoring, and adjunctive modalities to provide organ protection. We recommend that these procedures be performed in centers with experience and the infrastructure to offer these protective measures.
胸主动脉腔内治疗手术的数量正在迅速增加，临床结果在很大程度上取决于潜在的主动脉病变。当初次支架植入失败时，二次腔内治疗方案大多可行。然而，在反复出现腔内治疗失败且没有进一步的微创选择时，保守治疗或转为开放手术是仅存的治疗策略。
根据我们的经验，106例患者接受了胸主动脉腔内治疗。其中5例患者以及其他中心的3例患者因4例假性动脉瘤I型内漏（3例胸主动脉瘤、1例创伤性破裂）、2例逆行A型夹层、1例伴有局限性破裂的Ib型内漏以及1例因支架移植物移位导致的继发性假性动脉瘤破裂而转为开放修复。后4例为外科急症；其他4例为急诊或择期手术。3例患者通过胸骨正中切开术进行了冠状动脉上主动脉弓置换。1例患者进行了主动脉弓和近端降主动脉置换，3例进行了半弓和降主动脉置换，1例通过左胸切开术进行了降主动脉置换。5个支架移植物被完全移除，3个腔内移植物留在原位。所有转换均按照包括全体外循环（n = 7）或左心转流（n = 1）、脑脊液引流以及监测运动诱发电位、经颅多普勒和脑电图的方案进行。
所有患者均在手术中存活。6例患者术后恢复顺利，而1例患者发生坏死性胆囊炎，需要进行胆囊切除术并延长重症监护时间。1例多发伤患者在支架移植物取出术后24天因假体感染继发破裂死亡。未发生中风、截瘫、肾衰竭或其他重大并发症。平均随访14个月（范围4 - 71个月），7例患者存活，无主动脉复发问题的任何迹象。
胸主动脉腔内修复失败构成一种新的主动脉病变。二次腔内治疗在大多数患者中是可行的；然而，一些患者将需要开放手术来修复胸主动脉腔内治疗的失败。这些手术构成较大的手术创伤，需要广泛的方案，包括体外循环、神经监测和辅助手段以提供器官保护。我们建议这些手术应在有经验且具备提供这些保护措施基础设施的中心进行。
