Pochettino Alberto, Brinkman William T, Moeller Patrick, Szeto Wilson Y, Moser William, Cornelius Katherine, Bowen Frank W, Woo Y Joseph, Bavaria Joseph E
Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104-4283, USA.
Ann Thorac Surg. 2009 Aug;88(2):482-9; discussion 489-90. doi: 10.1016/j.athoracsur.2009.04.046.
Acute DeBakey I dissection repair consists of ascending aortic resection, aortic root repair or replacement, and variable aortic arch replacement. This "proximal" strategy leaves most patients with a patent residual "type B" dissection which leads to greater than 30% distal "open" reoperations for dissecting aneurysm. This report tests whether antegrade stent-grafting of the proximal descending thoracic aorta during acute DeBakey I dissection decreases future distal aortic aneurysms without an increase in surgical risk.
Between June 2005 and June 2008, 150 patients were treated surgically for acute type A aortic dissection at the Hospital of the University of Pennsylvania. Of these, 78 were DeBakey I dissections: 42 patients underwent standard open repair, while 36 underwent additional thoracic stent-grafting by the open arch. Arch repairs were performed with a combination of retrograde cerebral and selective antegrade perfusion.
Mean follow-up was 15.9 months. Hospital mortality was 5 of 36 (14%) for stented and 6 of 42 (14%) for nonstented repairs. Postoperative strokes were 1 of 36 (3%) in stented versus 4 of 42 (10%) in nonstented repairs (p = not significant [NS]) despite longer circulatory arrest times in the stented group; 60 +/- 13 minutes versus 41 +/- 18 minutes (p < 0.0001). Transient paraparesis was 3 of 36 (9%) in the stented versus 1 of 42 (2%) in the nonstented group (p = NS) with no permanent deficits. Stented thoracic false lumen obliteration was achieved in 24 of 30 (80%) with 5 of these (17%) achieving complete thoracoabdominal false lumen thrombosis. Eight of 31 (26%) stented patients underwent endovascular reintervention to achieve the desired false lumen obliteration. Open thoracoabdominal aortic aneurysm repairs were performed in 0 of 31 in the stented group and 4 of 36 (11%) in the standard group (p = 0.083).
Antegrade stent graft deployment during acute DeBakey I dissection repair is a safe method to obliterate the thoracic false lumen. Endovascular reinterventions were well-tolerated. "Elephant trunk" thoracic stent-grafting as part of the repair for acute DeBakey I dissection gives equal short-term results compared with standard repair, and lowers morbidity and mortality during follow-up.
急性DeBakey I型夹层修复包括升主动脉切除、主动脉根部修复或置换以及不同程度的主动脉弓置换。这种“近端”策略使大多数患者残留有“B型”夹层，这导致超过30%的患者因夹层动脉瘤而进行远端“开放”再次手术。本报告旨在测试在急性DeBakey I型夹层期间对胸降主动脉近端进行顺行支架植入是否能减少未来远端主动脉瘤的发生，且不增加手术风险。
2005年6月至2008年6月期间，150例患者在宾夕法尼亚大学医院接受了急性A型主动脉夹层手术治疗。其中，78例为DeBakey I型夹层：42例患者接受了标准的开放修复，而36例患者通过开放弓进行了额外的胸段支架植入。弓部修复采用逆行脑灌注和选择性顺行灌注相结合的方法。
平均随访时间为15.9个月。支架植入组36例中有5例（14%）住院死亡，非支架植入组42例中有6例（14%）住院死亡。支架植入组术后中风发生率为36例中的1例（3%），非支架植入组为42例中的4例（10%）（p =无统计学意义[NS]），尽管支架植入组的循环阻断时间更长；分别为60±13分钟和41±18分钟（p < 0.0001）。支架植入组短暂性截瘫发生率为36例中的3例（9%），非支架植入组为42例中的1例（2%）（p = NS），且无永久性神经功能缺损。30例中有24例（80%）实现了支架植入胸段假腔闭塞，其中5例（17%）实现了胸腹段假腔完全血栓形成。31例支架植入患者中有8例（26%）接受了血管内再次干预以实现预期的假腔闭塞。支架植入组31例中0例进行了胸腹主动脉瘤开放修复，标准组36例中有4例（11%）进行了开放修复（p = 0.083）。
在急性DeBakey I型夹层修复期间进行顺行支架植入是闭塞胸段假腔的一种安全方法。血管内再次干预耐受性良好。作为急性DeBakey I型夹层修复一部分的“象鼻”胸段支架植入与标准修复相比，短期结果相当，且在随访期间降低了发病率和死亡率。
