Etz Christian D, Zoli Stefano, Kari Fabian A, Mueller Christoph S, Bodian Carol A, Di Luozzo Gabriele, Plestis Konstadinos A, Griepp Randall B
Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York 10029, USA.
Ann Thorac Surg. 2009 Sep;88(3):758-66; discussion 767. doi: 10.1016/j.athoracsur.2009.04.140.
Reoperative descending thoracic aorta (DTA) or thoracoabdominal aortic aneurysm (TAAA) surgery is a challenge because of increased risk of lung injury and diffuse bleeding.
Sixty patients (34 male, mean age 54.4 years) underwent redo thoracotomy for DTA (22 patients) or extended thoracoabdominal incision for reoperative TAAA (38 patients) from March 1988 to June 2007, after 1.7 +/- 0.9 previous cardioaortic procedures. Forty-one patients were hypertensive (68%), 18 were smokers (30%), 9 had Marfan syndrome (15%), 9 had coronary artery disease (15%), 5 had chronic obstructive pulmonary disease (8%), and 3 had diabetes mellitus (5%). In all, 45% (27 patients) had previous dissection, 30% (18) had atherosclerotic aneurysms, 15% had coarctation surgery (9), and 6 patients had other etiologies. Mean follow-up, 100% complete, was 6.5 years.
Hospital mortality for reoperative DTA/TAAA was 13.3% (8 patients). Although 6.3 +/- 2.9 (0 to 14) segmental artery pairs were sacrificed at reoperation-and 6.2 +/- 2.3 (1 to 12) initially-for a total of 10.6 +/- 3.9 (2 to 15) segmental artery pairs sacrificed, only 1 patient had paraplegia (1.6%). Four patients had a 2-day procedure, with 12 to 24 hours of intensive care unit recovery after lysis of extensive adhesions: all survived. Respiratory complications occurred in 13 patients (21.6%), and permanent dialysis was required in 2 (3.3%), but there were no strokes. Adverse outcome-1-year mortality, stroke, permanent dialysis, or paraplegia-occurred in 13 patients (21.6%). Adverse outcome was marginally associated (p < 0.2) with increased age, atherosclerotic aneurysms (33% versus 17% other), TAA incision (30% versus 9%), and greater aneurysm extent, and was significantly associated with perfusion technique (p = 0.02). Adverse outcome occurred in 3 of 4 patients who had clamp-and-sew technique, 6 of 21 using partial cardiopulmonary bypass (28.6%), and 3 of 17 with partial left heart bypass (17.7%), but only 1 of 18 with hypothermic circulatory arrest (5.6%).
Reoperative DTA/TAAA repair was significantly safer with hypothermic circulatory arrest rather than partial cardiopulmonary bypass, partial left heart bypass, or clamp-and-sew strategy. A 2-day procedure may be advisable for patients with extensive adhesions.
再次进行降胸主动脉（DTA）或胸腹主动脉瘤（TAAA）手术具有挑战性，因为肺损伤和弥漫性出血的风险增加。
1988年3月至2007年6月，60例患者（34例男性，平均年龄54.4岁）接受了再次开胸手术治疗DTA（22例患者）或扩大胸腹切口进行再次TAAA手术（38例患者），此前平均接受过1.7±0.9次心脏主动脉手术。41例患者患有高血压（68%），18例为吸烟者（30%），9例患有马凡综合征（15%），9例患有冠状动脉疾病（15%），5例患有慢性阻塞性肺疾病（8%），3例患有糖尿病（5%）。总共有45%（27例患者）曾有过夹层，30%（18例）患有动脉粥样硬化性动脉瘤，15%接受过缩窄手术（9例），6例患者有其他病因。平均随访时间为6.5年，随访完整率为100%。
再次DTA/TAAA手术的医院死亡率为13.3%（8例患者）。尽管再次手术时牺牲了6.3±2.9（0至14）对节段动脉——最初为6.2±2.3（1至12）对——总共牺牲了10.6±3.9（2至15）对节段动脉，但只有1例患者发生截瘫（1.6%）。4例患者接受了为期2天的手术，在松解广泛粘连后在重症监护病房恢复12至24小时：均存活。13例患者发生呼吸并发症（21.6%），2例患者需要永久性透析（3.3%），但无中风发生。13例患者（21.6%）出现不良结局——1年死亡率、中风、永久性透析或截瘫。不良结局与年龄增加、动脉粥样硬化性动脉瘤（33%对其他病因的17%）、TAA切口（30%对9%）以及更大的动脉瘤范围存在微弱关联（p<0.2），并且与灌注技术显著相关（p = 0.02）。采用钳夹缝合技术的4例患者中有3例出现不良结局，使用部分体外循环的21例患者中有6例（28.6%），采用部分左心转流的17例患者中有3例（17.7%），但采用低温循环停止的18例患者中只有1例（5.6%）。
与部分体外循环、部分左心转流或钳夹缝合策略相比，采用低温循环停止进行再次DTA/TAAA修复明显更安全。对于有广泛粘连的患者，为期2天的手术可能是可取之策。
