Patel Himanshu J, Williams David M, Upchurch Gilbert R, Dasika Narasimham L, Deeb G Michael
Department of Surgery, University of Michigan Cardiovascular Center, Ann Arbor, Mich, USA.
J Vasc Surg. 2009 Dec;50(6):1265-70. doi: 10.1016/j.jvs.2009.07.091. Epub 2009 Sep 26.
Successful repair of the ruptured (non-traumatic) descending thoracic aorta (rTA) remains a formidable clinical challenge. Although effective for rTA, traditional open repair (DTAR) has significant associated morbidity. With expanding indications for thoracic endovascular aortic repair (TEVAR), we describe our experience with TEVAR and DTAR in this high-risk setting to elucidate their evolving roles.
Since the inception of our thoracic aortic endovascular program in 1993, 69 patients underwent DTAR (34) or TEVAR (35) for rTA. Patients underwent TEVAR if they were considered nonoperative candidates because of extensive comorbidities (n = 31; 88.6%) or had extremely favorable anatomy for endovascular repair (eg, mid-descending saccular aneurysm, n = 4). Aortic pathology causing rupture was fusiform aneurysm (18), saccular aneurysm/ulcer (22), and dissection (29). Associated aortobronchial fistulae (12) and aortoesophageal (1) fistulae were also present in 18.8%. Arch repair was needed in 46; total descending repair was needed in 33. Follow-up was 100% complete (mean 37.4 months).
Mean age was 65.9 years (DTAR 60.3 year vs TEVAR 71.3 years, P = .005). In-hospital or 30-day mortality was seen in 13 patients (TEVAR n = 4; 11.4% vs DTAR n = 9; 26.5%, P = .13). Median length of stay was shorter after TEVAR (8 days vs DTAR 15 days, P = .02). Mean Kaplan-Meier survival was similar between groups (TEVAR 67.4 months vs DTAR 65.0 months, P = .7). By multivariate analysis, independent predictors of a composite outcome of early mortality, stroke, permanent spinal cord ischemia, or need for dialysis or tracheostomy included the presentation with hemodynamic instability (P < .001) and treatment with conventional open repair (P = .02).
An endovascular approach for the ruptured (non-traumatic) descending thoracic aorta reduces early morbidity, mortality, and duration of hospitalization, while providing equivalent late outcomes even in an older group largely considered high risk for open repair. These data support a paradigm shift, with TEVAR emerging as the preferred therapy for all patients presenting with descending aortic rupture.
成功修复破裂（非创伤性）胸降主动脉（rTA）仍然是一项艰巨的临床挑战。尽管传统开放修复术（DTAR）对rTA有效，但有显著的相关并发症。随着胸主动脉腔内修复术（TEVAR）适应证的不断扩大，我们描述了在这种高风险情况下我们应用TEVAR和DTAR的经验，以阐明它们不断演变的作用。
自1993年我们开展胸主动脉腔内治疗项目以来，69例患者因rTA接受了DTAR（34例）或TEVAR（35例）治疗。如果患者因合并症广泛被认为不适合手术（n = 31；88.6%）或具有极其适合腔内修复的解剖结构（如降主动脉中部囊状动脉瘤，n = 4），则接受TEVAR治疗。导致破裂的主动脉病变包括梭形动脉瘤（18例）、囊状动脉瘤/溃疡（22例）和夹层（29例）。18.8%的患者还伴有主动脉支气管瘘（12例）和主动脉食管瘘（1例）。46例需要进行弓部修复；33例需要进行全降主动脉修复。随访率为100%（平均37.4个月）。
平均年龄为65.9岁（DTAR组60.3岁，TEVAR组71.3岁，P = 0.005）。13例患者出现院内或30天死亡率（TEVAR组4例；11.4%，DTAR组9例；26.5%，P = 0.13）。TEVAR术后中位住院时间较短（8天，DTAR组为15天，P = 0.02）。两组间平均Kaplan-Meier生存率相似（TEVAR组67.4个月，DTAR组65.0个月，P = 0.7）。多因素分析显示，早期死亡、中风、永久性脊髓缺血或需要透析或气管切开术的综合结果的独立预测因素包括血流动力学不稳定（P < 0.001）和采用传统开放修复术治疗（P = 0.02）。
对于破裂（非创伤性）胸降主动脉采用腔内治疗方法可降低早期并发症、死亡率和住院时间，同时即使在很大程度上被认为是开放修复高风险的老年患者组中也能提供相当的远期疗效。这些数据支持了一种模式转变，即TEVAR已成为所有出现降主动脉破裂患者的首选治疗方法。
