Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
Ann Thorac Surg. 2010 Aug;90(2):539-46. doi: 10.1016/j.athoracsur.2010.04.040.
Thoracic aortic disease involving the aortic arch presents a challenge to cardiovascular surgeons. The purpose of this study was to establish the safety and efficacy of antegrade delivery techniques of aortic stent grafting for the treatment of high-risk, complex thoracic aortic disease.
From April 2007 to December 2009, 38 patients underwent stent graft repair of complex thoracic aortic diseases not otherwise amenable to standard retrograde delivery. Chart review, query of the Social Security Death Index, and three-dimensional analysis of computed tomography was performed. Indications were elective (n = 17), urgent (n = 11), or emergent (n = 10). Causes included coarctation (n = 1), acute aortic dissection (n = 4), traumatic transection (n = 2), and aneurysm or pseudoaneurysm (n = 31), of which 6 were ruptured. Sites of delivery included axillary (n = 4), ascending aorta (n = 18), and direct aortic placement (frozen elephant trunk, n = 16). Eleven were performed off-pump, 4 were performed on pump with a beating heart, 3 with cardiac arrest, and 20 under deep hypothermic circulatory arrest. Delivery was facilitated by transesophageal echocardiography alone (n = 14), or with fluoroscopy (n = 24). All devices used were commercially available (TAG, 18; Talent, 1; TX2, 19). Concomitant procedures were performed in 26 patients including 17 ascending repairs, 16 coronary artery bypass graftings, and 4 aortic valve replacements.
Technical success was achieved in 97% (37 of 38 patients). Hospital mortality was 10% (n = 4), and serious complications included stroke (n = 4), paraparesis (transient n = 3, persistent n = 1), renal failure (n = 4), and respiratory failure (n = 12). Mean length of hospital stay was 14.7 days (range, 4 to 36 days), and 6.7 days (range, 1 to 20 days) in the intensive care unit. Overall survival was 74% at median follow-up of 1.2 + or - 0.8 years. Ten endoleaks in 9 patients (8 type II, 2 type I) required 3 late reinterventions.
Antegrade delivery of commercially available stent grafts to treat high-risk, complex thoracic aortic diseases is feasible with a high rate of technical success and good intermediate-term outcomes. Further evaluation of these alternative stent graft delivery techniques is warranted.
涉及主动脉弓的胸主动脉疾病对心血管外科医生提出了挑战。本研究的目的是确定顺行输送技术在治疗高危、复杂胸主动脉疾病中的安全性和有效性。
从 2007 年 4 月至 2009 年 12 月，38 例复杂胸主动脉疾病患者因标准逆行输送不可行而接受支架移植物修复。进行图表审查、社会安全死亡索引查询和计算机断层扫描三维分析。适应证为择期（n=17）、紧急（n=11）或紧急（n=10）。病因包括缩窄（n=1）、急性主动脉夹层（n=4）、创伤性横断（n=2）和动脉瘤或假性动脉瘤（n=31），其中 6 例破裂。输送部位包括腋窝（n=4）、升主动脉（n=18）和直接主动脉放置（冷冻象鼻，n=16）。11 例非体外循环下进行，4 例在心脏跳动下进行，3 例心脏停搏下进行，20 例在深低温循环停止下进行。单纯经食管超声心动图（n=14）或透视（n=24）辅助输送。所有使用的装置均为市售产品（TAG，18；Talent，1；TX2，19）。26 例患者同时进行了其他手术，包括 17 例升主动脉修复、16 例冠状动脉旁路移植术和 4 例主动脉瓣置换术。
技术成功率为 97%（37/38 例）。住院死亡率为 10%（n=4），严重并发症包括脑卒中（n=4）、截瘫（一过性 n=3，持续性 n=1）、肾衰竭（n=4）和呼吸衰竭（n=12）。平均住院时间为 14.7 天（范围，436 天），重症监护病房为 6.7 天（范围，120 天）。中位随访 1.2+0.8 年时，总体生存率为 74%。9 例患者中有 10 例发生 10 个漏（8 型 II 漏，2 型 I 漏），需要 3 例晚期再次干预。
顺行输送市售支架移植物治疗高危、复杂胸主动脉疾病是可行的，技术成功率高，中期结果良好。需要进一步评估这些替代支架移植物输送技术。
