Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
J Thorac Cardiovasc Surg. 2010 Sep;140(3):590-7. doi: 10.1016/j.jtcvs.2010.02.055.
Open total arch procedures have been associated with significant morbidity and mortality in patients with multiple comorbidities. Aortic arch debranching with endovascular graft placement, the hybrid arch procedure, has emerged as a surgical option in this patient population. This study evaluates the outcomes of a contemporary comparative series from one institution of open total arch and hybrid arch procedures for extensive aortic arch pathology.
From July 2000 to March 2009, 1196 open arch procedures were performed, including 45 elective and 7 emergency open total arch procedures. From 2005 to 2009, 64 hybrid arch procedures were performed: 37 emergency type A dissections and 27 elective open arch debranchings. Hemiarch procedures were excluded.
The hybrid arch cohort was significantly older (P = .008) and had greater predominance of atherosclerotic pathophysiology (P < .001). The incidence of permanent cerebral neurologic deficit was similar at 4% (1/27) for the hybrid arch cohort and 9% (4/45) for the open aortic arch cohort. In-hospital mortality was similar at 11% (3/27) for the hybrid arch cohort and 16% (7/45) for the open aortic arch cohort. However, in the open arch group, there was a significant difference in mortality between patients aged less than 75 years at 9% (3/34) and patients aged more than 75 years at 36% (4/11) (P = .05).
Hybrid arch procedures provide a safe alternative to open repair. This study suggests the hybrid arch approach has a lower mortality for high-risk patients aged more than 75 years. This extends the indication for the hybrid arch approach in patients with complex aortic arch pathology previously considered prohibitively high risk for conventional open total arch repair.
患有多种合并症的患者行全主动脉弓开放手术与较高的发病率和死亡率相关。主动脉弓离断并使用血管内移植物置入的杂交主动脉弓手术，已成为该患者人群的一种手术选择。本研究评估了同一机构在广泛主动脉弓病变的患者中，同期比较的开放全主动脉弓和杂交主动脉弓手术的结果。
2000 年 7 月至 2009 年 3 月，共进行了 1196 例开放主动脉弓手术，其中包括 45 例择期和 7 例急诊开放全主动脉弓手术。2005 年至 2009 年，共进行了 64 例杂交主动脉弓手术：37 例急症 A 型夹层和 27 例择期开放主动脉弓离断术。排除了半弓手术。
杂交主动脉弓组患者年龄显著较大（P =.008），且动脉粥样硬化病理生理学的发生率显著较高（P <.001）。永久性脑神经系统缺损的发生率在杂交主动脉弓组为 4%（1/27），与开放主动脉弓组的 9%（4/45）相似。院内死亡率在杂交主动脉弓组为 11%（3/27），与开放主动脉弓组的 16%（7/45）相似。然而，在开放主动脉弓组中，年龄小于 75 岁的患者死亡率为 9%（3/34），年龄大于 75 岁的患者死亡率为 36%（4/11），两组之间差异显著（P =.05）。
杂交主动脉弓手术为开放修复提供了一种安全的替代方法。本研究表明，杂交主动脉弓手术对于年龄大于 75 岁的高危患者具有较低的死亡率。这将杂交主动脉弓手术的适应证扩展到了先前被认为不适合进行传统的开放全主动脉弓修复的复杂主动脉弓病变的患者。
