Department of Vascular Surgery, Vascular Center Catholic Clinics Duesseldorf Augusta Hospital, Düsseldorf, Germany.
J Vasc Surg. 2011 May;53(5):1431-7. doi: 10.1016/j.jvs.2010.10.133. Epub 2011 Jan 26.
Endovascular treatment of the ascending aorta is particularly challenging because of the anatomic features of this aortic segment. Only patients without connective tissue disorders, clinically relevant aortic regurgitation or stenosis, or concomitant coronary artery disease can be considered for an endovascular procedure. We report our results in a series of patients with aneurysms or intramural hematoma, penetrating ulcers, or floating thrombus who were scheduled for stent grafting.
Only patients with ascending aortic pathology who were unfit for open surgery were treated with an endograft. When preoperative computed tomography imaging showed severe calcification of the aortic arch or thrombus lining, temporary clamping of the carotid arteries before wire and catheter introduction was performed. An extracorporeal bypass from the right groin to both carotid arteries with a roller pump was established and maintained during the procedure. The endograft was placed across the aortic valve into the left ventricle and deployed in a retrograde fashion. At the end of the procedure, ventriculography and, if necessary, coronary angiography was performed to rule out any damage to the left ventricle or the valve apparatus.
Eleven patients were scheduled for stent graft exclusion of ascending aortic pathology. In five cases because of discrepancies in length measurements and sizing, the thoracic endograft was cut to length intraoperatively after partial deployment on the operating table and reloaded to avoid covering of the innominate artery. The mean length of the ascending aorta covered was longer in aneurysm patients than in those with dissection. An 81-year-old patient presented with a type Ia leak. The distal landing zone in one patient was enlarged by debranching. One patient died after wire perforation of the left ventricle, and one patient sustained a cerebral stroke. Combined morbidity and mortality was 18%, and the technical success rate was 91%.
Stent grafting of the ascending aorta is technically feasible but should be reserved for selected high-risk patients only, preferably in centers where vascular specialists cooperate closely with interventional cardiologists. Cardiac surgery with cardiopulmonary bypass is still the gold standard to treat ascending aortic aneurysms. Stent graft exclusion of more advanced and complex ascending aortic pathology should be performed only in centers with the necessary experience in transvalvular cardiac procedures.
由于升主动脉的解剖学特点，腔内治疗升主动脉具有挑战性。只有没有结缔组织疾病、有临床意义的主动脉瓣反流或狭窄、或合并冠状动脉疾病的患者，才能考虑腔内治疗。我们报告了一系列患有动脉瘤或壁内血肿、穿透性溃疡或漂浮血栓的患者，这些患者计划接受支架移植物置入术。
只有不适合开放手术的升主动脉病变患者接受血管内移植物治疗。当术前计算机断层扫描成像显示主动脉弓严重钙化或血栓覆盖时，在导丝和导管引入前进行颈动脉临时夹闭。在手术过程中，从右腹股沟到双侧颈动脉建立并维持体外旁路，使用滚压泵。支架移植物穿过主动脉瓣进入左心室，并逆行展开。在手术结束时，进行心室造影，如果有必要，进行冠状动脉造影，以排除对左心室或瓣膜装置的任何损伤。
11 例患者计划进行支架移植物排除升主动脉病变。在 5 例患者中，由于长度测量和尺寸存在差异，在手术台上部分展开后，术中对胸主动脉移植物进行了切割以适应长度，并重新装载以避免覆盖无名动脉。在动脉瘤患者中，覆盖的升主动脉长度比夹层患者长。一位 81 岁的患者出现 Ia 型漏。一名患者的远端着陆区通过去分支扩大。一名患者因左心室导丝穿孔而死亡，一名患者发生脑卒。总并发症和死亡率为 18%，技术成功率为 91%。
升主动脉支架置入术在技术上是可行的，但应仅保留给选择的高危患者，最好在血管外科专家与介入心脏病学家密切合作的中心。体外循环下心外科手术仍然是治疗升主动脉瘤的金标准。只有在具有跨瓣心脏手术必要经验的中心，才能对更先进和复杂的升主动脉病变进行支架移植物排除。
