Department of Cardiovascular Surgery, Japan Labor Health and Welfare Organization, Osaka Rosai Hospital, Osaka, Japan.
Eur J Cardiothorac Surg. 2012 Nov;42(5):840-8; discussion 848. doi: 10.1093/ejcts/ezs117. Epub 2012 Apr 19.
Total arch replacement, with a long elephant trunk (ET) anastomosed at the base of the innominate artery using an undersized graft, is performed for a variety of arch aneurysms. We investigated the long-term clinical outcomes of this procedure, as well as its long-term effectiveness for preventing retrograde flow into the aneurysm and further dilation of the descending aorta.
We treated 127 consecutive patients with an arch aneurysm, who were divided into two groups according to the diameter of the descending aorta at the Th6-Th8 thoracic vertebral level: 35 mm or less (Single-ET, n = 94) and >35 mm (Staged-ET, n = 33). The graft diameter was undersized by 10-20% of the distal aortic diameter. ET length was determined by preoperative computed tomography (CT) to locate the distal end at Th6-Th8. Thrombosis around the ET and the descending aorta diameter around the distal end of the ET were evaluated using CT.
Two patients (1.6%) died within 30 days, while seven (5.5%) died in the hospital, three (2.4%) had a new stroke, three (2.4%) had permanent paraplegia and one (0.8%) had paraparesis. CT demonstrated complete thrombosis of the perigraft space around the ET in 81 patients (86%) in the Single-ET group and 11 (33%) in the Staged-ET group within 1 month after surgery, but not in the remaining 35 patients. Twenty-seven of the 35 patients without complete thrombosis underwent a subsequent second-stage operation. In those, the descending aorta showed no further dilation around the distal end of the ET, while new-onset perigraft perfusion occurred in two patients in the Single-ET group at 14 and 126 months, respectively. Overall survival was 89, 86, 78 and 74% at 1, 3, 5 and 7 years, respectively.
Our operative strategy for extensive thoracic aortic aneurysms using a long ET technique yielded satisfactory short- and long-term outcomes.
对于各种主动脉弓部动脉瘤，采用一种较小口径的移植物在无名动脉基底进行全主动脉弓置换，同时吻合长的象鼻（ET）。我们研究了该手术的长期临床结果，以及其在防止逆行血流进入动脉瘤和进一步扩张降主动脉方面的长期效果。
我们治疗了 127 例连续的主动脉弓部动脉瘤患者，根据第 6-8 胸椎水平降主动脉直径将患者分为两组：35mm 或更小（单 ET，n=94）和>35mm（分期 ET，n=33）。移植物直径比远端主动脉直径小 10-20%。根据术前 CT（CT）确定 ET 的长度，以将其远端定位在第 6-8 胸椎。使用 CT 评估 ET 周围血栓形成和 ET 远端降主动脉直径。
2 例患者（1.6%）在 30 天内死亡，7 例（5.5%）在院内死亡，3 例（2.4%）新发脑卒中，3 例（2.4%）永久性截瘫，1 例（0.8%）截瘫。在单 ET 组的 81 例患者（86%）和分期 ET 组的 11 例患者（33%）中，术后 1 个月 CT 显示 ET 周围的移植物空间完全血栓形成，但在其余 35 例患者中未见完全血栓形成。在未完全血栓形成的 35 例患者中，有 27 例接受了随后的二期手术。在这些患者中，在 ET 远端降主动脉周围没有进一步扩张，而在单 ET 组的 2 例患者中分别在第 14 和 126 个月时出现新的移植物周围灌注。总的生存率分别为 1、3、5 和 7 年时的 89%、86%、78%和 74%。
我们采用长 ET 技术治疗广泛的胸主动脉瘤的手术策略取得了满意的短期和长期效果。
