Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195-5108, USA.
Ann Thorac Surg. 2012 Sep;94(3):751-6; discussion 757-8. doi: 10.1016/j.athoracsur.2012.04.033. Epub 2012 Jun 16.
Open, hybrid, and endovascular procedures are used for grown-up patients with aortic coarctation and complications after repair, an expanding population. We sought to characterize patients and procedures, assess early and late outcomes, and describe indications to guide treatment of these complex patients.
Between May 1999 and January 2011, 110 patients underwent open (n=40), hybrid (n=11), or endovascular (n=59) repair of coarctation (n=43), recurrent aortic coarctation (n=42), or postrepair aneurysm (n=25). Mean age was 38±14 years. Sixty-eight had previous repairs (median 27 years earlier; range, 1 to 50). Twenty-two had prior cardiovascular operations other than coarctation and 50% had bicuspid valve. Fifty-nine concomitant procedures were performed in 45 patients (40%). Data were from the prospective database, chart review, and Social Security Death Index.
Technical success was achieved in 100%, with no hospital deaths, no strokes, and no paraplegia. Complications were uncommon and included respiratory failure (n=2, 1.8%), and temporary renal failure (n=2, 1.8%). Twenty-two patients required reinterventions, but half of those were planned. There was no difference in occurrence of unplanned reintervention between approaches (endovascular 12%, hybrid 18%, open 12.5%). Length of stay was 4.8±4.8 days. Transcoarct gradient fell from 37.6±18 mm Hg preoperatively to 7.0±6.9 mm Hg in coarctation patients. Postrepair aneurysm patients had no late ruptures, and maximum diameter shrunk from 5.9±1.3 cm preoperatively to 4.8±1.3 cm. Estimated survival at 1, 5, and 8 years was 95%, 95%, and 90%, respectively.
Coarctation, recurrent coarctation, and postrepair aneurysm/pseudoaneurysm in adolescent and adult patients can be safely and effectively managed with open, hybrid, or endovascular techniques. Optimal results are achievable in this complex population of patients with a multimodality approach tailored to surgical indication and anatomy. All survivors of coarctation repair require lifelong surveillance.
对于患有主动脉缩窄和修复后并发症的成年患者，开放、杂交和血管内手术被用于治疗这一不断扩大的人群。我们旨在描述患者和手术过程，评估早期和晚期结果，并描述指导这些复杂患者治疗的适应证。
1999 年 5 月至 2011 年 1 月期间，110 例患者接受了主动脉缩窄（n=43）、复发性主动脉缩窄（n=42）或修复后动脉瘤/假性动脉瘤（n=25）的开放（n=40）、杂交（n=11）或血管内（n=59）修复。平均年龄为 38±14 岁。68 例患者有既往修复史（中位数为 27 年前；范围，1 至 50 年）。22 例患者有除主动脉缩窄以外的其他心血管手术史，50%为二叶瓣。45 例患者（40%）共进行了 59 次伴随手术。数据来自前瞻性数据库、图表回顾和社会安全死亡索引。
技术成功率为 100%，无院内死亡、无卒中、无截瘫。并发症少见，包括呼吸衰竭（n=2，1.8%）和暂时性肾功能衰竭（n=2，1.8%）。22 例患者需要再次介入治疗，但其中一半是计划进行的。三种治疗方法之间（血管内治疗 12%，杂交治疗 18%，开放治疗 12.5%）无计划再次介入治疗的发生率无差异。住院时间为 4.8±4.8 天。缩窄段压差从术前的 37.6±18mmHg 降至主动脉缩窄患者的 7.0±6.9mmHg。修复后动脉瘤患者无晚期破裂，最大直径从术前的 5.9±1.3cm 缩小至 4.8±1.3cm。1、5、8 年的估计生存率分别为 95%、95%和 90%。
对于青少年和成年患者的主动脉缩窄、复发性主动脉缩窄以及修复后动脉瘤/假性动脉瘤，可以安全有效地采用开放、杂交或血管内技术进行治疗。对于这一复杂人群，采用针对手术适应证和解剖结构的多模式方法，可以实现最佳结果。所有主动脉缩窄修复的幸存者都需要终身监测。
