Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA 22908, USA.
J Vasc Surg. 2012 Dec;56(6):1495-502. doi: 10.1016/j.jvs.2012.05.091. Epub 2012 Jul 24.
Repair of patients with extent I and II thoracoabdominal aortic aneurysms (TAAAs) is associated with significant morbidity and mortality, whereas repair of more distal extent III and IV TAAAs has a lower risk of paraplegia and death. Therefore, we describe an approach using thoracic endovascular aneurysm repair (TEVAR) as the index operation to convert extent I and II TAAAs to extent III and IV TAAAs amenable to subsequent open aortic repair to minimize patient risk.
Between July 2007 and March 2012, 10 staged hybrid operations were performed to treat one extent I and nine extent II TAAAs. Aortic aneurysm pathology included five chronic type B dissections, three acute type B dissections, and two penetrating aortic ulcers. Initially, the proximal descending thoracic aorta was repaired with TEVAR for coverage of the most proximal fenestration or penetrating ulcer, with seven elective and three emergent repairs. Interval open distal aortic replacement was performed in a short-term planned setting or for progressive dilation of the distal aortic segment. In the open repair, the proximal end of the graft was sewn directly to the distal end of the TEVAR and outer wall of the aorta.
Average patient age was 48 years, and 60% were men. Risk factors included hypertension (80%), current tobacco use (50%), and Marfan syndrome (30%). Complications after TEVAR included type IA (n=1) and type II (n=3) endoleaks, pleural effusions (n=3), and acute kidney injury (n=1). Three patients required endovascular reinterventions. In patients with dissection, persistent filling of the false lumen was common and associated with distal thoracic aortic dilation. Complications of open repair included acute kidney injury in two patients, but no cardiac, pulmonary, or neurologic morbidity. Median time between TEVAR and open repair was 14 weeks. Most importantly, no deaths or neurologic deficits occurred after either procedure during a median follow-up of 35 weeks.
A staged hybrid approach to extensive TAAAs combining proximal TEVAR, followed by interval open distal TAAA repair, is safe and appears to be an effective alternative to traditional open repair. This approach may decrease the significant morbidity associated with single-stage open extent I and II TAAA repairs and may be applicable to multiple TAAA etiologies.
治疗 I 型和 II 型胸腹主动脉瘤（TAAA）的患者存在显著的发病率和死亡率，而治疗更远处的 III 型和 IV 型 TAAA 的风险较低，出现截瘫和死亡的风险也较低。因此，我们描述了一种采用胸主动脉腔内修复术（TEVAR）作为索引手术的方法，将 I 型和 II 型 TAAA 转换为 III 型和 IV 型 TAAA，使其能够随后进行开放主动脉修复，以最大程度地降低患者风险。
在 2007 年 7 月至 2012 年 3 月期间，对 1 例 I 型和 9 例 II 型 TAAA 进行了 10 例分期杂交手术。主动脉瘤病理包括 5 例慢性 B 型夹层、3 例急性 B 型夹层和 2 例穿透性主动脉溃疡。最初，通过 TEVAR 修复近端降主动脉，以覆盖最近端的开窗或穿透性溃疡，其中 7 例为择期修复，3 例为急诊修复。在短期计划或因远端主动脉节段进行性扩张的情况下进行开放的远端主动脉置换。在开放修复中，移植物的近端直接缝合到 TEVAR 的远端和主动脉的外壁。
患者平均年龄为 48 岁，其中 60%为男性。危险因素包括高血压（80%）、当前吸烟（50%）和马凡综合征（30%）。TEVAR 后的并发症包括 I 型（n=1）和 II 型（n=3）内漏、胸腔积液（n=3）和急性肾损伤（n=1）。3 例患者需要血管内再介入治疗。在夹层患者中，假腔的持续充盈很常见，并与胸主动脉扩张有关。开放修复的并发症包括 2 例患者发生急性肾损伤，但无心脏、肺部或神经系统并发症。TEVAR 和开放修复之间的中位时间为 14 周。最重要的是，在中位随访 35 周期间，无论是在接受 TEVAR 还是开放修复后，均无死亡或神经功能缺损发生。
对于广泛的 TAAA，采用近端 TEVAR 联合间隔开放远端 TAAA 修复的分期杂交方法是安全的，并且似乎是传统开放修复的有效替代方法。这种方法可能会降低 I 型和 II 型 TAAA 单一阶段开放修复的显著发病率，并且可能适用于多种 TAAA 病因。
