Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Philadelphia, Pa, USA
J Thorac Cardiovasc Surg. 2013 Mar;145(3 Suppl):S85-90. doi: 10.1016/j.jtcvs.2012.11.044. Epub 2012 Dec 20.
The combined open surgical and endovascular approach for the treatment of aortic arch aneurysms has emerged as a safe treatment modality. This platform may have an especially important role in treating patients of old age and with a greater comorbid burden. We describe our institutional experience with the hybrid aortic arch approach, with midterm outcomes.
From 2005 to the present, 685 patients have undergone thoracic endovascular repair (TEVAR); 104 had a hybrid arch repair (open plus endovascular approach). Of these, 47 patients had treatment for an aortic arch aneurysm with or without a proximal ascending aortic aneurysm. All these patients had a median sternotomy approach for arch vessel debranching and antegrade with or without retrograde TEVAR stent grafting of the arch. Results from a prospectively maintained database are reported.
Twenty-eight patients had type I repair, 8 patients had type II repair, and 11 patients had type III arch hybrid repair. Those with type III repair were excluded from the analysis. Stent graft deployment rate was 100% after arch vessel debranching. Mean age was 71 ± 8 years. Fourteen percent of cases involved a redo sternotomy. Average cardiopulmonary bypass time was 215 ± 64 minutes, with a crossclamp time of 70 ± 55 minutes and a circulatory arrest time of 19 ± 10 minutes. The paraplegia rate was 5.5% (n = 2), with a stroke rate of 8% (n = 3). In-hospital mortality was 8% (n = 3). There were no postoperative endoleaks. The mean length of stay was 17.2 ± 14 days. The median follow-up was 30 ± 21 months. Freedom from all-cause mortality was 71%, 60%, and 48% at 1, 3, and 5 years, respectively. The aortic reoperation rate was 2.7% (n = 1). No patient has a type 1 or 3 endoleak at latest follow-up.
The hybrid approach to aortic arch aneurysm involving a zone 0 stent graft landing can be safely adopted with good midterm results in a cohort of old patients with significant comorbidity. This procedure can be performed with no type 1 or 3 endoleaks and may represent a technical advancement in the field of aortic arch surgery.
主动脉弓动脉瘤的开放手术联合血管内治疗已成为一种安全的治疗方式。这种治疗方案在治疗高龄患者和合并症较多的患者方面可能具有特别重要的作用。我们描述了我们机构使用杂交主动脉弓方法的经验，并提供了中期结果。
从 2005 年至今，共有 685 例患者接受了胸主动脉腔内修复术（TEVAR）治疗；其中 104 例行杂交弓修复术（开放加血管内治疗）。这些患者中，有 47 例因主动脉弓动脉瘤或合并升主动脉近端动脉瘤而行治疗。所有这些患者均经正中胸骨切开术行弓血管分支，并采用顺行或逆行 TEVAR 支架移植物进行弓部治疗。报告了从前瞻性维护的数据库中获得的结果。
28 例患者行 I 型修复，8 例患者行 II 型修复，11 例患者行 III 型弓部杂交修复。其中，III 型修复的患者被排除在分析之外。弓血管分支后，支架移植物的植入率为 100%。平均年龄为 71±8 岁。14%的病例涉及再次正中开胸。平均体外循环时间为 215±64 分钟，主动脉阻断时间为 70±55 分钟，停循环时间为 19±10 分钟。截瘫发生率为 5.5%（n=2），卒中发生率为 8%（n=3）。住院期间死亡率为 8%（n=3）。无术后内漏。平均住院时间为 17.2±14 天。中位随访时间为 30±21 个月。1、3、5 年全因死亡率分别为 71%、60%和 48%。主动脉再次手术率为 2.7%（n=1）。截至最新随访时，无患者出现 1 型或 3 型内漏。
对于合并症较多的高龄患者，采用 Zone0 支架移植物着陆的杂交弓方法是安全的，中期结果良好。该手术可避免 1 型或 3 型内漏，可能是主动脉弓手术领域的一项技术进步。
