Conzelmann L O, Doemland M, Weigang E, Frieß T, Schotten S, Düber C, Vahl C F
Department of Cardiothoracic and , Vascular Surgery, University Medical Center Mainz, Mainz, Germany.
J Cardiovasc Surg (Torino). 2013 Apr;54(2):151-9.
The aim of the present study was to evaluate the outcome of endovascular treatment of true-lumen collapse (TLC) of the downstream aorta after open surgery for acute aortic dissection type A (AADA).
Retrospective, observational study with follow-up of 16 ± 7.6 months. From April 2010 to January 2012, 89 AADA-patients underwent aortic surgery. Out of these, computed tomography revealed a TLC of the downstream aorta in 13 patients (14.6%). They all received additional thoracic endovascular aortic repair (TEVAR) in consequence of malperfusion syndromes.
In all 13 TLC-patients, dissection after AADA-surgery extended from the aortic arch to the abdominal aorta and malperfusion syndromes occurred. Remodeling of the true-lumen was achieved by TEVAR with complemental stent disposal in abdominal and iliac arteries in all cases. One patient died on the third postoperative day due to intracerebral hemorrhage. Another patient, who presented under severe cardiogenic shock died despite AADA-surgery and TEVAR-treatment. Thirty-day mortality was 15.4% in TLC-patients (N = 2/13). In the follow-up period, 3 patients required additional aortic stents after the emergency TEVAR procedures. After 20 weeks, a third patient died secondary to malperfusion due to false-lumen recanalization. Therefore, late mortality was 23.1%.
After proximal aortic repair for AADA, early postoperative computed tomography should be demanded in all patients to exclude a TLC of the descending aorta. Mortality is still substantial in these patients despite instant TEVAR application. Thus, in case of TLC and malperfusion syndrome of the downstream aorta, TEVAR should be performed early to alleviate or even prevent ischemic injury.
本研究旨在评估A型急性主动脉夹层（AADA）开放手术后降主动脉真腔塌陷（TLC）的血管内治疗效果。
回顾性观察研究，随访时间为16±7.6个月。2010年4月至2012年1月，89例AADA患者接受了主动脉手术。其中，计算机断层扫描显示13例患者（14.6%）存在降主动脉TLC。由于出现灌注不良综合征，他们均接受了额外的胸段血管腔内主动脉修复术（TEVAR）。
所有13例TLC患者中，AADA手术后夹层从主动脉弓延伸至腹主动脉，并出现灌注不良综合征。所有病例均通过TEVAR并在腹主动脉和髂动脉中补充置入支架实现了真腔重塑。1例患者术后第3天因脑出血死亡。另1例患者在严重心源性休克状态下就诊，尽管接受了AADA手术和TEVAR治疗仍死亡。TLC患者的30天死亡率为15.4%（n = 2/13）。在随访期间，3例患者在紧急TEVAR手术后需要额外的主动脉支架。20周后，第3例患者因假腔再通导致灌注不良继发死亡。因此，晚期死亡率为23.1%。
对于AADA进行近端主动脉修复后，应要求所有患者在术后早期进行计算机断层扫描，以排除降主动脉TLC。尽管立即应用TEVAR，这些患者的死亡率仍然很高。因此，对于降主动脉TLC和灌注不良综合征，应尽早进行TEVAR以减轻甚至预防缺血性损伤。
