Sood Vikram, Patel Himanshu J, Williams David M, Dasika Narasimham L, Yang Bo, Deeb G Michael
Department of Cardiac Surgery, University of Michigan Cardiovascular Center, Ann Arbor, Mich.
Department of Cardiac Surgery, University of Michigan Cardiovascular Center, Ann Arbor, Mich.
J Vasc Surg. 2014 Jul;60(1):57-63. doi: 10.1016/j.jvs.2014.01.066. Epub 2014 Mar 19.
Repair of isolated aortic arch aneurysms (nontraumatic) by either open (OAR) or endovascular (TEVAR) methods is associated with need for hypothermic circulatory arrest, complex debranching procedures, or use of marginal proximal landing zones. This study evaluates outcomes for treatment of this cohort.
Of 2153 patients undergoing arch repair (1993-2013), 137 (mean age, 60 years) were treated with isolated arch resection for nontraumatic aneurysms. Treatment was by open (n = 93), hybrid (n = 11), or TEVAR (n = 33) methods, with the last two approaches reserved for poor OAR candidates. Treatment was predominantly for saccular (n = 53) or fusiform (n = 30) aneurysms or dissection (n = 15). Rupture was present in 15%. Prior aortic repair was performed in the ascending (n = 30), arch (n = 40), descending (n = 24), or abdominal (n = 9) aorta. Propensity score adjustment was performed for multivariable analysis to account for baseline differences in patient groups as well as treatment selection bias.
Early mortality was seen in nine patients (7%). Morbidity included stroke (n = 9), paraplegia (n = 1), and need for dialysis (n = 5) or tracheostomy (n = 10). A composite outcome of death and stroke was independently predicted by advancing age (P = .055) and performance of a hybrid procedure (P = .012). The 15-year survival was 59%, with late mortality predicted by increasing age, presence of peripheral vascular disease, and perioperative stroke (all P < .05). The 10-year freedom from aortic rupture or reintervention was 75% and was higher after OAR (2-year OAR, 94% vs TEVAR or hybrid, 78%; P = .018). After propensity-adjusted Cox regression analysis, both prior abdominal aortic aneurysmectomy (P = .017) and an endovascular or hybrid procedure (P = .001) independently predicted late aortic rupture or need for reintervention.
Isolated arch repair remains a high-risk procedure occurring frequently in the reoperative setting. Despite being performed in a higher risk group, endovascular strategies yielded similar outcomes but with an increased risk for aorta-related complications. These data support ongoing efforts to develop branched endografts specifically tailored for arch disease to potentially reduce morbidity related to currently available approaches.
采用开放手术（OAR）或血管腔内修复术（TEVAR）修复孤立性主动脉弓动脉瘤（非创伤性），需要进行低温循环骤停、复杂的分支血管重建手术，或使用边缘近端锚定区。本研究评估该队列患者的治疗结果。
在2153例行主动脉弓修复术的患者（1993 - 2013年）中，137例（平均年龄60岁）因非创伤性动脉瘤接受了孤立性主动脉弓切除术。治疗方法包括开放手术（n = 93）、杂交手术（n = 11）或TEVAR（n = 33），后两种方法用于不适合行开放手术的患者。主要治疗囊状动脉瘤（n = 53）、梭形动脉瘤（n = 30）或夹层动脉瘤（n = 15）。15%的患者存在动脉瘤破裂。既往主动脉修复手术分别在升主动脉（n = 30）、主动脉弓（n = 40）、降主动脉（n = 24）或腹主动脉（n = 9）进行。进行倾向评分调整以用于多变量分析，以考虑患者组间的基线差异以及治疗选择偏倚。
9例患者（7%）出现早期死亡。并发症包括卒中（n = 9）、截瘫（n = 1）、需要透析（n = 5）或气管切开（n = 10）。年龄增长（P = .055）和杂交手术的实施（P = .012）可独立预测死亡和卒中的复合结局。15年生存率为59%，年龄增加、存在外周血管疾病和围手术期卒中可预测晚期死亡率（均P < .05）。10年无主动脉破裂或再次干预的自由度为75%，开放手术后该比例更高（开放手术2年时为94%，而TEVAR或杂交手术为78%；P = .018）。经过倾向调整的Cox回归分析，既往腹主动脉瘤切除术（P = .017）以及血管腔内或杂交手术（P = .001）均可独立预测晚期主动脉破裂或再次干预的需要。
孤立性主动脉弓修复仍然是一种高风险手术，在再次手术的情况下经常进行。尽管在风险较高的患者组中进行，但血管腔内治疗策略产生了相似的结果，但主动脉相关并发症的风险增加。这些数据支持持续努力开发专门针对主动脉弓疾病的分支型腔内移植物，以潜在降低与现有治疗方法相关的发病率。
