Aftab Muhammad, Coselli Joseph S
Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
J Thorac Cardiovasc Surg. 2014 Dec;148(6):2963-6. doi: 10.1016/j.jtcvs.2014.06.072. Epub 2014 Jul 21.
Open thoracoabdominal aortic aneurysm (TAAA) repair traditionally carries substantial perioperative morbidity and mortality, primarily from distal aortic ischemia. Advances in surgical techniques, adjuncts, and strategies have greatly improved outcomes.
We analyzed outcomes of 1267 open consecutive TAAA repairs between January 2005 and September 2013. We provided cold crystalloid renal perfusion whenever the renal ostia were accessible; according to extent of repair, we selectively used left heart bypass and provided isothermic blood to the celiac axis and superior mesenteric artery. Repair was extensive (Crawford extent I and II) in 717 cases (57%). Left heart bypass was used in 645 (51%) cases, cold crystalloid renal perfusion in 987 (78%), and isothermic visceral perfusion in 318 (25%). Additional patient-specific surgical adjuncts included endarterectomy of renal or visceral vessels, open stent placement within these vessels, or use of both techniques; at least one was used in 447 repairs (35%).
Thirty-day survival was 95% (1198/1267); overall operative mortality was 8% (104/1267). Acute renal dysfunction occurred in 155 (12%), renal failure requiring hemodialysis at hospital discharge in 84 (7%), and bowel ischemia in 9 (<1%). Extent II and III TAAA repairs carried the highest risks of postoperative renal dysfunction and renal failure requiring hemodialysis at hospital discharge.
Contemporary protective strategies allow open TAAA repair with substantially fewer renal and visceral ischemic complications. Although bowel ischemia is uncommon, renal failure remains a concern, especially in extent II and extent III TAAA repairs. Additional studies are needed to identify and improve renal protection strategies.
传统的开放性胸腹主动脉瘤（TAAA）修复术围手术期发病率和死亡率较高，主要源于远端主动脉缺血。手术技术、辅助手段和策略的进步已显著改善了治疗效果。
我们分析了2005年1月至2013年9月间连续进行的1267例开放性TAAA修复术的结果。只要能触及肾动脉开口，我们就进行冷晶体肾灌注；根据修复范围，我们选择性地使用左心旁路，并向腹腔干和肠系膜上动脉提供等温血。717例（57%）为广泛修复（Crawford范围I和II）。645例（51%）使用了左心旁路，987例（78%）进行了冷晶体肾灌注，318例（25%）进行了等温内脏灌注。其他针对患者的手术辅助手段包括肾或内脏血管内膜切除术、在这些血管内放置开放支架或使用两种技术；447例修复术（35%）中至少使用了一种。
30天生存率为95%（1198/1267）；总体手术死亡率为8%（104/1267）。155例（12%）发生急性肾功能不全，84例（7%）在出院时因肾衰竭需要血液透析，9例（<1%）发生肠缺血。范围II和III的TAAA修复术术后发生肾功能不全和出院时因肾衰竭需要血液透析的风险最高。
当代的保护策略使开放性TAAA修复术的肾和内脏缺血并发症大幅减少。虽然肠缺血并不常见，但肾衰竭仍然是一个问题，尤其是在范围II和范围III的TAAA修复术中。需要进一步研究以确定和改进肾脏保护策略。
