Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.
Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.
J Thorac Cardiovasc Surg. 2015 Feb;149(2 Suppl):S91-8.e1. doi: 10.1016/j.jtcvs.2014.08.008. Epub 2014 Aug 13.
We investigated the long-term outcomes of repair for acute type A aortic dissection on the basis of false lumen status and assessed treatment modalities for the enlarged downstream aorta.
Between January 1990 and March 2013, 534 patients underwent surgery for acute type A aortic dissection. In-hospital mortality was 9.3% (50/534), and follow-up was 98% (472/484). Of the 472 hospital survivors, 451 (96%) underwent contrast-enhanced computed tomography within 1 month of surgery. Risk-adjusted survival and distal aortic events were investigated in these 451 patients. Surgical outcomes of distal reoperations were assessed in 37 patients.
Postoperative false lumen patency was 62% (280/451). Eighteen patients died of aortic rupture, 17 (94%) with a patent false lumen. A patent false lumen decreased survival (hazard ratio [HR], 1.70; P = .012) and increased distal aortic events (HR, 4.11; P = .001). Other predictors identified were age (HR, 1.07; P < .001) and male sex (HR, 1.89; P = .002) for late mortality, and Marfan syndrome (HR, 6.6; P < .001), distal aortic diameter greater than 45 mm (HR, 4.4; P < .001), and nonresection of the primary entry (HR, 2.3; P = .005) for distal aortic events. Distal reoperations comprised open repair of the arch (n = 13), descending aorta (n = 16), or thoracoabdominal aorta (n = 7) or thoracic endovascular aortic repair (n = 7), with no in-hospital death or paraplegia. Although thoracic endovascular aortic repair yielded false lumen thrombosis around the stent graft in 80% of patients (4/5), complete false lumen thrombosis was achieved in 20% (1/5).
False lumen patency influences the late outcomes of acute type A aortic dissection repair. Outcomes of distal reoperation were acceptable; thus, careful follow-up and timely reoperation may improve the late outcomes.
基于假腔状态，我们研究了急性 A 型主动脉夹层修复的长期结果，并评估了扩大下游主动脉的治疗方式。
1990 年 1 月至 2013 年 3 月期间，534 例患者接受了急性 A 型主动脉夹层手术。院内死亡率为 9.3%（50/534），随访率为 98%（472/484）。在 472 例住院存活患者中，451 例（96%）在术后 1 个月内行增强计算机断层扫描检查。对这 451 例患者进行风险调整后的生存和远端主动脉事件的调查。对 37 例远端再手术患者的手术结果进行评估。
术后假腔通畅率为 62%（280/451）。18 例患者死于主动脉破裂，其中 17 例（94%）假腔通畅。假腔通畅降低了生存率（风险比[HR]，1.70；P=.012）并增加了远端主动脉事件（HR，4.11；P=.001）。其他确定的预测因素为年龄（HR，1.07；P<.001）和男性（HR，1.89；P=.002），晚期死亡率，马凡综合征（HR，6.6；P<.001），远端主动脉直径大于 45 毫米（HR，4.4；P<.001）和未切除原发入口（HR，2.3；P=.005），用于远端主动脉事件。远端再手术包括弓部（n=13）、降主动脉（n=16）或胸腹主动脉（n=7）或胸主动脉腔内修复术（n=7）的开放修复，无院内死亡或截瘫。虽然胸主动脉腔内修复术在 80%的患者（4/5）中使支架移植物周围的假腔血栓形成，但在 20%的患者（1/5）中实现了完全假腔血栓形成。
假腔通畅情况影响急性 A 型主动脉夹层修复的晚期结果。远端再手术的结果是可以接受的；因此，仔细的随访和及时的再手术可能会改善晚期结果。
