Nagamine Hiroshi, Miyazaki Manami, Wakabayashi Naohiro, Sugita Hiroaki, Hara Hiroiku, Kawase Yushi
Department of Thoracic and Cardiovascular Surgery, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
Department of Thoracic and Cardiovascular Surgery, Yokohama Sakae Kyosai Hospital, Yokohama, Japan.
Eur J Cardiothorac Surg. 2015 Nov;48(5):671-8. doi: 10.1093/ejcts/ezu474. Epub 2014 Dec 11.
Upon onset of acute type A aortic dissection, the aortic true lumen generally becomes fixed around the supra-aortic branches in the greater curvature and Botallo's ligament in the lesser curvature of the aortic arch. Therefore, the pathways of the false lumen through the arch can be categorized as anterior, bilateral and posterior. We investigated the relationship between a false lumen pathway through the arch and cervical branch compromise, stratified by primary tear location.
Sixty-four consecutive patients with acute type A aortic dissection underwent emergency surgery at our institution between March 2005 and October 2013. Of these, 40 cases (63%) were DeBakey type I, 15 cases (23%) were type II and 9 cases (14%) were type III-D (retrograde type A). We conducted a retrospective review of preoperative computed tomographic angiography using three-dimensional image post-processing tools for 43 cases, excluding 15 cases with type II and 6 cases with type I for which preoperative digital image data were not available.
Of the 43 cases, 14, 18 and 11 revealed anterior, bilateral and posterior pathways, respectively. Twenty-one cases (49%) showed a primary intimal tear in the ascending aorta (8 anterior, 12 bilateral and 1 posterior), 12 cases (28%) showed a primary intimal tear in the aortic arch (5 anterior, 3 bilateral and 4 posterior) and 10 cases (23%) showed a primary intimal tear in the descending aorta (1 anterior, 3 bilateral and 6 posterior). Twelve of the 14 anterior pathway cases (86%) had a total of 26 supra-aortic branch compromises, 13 of the 18 bilateral pathway cases (72%) had a total of 20 supra-aortic branch compromises, while only 4 of the 11 posterior pathway cases (36%) had a total of four supra-aortic branch compromises. None of the 11 posterior pathway cases had a dissection extending into all 3 supra-aortic branches.
Posterior pathway cases generally showed primary tear locations in the arch or descending aorta, and cervical branch compromise was rare. Aortic dissections tended to extend into the cervical branches through the anterior side of the aortic arch. A false lumen pathway through the arch was strongly associated with cervical branch compromise in acute type A aortic dissections.
在急性A型主动脉夹层发病时，主动脉真腔通常在主动脉弓大弯侧的主动脉弓上分支周围及小弯侧的动脉导管韧带处固定。因此，假腔通过主动脉弓的路径可分为前路、双侧和后路。我们研究了按原发破口位置分层的主动脉弓假腔路径与颈部分支受累之间的关系。
2005年3月至2013年10月期间，64例连续的急性A型主动脉夹层患者在我院接受了急诊手术。其中，40例（63%）为DeBakey I型，15例（23%）为II型，9例（14%）为III-D型（逆行A型）。我们对43例患者的术前计算机断层血管造影进行了回顾性分析，使用三维图像后处理工具，排除了15例II型和6例术前无数字图像数据的I型患者。
43例患者中，分别有14例、18例和11例显示前路、双侧和后路路径。21例（49%）患者的原发内膜破口位于升主动脉（8例前路、12例双侧和1例后路），12例（28%）患者的原发内膜破口位于主动脉弓（5例前路、3例双侧和4例后路），10例（23%）患者的原发内膜破口位于降主动脉（1例前路、3例双侧和6例后路）。14例前路路径患者中有12例（86%）共有26处主动脉弓上分支受累，18例双侧路径患者中有13例（72%）共有20处主动脉弓上分支受累，而11例后路路径患者中只有4例（36%）共有4处主动脉弓上分支受累。11例后路路径患者中无一例夹层延伸至所有3支主动脉弓上分支。
后路路径患者的原发破口位置通常在主动脉弓或降主动脉，颈部分支受累少见。主动脉夹层倾向于通过主动脉弓前侧延伸至颈部分支。在急性A型主动脉夹层中，主动脉弓假腔路径与颈部分支受累密切相关。
