Department of Vascular Surgery, Cardiovascular Centre, Semmelweis University, Budapest, Hungary.
Department of Vascular Surgery, Cardiovascular Centre, Semmelweis University, Budapest, Hungary.
Eur J Vasc Endovasc Surg. 2015 Jul;50(1):44-50. doi: 10.1016/j.ejvs.2014.12.028. Epub 2015 Feb 12.
The purpose of this retrospective cohort study was to determine the early and long-term mortality and morbidity as well as to reveal risk factors influencing the long-term prognosis in patients with complicated acute type B aortic dissection (CABAD) undergoing open surgical suprarenal aortic fenestration (OSSAF).
Fifty-two patients with CABAD, defined as (impending) rupture, acute enlargement of the false lumen, malperfusion, and/or unrelenting back pain or uncontrollable hypertension despite maximum medical therapy were treated with by surgical repair between 2002 and 2008. Ten patients with (impending) rupture had aortic graft replacement, while 42 (33 men, mean age 55 ± 11 years) had OSSAF. Follow up visits were scheduled at 1, 3-6 and 12 months after the surgery and annually thereafter. Clinical examination and computed tomography angiography findings were investigated at baseline and at subsequent visits.
The indications for OSSAF were acute enlargement of the false lumen in four (10%), malperfusion in 17 (40%) (11 lower extremity [26%], 6 visceral [14%]), and unrelenting back pain or uncontrollable hypertension in 21 cases (50%). The 30 day mortality was 21.4% (2 multiple organ failure, 2 heart failure, 3 pneumonia, 1 intestinal necrosis, 1 major hemorrhage). The mean follow up was 84 ± 40 months. The 5 year survival was 70.6%. Eight patients (19%) died during the follow up period (6 aortic ruptures, 2 myocardial infarctions). None of the patients became paraplegic after the surgery. Further surgery or stenting was indicated in nine cases (21%).
OSSAF has been performed with an acceptable early mortality and low paraplegia rate, but late mortality is frequently related to aortic rupture. Stentgraft coverage of the primary entry tear decreases late aortic related deaths, but suprarenal fenestration remains an option for cases not suitable for endovascular techniques.
本回顾性队列研究旨在确定行开放手术肾上主动脉开窗术（OSSAF）的复杂急性型 B 主动脉夹层（CABAD）患者的早期和长期死亡率和发病率，并揭示影响长期预后的危险因素。
2002 年至 2008 年间，52 例 CABAD 患者（定义为破裂、假腔急性扩大、灌注不良和/或尽管最大药物治疗仍持续背痛或无法控制的高血压）接受了手术治疗。10 例（即将）破裂患者行主动脉移植置换术，42 例（33 例男性，平均年龄 55±11 岁）行 OSSAF。术后 1、3-6 和 12 个月以及此后每年进行随访。基线和后续就诊时进行临床检查和计算机断层血管造影检查。
OSSAF 的适应证为假腔急性扩大 4 例（10%），灌注不良 17 例（40%）（下肢 11 例[26%]，内脏 6 例[14%]），持续背痛或无法控制的高血压 21 例（50%）。30 天死亡率为 21.4%（2 例多器官衰竭，2 例心力衰竭，3 例肺炎，1 例肠坏死，1 例大出血）。平均随访 84±40 个月。5 年生存率为 70.6%。8 例（19%）在随访期间死亡（6 例主动脉破裂，2 例心肌梗死）。手术后无患者截瘫。9 例（21%）需要进一步手术或支架置入。
OSSAF 的早期死亡率和低截瘫率可接受，但晚期死亡率常与主动脉破裂有关。支架置入覆盖原发入口撕裂可降低晚期主动脉相关死亡，但对于不适合血管内技术的病例，肾上开窗术仍然是一种选择。
