Idrees Jay J, Roselli Eric E, Wojnarski Charles M, Feng Ke, Aftab Muhammad, Johnston Douglas R, Soltesz Edward G, Sabik Joseph F, Svensson Lars G
Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
J Thorac Cardiovasc Surg. 2015 Nov;150(5):1150-5. doi: 10.1016/j.jtcvs.2015.07.077. Epub 2015 Jul 30.
Staged elephant trunk (ET) repair is a commonly performed procedure for extensive aortic disease. A significant proportion of patients with predominantly proximal aortic pathology often have in addition a moderately dilated descending aorta (<5 cm) that can progress over time. Objectives were to characterize patients, determine completion rate after prophylactic stage 1 ET, and assess outcomes.
From 1992 to 2012, a total of 572 patients underwent stage 1 ET for degenerative aneurysm and dissection at Cleveland Clinic. Prophylactic stage 1 ET was performed in 117 (20.5%) who had predominantly proximal disease (5.5 ± 1 cm) with moderate dilation of the descending aorta (4 ± 0.6 cm). Aortic pathology included: aneurysm (n = 56 [48%]); chronic dissection (n = 41 [35%]); pseudoaneurysm (n = 9 [7.7%]); penetrating ulcer (n = 9 [7.7%]); and intramural hematoma (n = 2 [1.7%]). Other diagnoses included connective tissue disorder (12 [10%]); aortitis (20 [17%]); bicuspid aortic valve (9 [7.6%]); and previous type A dissection repair (27 [23%]).
Operative mortality was 0.8% (1 of 117). This patient suffered postoperative myocardial infarction and mesenteric ischemia, resulting in sepsis and death. Other complications included: stroke (n = 7 [6%]); tracheostomy (n = 6 [5%]); renal dialysis (n = 4 [3.3%]); and reoperation for bleeding (n = 7 [6%]). The mean follow-up time was 4 ± 3 years. Fifty-three (45%) patients completed the stage 2 ET (open: 20 [38%]; endovascular: 33 [62%]) at a median interval of 6 months (9 days-10 years). The mean descending diameter increased from 4.1 ± 0.6 cm to 5 ± 1 cm at the time of stage 2 completion. In 11 patients, stage 2 was performed for acute aortic events. Estimated survival at 1, 5, and 8 years was 94%, 88%, and 74%, respectively.
Prophylactic ET for moderately dilated descending aorta is an effective strategy for staged repair, especially in patients with chronic dissection, connective tissue disorder, and aortitis. In addition, this approach can be beneficial for emergency treatment of late distal aortic complications.
分期象鼻术（ET）修复是广泛主动脉疾病常用的手术方法。相当一部分以主动脉近端病变为主的患者，其降主动脉通常也有中度扩张（<5 cm），且可能随时间进展。本研究旨在明确这类患者的特征，确定预防性一期ET后的完成率，并评估手术效果。
1992年至2012年，克利夫兰诊所共有572例患者因退行性动脉瘤和夹层行一期ET手术。117例（20.5%）主要为近端病变（5.5±1 cm）且降主动脉中度扩张（4±0.6 cm）的患者接受了预防性一期ET手术。主动脉病变包括：动脉瘤（n = 56 [48%]）；慢性夹层（n = 41 [35%]）；假性动脉瘤（n = 9 [7.7%]）；穿透性溃疡（n = 9 [7.7%]）；壁内血肿（n = 2 [1.7%]）。其他诊断包括结缔组织病（12 [10%]）；主动脉炎（20 [17%]）；二叶式主动脉瓣（9 [7.6%]）；既往A型夹层修复术（27 [23%]）。
手术死亡率为0.8%（117例中的1例）。该患者术后发生心肌梗死和肠系膜缺血，导致脓毒症和死亡。其他并发症包括：卒中（n = 7 [6%]）；气管切开术（n = 6 [5%]）；肾透析（n = 4 [3.3%]）；因出血再次手术（n = 7 [6%]）。平均随访时间为4±3年。53例（45%）患者完成了二期ET（开放手术：20 [38%]；血管腔内手术：33 [62%]），中位间隔时间为6个月（9天至10年）。二期手术完成时，降主动脉平均直径从4.1±0.6 cm增加到5±1 cm。11例患者因急性主动脉事件行二期手术。1年、5年和8年的估计生存率分别为94%、88%和74%。
对于降主动脉中度扩张行预防性ET是一种有效的分期修复策略，尤其适用于慢性夹层、结缔组织病和主动脉炎患者。此外，这种方法对晚期主动脉远端并发症的急诊治疗也可能有益。
