Vallabhajosyula Prashanth, Gottret Jean Paul, Robb J Daniel, Szeto Wilson Y, Desai Nimesh D, Pochettino Alberto, Bavaria Joseph E
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA.
Eur J Cardiothorac Surg. 2016 Apr;49(4):1256-61; discussion 1261. doi: 10.1093/ejcts/ezv374. Epub 2015 Oct 29.
For acute DeBakey I aortic dissection with arch tear, conventional distal reconstruction entails total arch replacement (TAR). Some surgeons at our institution have utilized an alternative reconstructive strategy-primary arch tear repair and transverse hemiarch reconstruction (THR) with concomitant antegrade thoracic endovascular aortic repair (TEVAR). We assessed early and mid-term outcomes comparing these two surgical strategies for arch tear management.
A retrospective review of a prospectively maintained institutional aortic dissection database was carried out to compare early and mid-term outcomes for patients undergoing intervention for DeBakey I aortic dissection with arch tear. Hemiarch reconstruction with concomitant antegrade TEVAR was compared against conventional TAR. Arch tear at the origin of great vessels or greater curve was primarily repaired with interrupted sutures in TEVAR patients.
From 2006 to 2013, 61 of 284 DeBakey I aortic dissection patients undergoing intervention for arch tear were retrospectively reviewed. Thirty-one patients had TAR (TAR group) and 30 patients had hemiarch + TEVAR (TEVAR group). Demographics and clinical presentation were similar. TEVAR group had more patients presenting in cardiogenic shock [3% (n = 1) vs 13% (n = 4), P = 0.2] and tamponade [10% (n = 3) vs 23% (n = 7), P = 0.2]. Intraoperatively, TEVAR group had lower cardiopulmonary bypass (239 ± 34 vs 313 ± 80 min, p0.001) and circulatory arrest (60 ± 15 vs 78 ± 45 min, P = 0.04) times. TAR group had higher in-hospital/30-day mortality [26% (n = 8) vs 13% (n = 4), P = 0.3], but stroke rates were similar [6% (n = 2) vs 7% (n = 2), P = 1]. One-year (80 ± 7.3 vs 71 ± 8.3%), 3-year (73 ± 8.3 vs 67 ± 8.6%) and 5-year (73 ± 8.3 vs 67 ± 8.6%) actuarial survival were improved in TEVAR group, although not significantly (log-rank, P = 0.56). TEVAR promoted increased false lumen thrombosis (43 vs 85%, P = 0.002).
In treating DeBakey I aortic dissection with arch tear, hemiarch replacement with primary tear repair and concomitant TEVAR is a safe alternative to conventional TAR, with improved distal aortic remodelling.
对于合并主动脉弓部撕裂的急性DeBakey I型主动脉夹层，传统的远端重建需要进行全弓置换（TAR）。我们机构的一些外科医生采用了另一种重建策略——主动脉弓部撕裂的一期修复和横断半弓重建（THR）并同期进行顺行性胸主动脉腔内修复术（TEVAR）。我们比较了这两种治疗主动脉弓部撕裂的手术策略的早期和中期结果。
对前瞻性维护的机构主动脉夹层数据库进行回顾性分析，以比较接受干预治疗合并主动脉弓部撕裂的DeBakey I型主动脉夹层患者的早期和中期结果。将半弓重建并同期顺行性TEVAR与传统的TAR进行比较。在TEVAR组中，大血管起源处或大弯处的主动脉弓部撕裂主要用间断缝合修复。
2006年至2013年，对284例接受主动脉弓部撕裂干预治疗的DeBakey I型主动脉夹层患者中的61例进行了回顾性分析。31例患者接受了TAR（TAR组），30例患者接受了半弓+TEVAR（TEVAR组）。人口统计学和临床表现相似。TEVAR组心源性休克患者更多[3%（n = 1）对13%（n = 4），P = 0.2]，心包填塞患者更多[10%（n = 3）对23%（n = 7），P = 0.2]。术中，TEVAR组体外循环时间（239±34对313±80分钟，p<0.001）和循环阻断时间（60±15对78±45分钟，P = 0.04）更短。TAR组住院/30天死亡率更高[26%（n = 8）对13%（n = 4），P = 0.3]，但卒中发生率相似[6%（n = 2）对7%（n = 2），P = 1]。TEVAR组的1年（80±7.3%对71±8.3%）、3年（73±8.3%对67±8.6%）和5年（73±8.3%对67±8.6%）精算生存率有所提高，尽管差异不显著（对数秩检验，P = 0.56）。TEVAR促进了假腔血栓形成增加（43%对85%，P = 0.002）。
在治疗合并主动脉弓部撕裂的DeBakey I型主动脉夹层时，一期撕裂修复并同期TEVAR的半弓置换是传统TAR的一种安全替代方法，可改善远端主动脉重塑。
