Benrashid Ehsan, Wang Hanghang, Keenan Jeffrey E, Andersen Nicholas D, Meza James M, McCann Richard L, Hughes G Chad
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
J Vasc Surg. 2016 Feb;63(2):323-31. doi: 10.1016/j.jvs.2015.09.004. Epub 2015 Oct 27.
The role of hybrid repair in the management of aortic arch pathology, and long-term outcomes with these techniques, remains uncertain. We report a decade of experience with hybrid arch repair (HAR) and assess institutional practice patterns with regard to the use of hybrid and open techniques.
Hybrid and open total and distal arch procedures performed between July 2005 and January 2015 were identified from a prospectively maintained, institutional aortic surgery database. Perioperative morbidity and mortality, freedom from reintervention, and long-term survival were calculated. Hybrid and open procedural volumes over the study period were assessed to evaluate for potential practice pattern changes.
During the study period 148 consecutive procedures were performed for repair of transverse and distal aortic arch pathology, including 101 hybrid repairs and 47 open total or distal arch repairs. Patients in the hybrid repair group were significantly older with a greater incidence of chronic kidney disease, peripheral vascular disease, and chronic lung disease. Perioperative mortality and outcomes were not significantly different between the hybrid and open groups, aside from decreased median length of stay after hybrid repair. Need for subsequent reintervention was significantly greater after hybrid repair. Unadjusted long-term survival was superior after open repair (70% 5-year survival open vs 47% hybrid; P = .03), although aorta-specific survival was similar (98% 5-year aorta-specific survival open vs 93% hybrid; P = .59). Institutional use of HAR decreased over the final 3 years of the study, with an associated increased use of open total or distal arch repairs. This was primarily the result of decreased use of native zone 0 hybrid procedures. Concurrent with this apparent increased stringency around patient selection for HAR, perioperative morbidity and mortality was reduced, including avoidance of retrograde type A dissection.
HAR remains a viable option for higher-risk patients with transverse arch pathology with perioperative outcomes and long-term aorta-specific survival similar to open repair, albeit at a cost of increased reintervention. This observational single-institution study would suggest decreased use in more recent years in favor of open repair due to avoidance of native zone 0 hybrid procedures. This decline in the institutional use of native zone 0 hybrid repairs was associated with improved perioperative outcomes.
杂交修复在主动脉弓病变治疗中的作用以及这些技术的长期疗效仍不明确。我们报告了十年的杂交主动脉弓修复（HAR）经验，并评估了关于杂交技术和开放技术使用的机构实践模式。
从一个前瞻性维护的机构主动脉手术数据库中识别出2005年7月至2015年1月期间进行的杂交和开放的全主动脉弓及远端主动脉弓手术。计算围手术期发病率和死亡率、再次干预的自由度以及长期生存率。评估研究期间杂交和开放手术的数量，以评估潜在的实践模式变化。
在研究期间，共进行了148例连续手术以修复横断和远端主动脉弓病变，包括101例杂交修复和47例开放的全主动脉弓或远端主动脉弓修复。杂交修复组的患者年龄显著更大，慢性肾脏病、外周血管疾病和慢性肺病的发生率更高。除了杂交修复后中位住院时间缩短外，杂交组和开放组的围手术期死亡率和结局没有显著差异。杂交修复后后续再次干预的需求显著更大。开放修复后的未调整长期生存率更高（开放修复5年生存率为70%，杂交修复为47%；P = 0.03），尽管主动脉特异性生存率相似（开放修复5年主动脉特异性生存率为98%，杂交修复为93%；P = 0.59）。在研究的最后3年中，机构对HAR的使用减少，同时开放的全主动脉弓或远端主动脉弓修复的使用增加。这主要是由于原位0区杂交手术的使用减少。与此同时，随着对HAR患者选择明显更加严格，围手术期发病率和死亡率降低，包括避免逆行A型夹层。
对于有横断主动脉弓病变的高危患者，HAR仍然是一个可行的选择，其围手术期结局和长期主动脉特异性生存率与开放修复相似，尽管代价是再次干预增加。这项观察性单机构研究表明，由于避免了原位0区杂交手术，近年来其使用减少，转而倾向于开放修复。机构原位0区杂交修复使用的下降与围手术期结局改善相关。
