Smith Holly N, Boodhwani Munir, Ouzounian Maral, Saczkowski Richard, Gregory Alexander J, Herget Eric J, Appoo Jehangir J
Toronto Western Hospital EW 1-433, Toronto, Ontario, Canada.
Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
Interact Cardiovasc Thorac Surg. 2017 Mar 1;24(3):450-459. doi: 10.1093/icvts/ivw355.
Distal extent of repair in patients undergoing surgery for acute Type A aortic dissection (ATAAD) is controversial. Emerging hybrid techniques involving open and endovascular surgery have been reported in small numbers by select individual centres. A systematic review and meta-analysis was performed to investigate the outcomes following extended arch repair for ATAAD. A classification system is proposed of the different techniques to facilitate discussion and further investigation.
Using Ovid MEDLINE, 38 studies were identified reporting outcomes for 2140 patients. Studies were categorized into four groups on the basis of extent of surgical aortic resection and the method of descending thoracic aortic stent graft deployment; during circulatory arrest (frozen stented elephant trunk) or with normothermic perfusion and use of fluoroscopy (warm stent graft): (I) surgical total arch replacement, (II) total arch and frozen stented elephant trunk, (III) hemiarch and frozen stented elephant trunk and (IV) total arch and warm stent graft. Perioperative event rates were obtained for each of the four groups and the entire cohort using pooled summary estimates. Linearized rates of late mortality and reoperation were calculated.
Overall pooled hospital mortality for extended arch techniques was 8.6% (95% CI 7.2-10.0). Pooled data categorized by surgical technique resulted in hospital mortality of 11.9% for total arch, 8.6% total arch and frozen stented elephant trunk, 6.3% hemiarch and frozen stented elephant trunk and 5.5% total arch and 'warm stent graft'. Overall incidence of stroke for the entire cohort was 5.7% (95% CI 3.6-8.2). Rate of spinal cord ischaemia was 2.0% (95% CI 1.2-3.0). Pooled linearized rate of late mortality was 1.66%/pt-yr (95% CI 1.34-2.07) with linearized rate of re-operation of 1.62%/pt-yr (95% CI 1.24-2.05).
Perioperative results of extended arch procedures are encouraging. Further follow-up is required to see if long-term complications are reduced with these emerging techniques. The proposed classification system will facilitate future comparison of short- and long-term results of different techniques of extended arch repair for ATAAD.
急性A型主动脉夹层（ATAAD）手术患者的远端修复范围存在争议。少数个别中心报告了涉及开放手术和血管腔内手术的新型杂交技术。进行了一项系统评价和荟萃分析，以研究ATAAD扩大主动脉弓修复后的结果。提出了一种不同技术的分类系统，以促进讨论和进一步研究。
通过Ovid MEDLINE检索，确定了38项报告2140例患者结果的研究。根据主动脉手术切除范围和降主动脉支架移植物置入方法，将研究分为四组；在循环停止期间（冷冻带支架象鼻术）或在常温灌注和使用荧光透视的情况下（温热支架移植物）：（I）手术全主动脉弓置换，（II）全主动脉弓和冷冻带支架象鼻术，（III）半主动脉弓和冷冻带支架象鼻术，以及（IV）全主动脉弓和温热支架移植物。使用汇总估计值获得四组和整个队列的围手术期事件发生率。计算晚期死亡率和再次手术的线性化率。
扩大主动脉弓技术的总体汇总住院死亡率为8.6%（95%CI 7.2-10.0）。按手术技术分类的汇总数据显示，全主动脉弓的住院死亡率为11.9%，全主动脉弓和冷冻带支架象鼻术为8.6%，半主动脉弓和冷冻带支架象鼻术为6.3%，全主动脉弓和“温热支架移植物”为5.5%。整个队列的总体卒中发生率为5.7%（95%CI 3.6-8.2）。脊髓缺血发生率为2.0%（95%CI 1.2-3.0）。晚期死亡率的汇总线性化率为1.66%/患者年（95%CI 1.3-2.07），再次手术的线性化率为1.62%/患者年（95%CI 1.24-2.05）。
扩大主动脉弓手术的围手术期结果令人鼓舞。需要进一步随访，以观察这些新兴技术是否能减少长期并发症。所提出的分类系统将有助于未来比较ATAAD扩大主动脉弓修复不同技术的短期和长期结果。
