Pecoraro Felice, Lachat Mario, Hofmann Michael, Cayne Neal S, Chaykovska Lyubov, Rancic Zoran, Puippe Gilbert, Pfammatter Thomas, Mangialardi Nicola, Veith Frank J, Bettex Dominique, Maisano Francesco, Neff Thomas A
Cardiovascular Surgery Unit, University Hospital Zurich, Zurich, Switzerland.
University of Palermo, Vascular Surgery Unit, AOUP "P. Giaccone", Palermo, Italy.
Interact Cardiovasc Thorac Surg. 2017 Jun 1;24(6):882-889. doi: 10.1093/icvts/ivx016.
Surgical repair of aneurysmal disease involving the ascending aorta, aortic arch and eventually the descending aorta is generally associated with significant morbidity and mortality. A less invasive approach with the ascending wrapping technique (WT), supra-aortic vessel debranching (SADB) and thoracic endovascular aneurysm repair (TEVAR) in zone 0 was developed to reduce the associated risk in these patients.
During a 10-year period, consecutive patients treated by the ascending WT, SADB and TEVAR in zone 0 were included. All patients were considered at high risk for conventional surgery. Measured outcomes included perioperative deaths and morbidity, maximal aortic transverse diameter (TD) and its postoperative evolution, endoleak, survival, freedom from cardiovascular reinterventions, SADB freedom from occlusion and aortic valve function during follow-up. Median follow-up was 37.4 [mean = 34; range, 0-65; standard deviation (SD) = 20] months.
Twenty-six cases were included with a mean age of 71.88 ( r = 56-87; SD = 8) years. A mean of 2.9 supra-aortic vessels (75) per patient was debranched from the ascending aorta. The mean time interval from WT/SADB and TEVAR was 29 ( r = 0-204; SD = 48) days. TEVAR was associated with chimney and/or periscope grafts in 6 (23%) patients, and extra-anatomical supra-aortic bypasses were performed in 6 (23%) patients. Perioperative mortality was 7.7% (2/26). Neurological events were registered in 3 (11.5%) cases, and a reintervention was required in 3 (11.5%) cases. After the WT, the ascending diameter remained stable during the follow-up period in all cases. At mean follow-up, significant shrinkage of the arch/descending aorta diameter was observed. A type I/III endoleak occurred in 3 cases. At 5 years, the rates of survival, freedom from cardiovascular reinterventions and SADB freedom from occlusion were 71.7, 82.3 and 96%, respectively.
The use of the ascending WT, SADB and TEVAR in selected patients with complex thoracic aorta disease is safe and shows promising mid-term results at 3 years. The combination of these techniques could represent an alternative to the standard open surgical repair, especially in older patients or in patients unfit for cardiopulmonary bypass.
涉及升主动脉、主动脉弓以及最终降主动脉的动脉瘤性疾病的外科修复通常伴随着显著的发病率和死亡率。采用升主动脉包裹技术（WT）、主动脉弓上血管去分支术（SADB）和0区胸段血管腔内修复术（TEVAR）的微创方法被开发出来，以降低这些患者的相关风险。
在10年期间，纳入了接受升主动脉WT、SADB和0区TEVAR治疗的连续患者。所有患者均被认为进行传统手术的风险较高。测量的结果包括围手术期死亡和发病率、最大主动脉横径（TD）及其术后变化、内漏、生存率、无心血管再次干预、SADB无闭塞以及随访期间的主动脉瓣功能。中位随访时间为37.4[平均=34；范围，0 - 65；标准差（SD）=20]个月。
纳入26例患者，平均年龄为71.88（r = 56 - 87；SD = 8）岁。每位患者平均有2.9根（75%）主动脉弓上血管从升主动脉去分支。从WT/SADB到TEVAR的平均时间间隔为29（r = 0 - 204；SD = 48）天。6例（23%）患者的TEVAR与烟囱和/或潜望镜移植物相关，6例（23%）患者进行了非解剖学主动脉弓上旁路手术。围手术期死亡率为7.7%（2/26）。3例（11.5%）患者发生神经事件，3例（11.5%）患者需要再次干预。WT术后，随访期间所有病例的升主动脉直径保持稳定。平均随访时，观察到主动脉弓/降主动脉直径显著缩小。3例发生I/III型内漏。5年时，生存率、无心血管再次干预率和SADB无闭塞率分别为71.7%、82.3%和96%。
在选定的复杂胸主动脉疾病患者中使用升主动脉WT、SADB和TEVAR是安全的，并且在3年时显示出有前景的中期结果。这些技术的联合应用可能是标准开放手术修复的一种替代方法，特别是在老年患者或不适合体外循环的患者中。
