Hu Xiaoping, Wang Zhiwei, Ren Zongli, Hu Rui, Wu Hongbing
Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, P.R. China.
Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, P.R. China.
J Vasc Surg. 2017 Sep;66(3):711-717. doi: 10.1016/j.jvs.2017.01.030. Epub 2017 Mar 27.
Total arch replacement combined with stented elephant trunk implantation in the descending aorta has successfully improved the outcomes of acute type A aortic dissection (AAAD). However, the optimal surgical strategy for the left subclavian artery (LSA) during the procedure remains a challenge. This study aimed to present our new technique of in situ stent graft fenestration to simplify the surgical procedure for suitable cases of AAAD.
From August 2008 to December 2015, a total of 106 patients underwent simplified total aortic arch replacement with an in situ stent graft fenestration technique. The mean age of the patients was 50.71 ± 11.54 years (range, 24-78 years). Both perioperative variables and postoperative follow-up outcome of the procedure were assessed.
The in-hospital mortality rate was 7.5%. The mean cardiopulmonary bypass time was 162.73 ± 68.49 minutes, cross-clamp time was 93.13 ± 22.29 minutes, and circulatory arrest time was 23.28 ± 5.56 minutes. Transient neurologic dysfunction was observed in five patients. No permanent neurologic dysfunction was observed, and no stroke or left arm ischemia occurred. During the follow-up period (mean, 43.4 ± 21.53 months), the survival rates of patients were 90.6%, 85.5%, and 78.8% at 1 year, 2 years, and 7 years, respectively. No stroke or left limb ischemia was observed. The LSA perfusion was well preserved in all surviving patients, and there was no endoleak or dissection around the LSA. All patients were free from reoperation.
The in situ graft fenestration technique could simplify the procedure of LSA reconstruction during total arch replacement, provide a good surgical view for anastomosis and hemostasis, shorten the operation time, and yield satisfactory early and midterm results. It is a safe and effective alternative approach for suitable patients with AAAD. However, the long-term results of this technique need further evaluation.
全主动脉弓置换联合降主动脉带支架象鼻植入术已成功改善急性A型主动脉夹层（AAAD）的治疗效果。然而，手术过程中左锁骨下动脉（LSA）的最佳手术策略仍是一项挑战。本研究旨在介绍我们新的原位支架移植物开窗技术，以简化适合AAAD病例的手术过程。
2008年8月至2015年12月，共有106例患者接受了原位支架移植物开窗技术简化全主动脉弓置换术。患者的平均年龄为50.71±11.54岁（范围24 - 78岁）。评估了该手术的围手术期变量和术后随访结果。
住院死亡率为7.5%。平均体外循环时间为162.73±68.49分钟，主动脉阻断时间为93.13±22.29分钟，循环停止时间为23.28±5.56分钟。5例患者出现短暂性神经功能障碍。未观察到永久性神经功能障碍，也未发生中风或左臂缺血。在随访期间（平均43.4±21.53个月），患者1年、2年和7年的生存率分别为90.6%、85.5%和78.8%。未观察到中风或左下肢缺血。所有存活患者的LSA灌注均得到良好保留，LSA周围无内漏或夹层。所有患者均无需再次手术。
原位移植物开窗技术可简化全弓置换术中LSA重建的手术过程，为吻合和止血提供良好的手术视野，缩短手术时间，并产生令人满意的早期和中期结果。对于适合的AAAD患者，这是一种安全有效的替代方法。然而，该技术的长期结果需要进一步评估。
