Kamman Arnoud V, Yang Bo, Kim Karen M, Williams David M, Michael Deeb George, Patel Himanshu J
Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan.
Department of Radiology, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan.
Semin Thorac Cardiovasc Surg. 2017;29(2):173-178. doi: 10.1053/j.semtcvs.2016.10.002. Epub 2016 Oct 14.
One of the most dreaded complications of acute aortic dissection is end-organ malperfusion. We summarize current evidence and describe our treatment paradigm in the setting of malperfusion in aortic dissection. Given the difficulty with identifying isolated visceral malperfusion in aortic dissection, both in the literature as well as in our practice, we have broadened the discussion to include data examining the presentation complex of malperfusion, particularly if mesenteric ischemia is identified. The approach to treating malperfusion syndrome is different depending on whether the patient presents with type A dissection vs type B dissection with malperfusion. Although thoracic endovascular aortic repair has emerged as the dominant strategy for resolving malperfusion for complicated type B dissection, fenestration may still have a role in its treatment. In contrast, for type A aortic dissection presenting with visceral malperfusion, the concept of operative repair after restoration of end-organ perfusion has been proposed with increasing frequency in recent reports. At the University of Michigan, we apply a patient-specific algorithm, based on the presence of malperfusion with end-organ dysfunction. In those patients presenting with visceral malperfusion, we prefer to first fenestrate, await resolution of the malperfusion syndrome and then perform central aortic repair. We recognize that other groups have implemented similar algorithms to reduce the dismal results of operative procedures in this cohort. However, the most appropriate period of delay remains unknown and there is a persistent risk of rupture before repair is performed. Future studies should be performed to determine whether these various treatment paradigms have merit.
急性主动脉夹层最可怕的并发症之一是终末器官灌注不良。我们总结了当前的证据，并描述了在主动脉夹层灌注不良情况下的治疗模式。鉴于在文献以及我们的实践中，识别主动脉夹层中孤立的内脏灌注不良都存在困难，我们扩大了讨论范围，纳入了研究灌注不良表现复合体的数据，特别是在识别出肠系膜缺血的情况下。治疗灌注不良综合征的方法因患者是A型夹层还是伴有灌注不良的B型夹层而异。尽管胸主动脉腔内修复术已成为解决复杂B型夹层灌注不良的主要策略，但开窗术在其治疗中可能仍有作用。相比之下，对于出现内脏灌注不良的A型主动脉夹层，近期报告中越来越频繁地提出在恢复终末器官灌注后进行手术修复的概念。在密歇根大学，我们基于存在伴有终末器官功能障碍的灌注不良情况，应用一种针对患者的算法。对于那些出现内脏灌注不良的患者，我们更倾向于先进行开窗术，等待灌注不良综合征缓解，然后进行主动脉中央修复。我们认识到其他团队也实施了类似的算法，以改善该队列手术的不良结果。然而，最合适的延迟时间仍然未知，并且在进行修复之前仍存在破裂的持续风险。未来应开展研究，以确定这些不同的治疗模式是否有价值。
