Di Marco Luca, Pacini Davide, Leone Alessandro, Pantaleo Antonio, Murana Giacomo, Di Bartolomeo Roberto
U.O. Cardiochirurgia, Dipartimento Cardio-Toraco-Vascolare, Policlinico S. Orsola, Università degli Studi, Bologna.
G Ital Cardiol (Rome). 2017 Sep;18(9):631-637. doi: 10.1714/2741.27946.
The treatment of patients with extensive disease of the thoracic aorta represents a formidable challenge for the cardiovascular surgeon. The beginning of thoracic aortic endovascular aortic arch repair has promoted the development of different hybrid approaches as the frozen elephant trunk (FET) strategy, which includes classic arch replacement and antegrade stenting of the descending thoracic aorta. It represents an interesting approach for patients with extensive disease of the thoracic aorta, and its application has significantly increased over recent years. Our indications for this technique include degenerative aneurysms of the aortic arch and acute and chronic aortic dissections. For many years, the conventional surgical approach for the treatment of complex lesions of the thoracic aorta considered the two-stage elephant trunk technique. However, it is still associated with high mortality and morbidity with only half of the patients who underwent the second stage of the operation. These shortcomings can be attenuated by the FET technique which allows to replace in one stage-approach all the thoracic aorta. Anyway, the main problem of the FET remains the paraplegia. Key points during this surgery are represented by an accurate preoperative assessment of the aortic anatomy by angiography computed tomography scan, the employment of reliable methods of organ protection and of effective surgical techniques and strategies. Antegrade selective cerebral perfusion represents a fundamental tool for cerebral protection. In type A chronic aortic dissection utilizing FET technique, it is possible to use the stent-graft as landing-zone for secondary endovascular extension in order to cover the re-entry tears at the distal descending thoracic aorta. Despite the satisfactory short- and mid-term results, longer-term studies are needed to show the benefits of the FET technique versus other types of management.
对于心血管外科医生而言，治疗胸主动脉广泛病变的患者是一项巨大的挑战。胸主动脉腔内主动脉弓修复术的开展推动了不同杂交手术方式的发展，如冷冻象鼻技术（FET），该技术包括经典的主动脉弓置换术和顺行性降主动脉支架置入术。对于胸主动脉广泛病变的患者，这是一种有趣的手术方式，近年来其应用显著增加。我们采用该技术的适应症包括主动脉弓退行性动脉瘤以及急慢性主动脉夹层。多年来，治疗胸主动脉复杂病变的传统手术方法是两阶段象鼻技术。然而，该方法仍与高死亡率和高发病率相关，只有一半的患者能接受第二阶段手术。FET技术可在一个阶段内替换整个胸主动脉，从而减轻这些缺点。无论如何，FET的主要问题仍是截瘫。该手术的关键点包括通过计算机断层扫描血管造影术对主动脉解剖结构进行准确的术前评估、采用可靠的器官保护方法以及有效的手术技术和策略。顺行性选择性脑灌注是脑保护的基本手段。在A型慢性主动脉夹层中使用FET技术时，可以将覆膜支架作为二期血管腔内延伸的着陆区，以覆盖降主动脉远端的再入口撕裂。尽管短期和中期结果令人满意，但仍需要长期研究来证明FET技术相对于其他治疗方式的优势。
