Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Manchester, United Kingdom.
J Am Heart Assoc. 2017 Sep 13;6(9):e006618. doi: 10.1161/JAHA.117.006618.
Thoracic endovascular aortic repair is characterized by a substantial need for reintervention. Secondary open aortic procedure becomes necessary when further endoluminal options are exhausted. This synopsis and quantitative analysis of available evidence aims to overcome the limitations of institutional cohort reports on secondary open aortic procedure.
Electronic databases were searched from 1994 to the present date with a prospectively registered protocol. Pooled quantification of pre/intraoperative variables, and proportional meta-analysis with random effect model of early and midterm outcomes were performed. Subgroup analysis was conducted for patients who had early mortality. Fifteen studies were elected for final analysis, encompassing 330 patients. The following values are expressed as "pooled mean, 95% confidence interval." Type B dissection was the most common pathology at index thoracic endovascular aortic repair (51.2%, 44.4-57.9). The most frequent indication for secondary open aortic procedure was endoleak (39.7%, 34.6-45.1). More than half of patients had surgery on the descending aorta (51.2%, 45.8-56.6), and one fourth on the arch (25.2%, 20.8-30.1). Operative mortality was 10.6% (7.4-14.9). Neurological morbidity was substantial between stroke (5.1%, 2.8-9.1) and paraplegia (8.3%, 5.2-13.1). At 2-year follow-up, mortality (20.4%, 11.5-33.5) and aortic adverse event (aortic death 7.7%, 4.3-13.3, tertiary aortic open procedure 7.4%, 4.0-13.2) were not negligible.
In the secondary open aortic procedure population, type B dissection was both the most common pathology and the one associated with the lowest early mortality, whereas aortic infection and extra-anatomical bypass were associated with the most ominous prognosis.
胸主动脉腔内修复术的特点是需要进行大量的再次干预。当进一步的腔内治疗选择用尽时，需要进行二次开放主动脉手术。本综述和对现有证据的定量分析旨在克服机构队列报告中关于二次开放主动脉手术的局限性。
从 1994 年至今，根据预先注册的方案，对电子数据库进行了搜索。对术前/术中变量进行了汇总量化，并采用随机效应模型进行了早期和中期结果的比例荟萃分析。对早期死亡率患者进行了亚组分析。最终分析了 15 项研究，共纳入 330 例患者。以下数值表示为“汇总均值，95%置信区间”。B 型夹层是索引胸主动脉腔内修复术最常见的病变（51.2%，44.4-57.9）。二次开放主动脉手术的最常见指征是内漏（39.7%，34.6-45.1）。超过一半的患者接受了降主动脉手术（51.2%，45.8-56.6），四分之一的患者接受了弓部手术（25.2%，20.8-30.1）。手术死亡率为 10.6%（7.4-14.9）。神经并发症包括中风（5.1%，2.8-9.1）和截瘫（8.3%，5.2-13.1），发生率较高。在 2 年随访时，死亡率（20.4%，11.5-33.5）和主动脉不良事件（主动脉死亡 7.7%，4.3-13.3，三级开放主动脉手术 7.4%，4.0-13.2）不容忽视。
在二次开放主动脉手术人群中，B 型夹层既是最常见的病变，也是早期死亡率最低的病变，而主动脉感染和非解剖旁路与最凶险的预后相关。
