Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Conn.
Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Conn.
J Thorac Cardiovasc Surg. 2019 May;157(5):1750-1758. doi: 10.1016/j.jtcvs.2018.09.020. Epub 2018 Sep 29.
Open-distal anastomosis is the preferred technique over clamp-on technique for surgical repair of acute type A aortic dissection (ATAAD). The aim of this study was to define how outcomes of ATAAD were affected by the use of either technique.
Nordic Consortium for Acute Type A Aortic Dissection includes 8 academic cardiothoracic hospitals in 4 Nordic countries. The cohort consisted of 1134 patients, 153 clamp-on and 981 open-distal, from 2005 to 2014.
Patients who underwent operation with the clamp-on were younger, more frequently had coronary artery disease, bicuspid aortic valve, hypotension/shock or syncope, and a greater PennClass than open-distal patients. Postoperative cerebral vascular accident occurred less frequently in clamp-on (14/153, 10%) compared with the open-distal group (190/981, 20%). Clamp-on had greater 30-day mortality (39/153, 25%) than the open-distal group (158/981, 16%), and 5-year survival was also worse in clamp-on (61.8% ± 4.4%) compared with the open-distal group (73.0% ± 1.6%). The open-distal technique was used more frequently in greater-volume hospitals but was not independently associated with 30-day mortality. Preoperative condition was an independent risk factor whereas hospital volume and later year of operation were beneficial in regard to short-term outcome. Open-distal was independently associated with improved mid-term survival.
Patients who underwent operation with the clamp-on were sicker on presentation and had worse short- and mid-term survival compared with the open-distal group. Patients in the open-distal group had greater rates of cerebrovascular complications. The results support the routine use of open-distal anastomosis as the primary operative strategy for ATAAD, although clamp-on can be performed successfully in select cases.
对于急性 A 型主动脉夹层（ATAAD）的外科修复，开放式远端吻合术优于夹闭技术。本研究旨在明确两种技术的应用如何影响 ATAAD 的结果。
北欧急性 A 型主动脉夹层研究协作组纳入了来自北欧 4 个国家的 8 所学术型心胸外科医院的 1134 名患者，其中 153 名接受夹闭技术，981 名接受开放式远端吻合术，患者的纳入时间为 2005 年至 2014 年。
接受夹闭手术的患者年龄更小，更常患有冠状动脉疾病、二叶式主动脉瓣、低血压/休克或晕厥，以及更大的 Penn 分级。与开放式远端组（190/981，20%）相比，夹闭组（14/153，10%）术后发生脑血管意外的频率较低。夹闭组的 30 天死亡率（39/153，25%）高于开放式远端组（158/981，16%），5 年生存率也较差（夹闭组 61.8%±4.4%，开放式远端组 73.0%±1.6%）。开放式远端技术在大手术量的医院中应用更为频繁，但与 30 天死亡率无独立相关性。术前情况是独立的危险因素，而医院手术量和手术年份则对短期结果有利。开放式远端与中期生存率的提高独立相关。
与开放式远端组相比，接受夹闭手术的患者在就诊时病情更严重，短期和中期生存率更差。开放式远端组的脑血管并发症发生率更高。这些结果支持将开放式远端吻合术作为 ATAAD 的主要手术策略常规应用，尽管夹闭技术在某些情况下也可以成功实施。
