Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany.
Department of Cardiology and Vascular Medicine, West German Heart and Vascular Centre Essen, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany.
Semin Thorac Cardiovasc Surg. 2019 Winter;31(4):740-748. doi: 10.1053/j.semtcvs.2018.11.012. Epub 2018 Dec 8.
Acute type I aortic dissection (AD) complicated by true lumen (TL) collapse and malperfusion downstream is associated with devastating prognosis. The study reports an institutional mid-term experience with TL stabilization by uncovered stents to restore perfusion as a supplement to proximal thoracic aortic surgery. Between January 2007 and May 2017, 181 out of 270 acute type A AD patients were operated on type I AD. Eighteen uncovered stents (10%) were used to expand the aortic TL in presence of visceral and/or peripheral malperfusion. The procedures took place in a hybrid operating room and were combined with proximal aortic surgery. During follow-up (mean ± standard deviation 3.44 ± 2.1 years), the fate of AD was evaluated by computed tomography. Indication for TL stenting included visceral (44%) or peripheral malperfusion (11%) or both (45%). Stenting of aortic branches followed in 33%. All patients underwent proximal repair and were combined with frozen elephant trunk (67%) or retrograde descending aorta stent grafting (11%). Thirty-day mortality was 16.7%. Two-year survival was 71.8%. The false lumen around the uncovered stents remained patent in 89% and the aortic diameter increased 0.1 cm/y. No intimal rupture or occlusion of arteries occurred. In 1 patient, the stented aortic lumen was visualized after 6.3 years and neointima ingrowth covering the nitinol frame was found. In acute type I AD, combined endovascular-surgical procedures in a hybrid operation room setting can be used safely to resolve distal malperfusion. Encapsulation of uncovered stents within the intimal wall provides a stable fundament for endovascular techniques to close entry tears and false lumen.
急性 I 型主动脉夹层（AD）并发真腔（TL）塌陷和下游灌注不良与灾难性预后相关。本研究报告了一种机构中期经验，即使用裸支架稳定 TL，以恢复灌注，作为近端胸主动脉手术的补充。2007 年 1 月至 2017 年 5 月，270 例急性 I 型 AD 患者中有 181 例接受 I 型 AD 手术。18 个裸支架（10%）用于在存在内脏和/或外周灌注不良的情况下扩张主动脉 TL。这些手术在杂交手术室进行，并与近端主动脉手术相结合。在随访期间（平均 ± 标准偏差 3.44 ± 2.1 年），通过计算机断层扫描评估 AD 的结局。TL 支架置入的指征包括内脏（44%）或外周灌注不良（11%）或两者兼有（45%）。随后对主动脉分支进行支架置入术，占 33%。所有患者均接受近端修复，并结合冷冻象鼻（67%）或逆行降主动脉支架移植术（11%）。30 天死亡率为 16.7%。2 年生存率为 71.8%。未覆盖支架周围的假腔在 89%的患者中保持通畅，主动脉直径每年增加 0.1cm。未发生内膜破裂或动脉闭塞。1 例患者在 6.3 年后观察到支架置入的主动脉管腔，发现新生内膜向内生长覆盖了镍钛合金框架。在急性 I 型 AD 中，杂交手术室环境下的联合血管内-手术程序可安全用于解决下游灌注不良。未覆盖支架被内膜包裹为血管内技术封闭入口撕裂和假腔提供了稳定的基础。
