Yoshizumi Tomo, Tokuda Yoshiyuki, Abe Tomonobu, Usui Akihiko
Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
Gen Thorac Cardiovasc Surg. 2019 Jul;67(7):602-607. doi: 10.1007/s11748-019-01075-w. Epub 2019 Jan 31.
Type A aortic dissection (TAAD) following hybrid arch repair (HAR) is a lethal complication. Open surgical repair is the ideal treatment, but this can be difficult, as most candidates have complications and are unsuitable for the conventional open aortic repair. We herein report three cases of TAAD after HAR and assess the treatment options.
Of 261 aortic arch repair cases between April 2010 and March 2018, 38 underwent HAR using debranching of all the arch vessels followed by stent graft implantation landing proximally in zone 0 (type 1 HAR). Three cases suffered from TAAD, and their background characteristics and post-operative outcomes were studied retrospectively.
The three TAAD cases were elderly with a high risk of mortality due to comorbidities. TAAD for Cases 1, 2, and 3 was detected on post-operative day (POD) 11, POD11, and during the procedure, respectively. Case 1 was complicated with both respiratory and renal failures, and Case 3 suffered from severe neurological impairment when TAAD was detected. No additional open aortic repair was performed in any cases. Case 3 died on POD5 due to aortic rupture. Cases 1 and 2 have survived for more than 50 months since their initial surgeries.
TAAD following HAR can be detected with post-operative imaging despite a lack of signs noted during the intra- and post-operative periods. Conservative therapy might, therefore, be an acceptable option for subacute-onset TAAD following HAR with stable hemodynamics, even though such patients do required a very careful follow-up.
杂交主动脉弓修复术（HAR）后发生的A型主动脉夹层（TAAD）是一种致命的并发症。开放手术修复是理想的治疗方法，但这可能具有挑战性，因为大多数患者都有并发症，不适合传统的开放性主动脉修复术。我们在此报告3例HAR术后发生TAAD的病例，并评估治疗方案。
在2010年4月至2018年3月期间的261例主动脉弓修复病例中，38例采用所有弓血管去分支后近端锚定于0区的支架植入术进行HAR（1型HAR）。3例发生TAAD，对其背景特征和术后结果进行回顾性研究。
3例TAAD患者均为老年人，因合并症死亡风险高。病例1、2和3的TAAD分别在术后第11天、术后第11天和手术过程中被发现。病例1合并呼吸和肾衰竭，病例3在发现TAAD时出现严重神经功能障碍。所有病例均未进行额外的开放性主动脉修复。病例3因主动脉破裂于术后第5天死亡。病例1和2自初次手术以来已存活超过50个月。
尽管在手术中和术后期间未发现明显体征，但HAR术后的TAAD可通过术后影像学检查发现。因此，对于HAR术后亚急性发作且血流动力学稳定的TAAD患者，保守治疗可能是一种可接受的选择，尽管这些患者确实需要非常仔细的随访。
