Shimizu Hideyuki, Hirahara Norimichi, Motomura Noboru, Miyata Hiroaki, Takamoto Shinichi
Department of Cardiovascular Surgery, School of Medicine, Keio University, Tokyo, Japan.
The Japan Society for Cardiovascular Surgery, 2-26-9 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
Gen Thorac Cardiovasc Surg. 2019 Sep;67(9):751-757. doi: 10.1007/s11748-019-01163-x. Epub 2019 Jul 16.
Thoracic and thoracoabdominal aortic diseases are treated using operative procedures like open aortic repair (OAR), thoracic endovascular aortic repair (TEVAR), or hybrid aortic repair (HAR), or a combination of OAR and TEVAR. The surgical approach to aortic repair has evolved over the decades. The purpose of this study was to examine the current trends in treatment.
We extracted nationwide data of aortic repair procedures performed in 2015 and 2016 from the Japan Cardiovascular Surgery Database (JCVSD). In addition to estimating the number of cases, we also reviewed the respective operative mortalities and associated major morbidities (e.g., stroke, spinal cord insufficiency, and renal failure) according to disease pathology (e.g., acute dissection, chronic dissection, ruptured aneurysm, and unruptured aneurysm), site of operative repair (i.e., aortic root, ascending aorta, aortic root to arch, aortic arch, descending aorta, and thoracoabdominal aorta), and the preferred surgical approach (i.e., OAR, HAR, or TEVAR).
The total number of cases studied was 35,427, with an overall operative mortality rate of 7.3%. Among the 3 procedures, 64% of patients were treated with OAR. Compared to the data from our previous report (also derived from the JCVSD in 2013 and 2014), the total number of cases and number of OAR, HAR, and TEVAR procedures have increased by 17.0%, 2.4%, 126.1%, and 34.9%, respectively. While the overall stroke rates following aortic arch surgical repair with HAR, OAR, and TEVAR were 10.1%, 8.4%, and 7.3%, respectively, OAR was found to have the lowest stroke rate when limited to cases presenting with a non-dissected/unruptured aorta. The incidence rates of paraplegia following descending/thoracoabdominal aortic surgical repair using HAR, OAR, and TEVAR were 6.3%/10.4%, 4.3%/8.9%, and 3.4%/4.6%, respectively. TEVAR was found to be associated with the lowest incidence of postoperative renal failure.
The number of operations for thoracic and thoracoabdominal aortic diseases has increased, though the rate of operations using an OAR approach has decreased. While TEVAR showed the lowest mortality and morbidity rates, OAR demonstrated the lowest postoperative stroke rate for non-dissecting aortic arch aneurysms.
胸主动脉和胸腹主动脉疾病的治疗采用诸如开放主动脉修复术（OAR）、胸主动脉腔内修复术（TEVAR）或杂交主动脉修复术（HAR）等手术方法，或采用OAR和TEVAR联合治疗。几十年来，主动脉修复的手术方式不断演变。本研究旨在探讨当前的治疗趋势。
我们从日本心血管外科数据库（JCVSD）中提取了2015年和2016年全国范围内主动脉修复手术的数据。除了估计病例数外，我们还根据疾病病理（如急性夹层、慢性夹层、破裂动脉瘤和未破裂动脉瘤）、手术修复部位（即主动脉根部、升主动脉、主动脉根部至弓部、主动脉弓、降主动脉和胸腹主动脉）以及首选手术方式（即OAR、HAR或TEVAR），回顾了各自的手术死亡率和相关主要并发症（如中风、脊髓功能不全和肾衰竭）。
研究的病例总数为35427例，总体手术死亡率为7.3%。在这三种手术方式中，64%的患者接受了OAR治疗。与我们之前报告的数据（同样来自2013年和2014年的JCVSD）相比，病例总数以及OAR、HAR和TEVAR手术的数量分别增加了17.0%、2.4%、126.1%和34.9%。虽然采用HAR、OAR和TEVAR进行主动脉弓手术修复后的总体中风率分别为10.1%、8.4%和7.3%，但在仅限于非夹层/未破裂主动脉病例时，发现OAR的中风率最低。采用HAR、OAR和TEVAR进行降主动脉/胸腹主动脉手术修复后的截瘫发生率分别为6.3%/10.4%、4.3%/8.9%和3.4%/4.6%。发现TEVAR与术后肾衰竭的发生率最低相关。
胸主动脉和胸腹主动脉疾病的手术数量有所增加，尽管采用OAR方法的手术率有所下降。虽然TEVAR的死亡率和发病率最低，但OAR对于非夹层主动脉弓动脉瘤的术后中风率最低。
