Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China.
Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China.
J Thorac Cardiovasc Surg. 2020 Jun;159(6):2202-2213.e4. doi: 10.1016/j.jtcvs.2019.03.143. Epub 2019 Jun 18.
Cervical aortic arch (CAA) is rare and difficult to repair. Clinical experience is limited. We report the surgical techniques and midterm outcomes in 35 patients with CAA based on an alternative classification scheme.
Of 35 patients with CAA, 30 (85.7%) had left-sided aortic arch and 5 had (14.3%) right-sided aortic arch (all 5 had a vascular ring). Mean age was 34.2 ± 13.1 years, 23 were female (65.7%), and 18 were asymptomatic (51.4%). Surgical access and procedure were chosen according to an alternative classification scheme that is based on the presence or absence of vascular ring and relationship of descending aorta to the side of the aortic arch. In the left-sided aortic arch group, aortic arch reconstruction though median sternotomy was performed in 15 patients, and distal arch and descending thoracic aortic replacement via left thoracotomy in 15 patients. In the right-sided aortic arch group, ascending-to-descending aortic bypass was done via median sternotomy in 2 patients and right thoracotomy in 1, and distal arch and descending thoracic aortic replacement via right thoracotomy in 2 patients.
Neither death nor spinal cord injury occurred. Left recurrent laryngeal nerve injury, prolonged ventilation, and reexploration for bleeding occurred in 1 each. In 11 patients with coarctation, the upper-lower limb gradient decreased significantly postoperatively (from 34.0 ± 12.7 to 10.2 ± 2.7 mm Hg; P < .01). The diseased aortic segment was excluded in 34 patients, except 1 with residual aneurysm in the proximal descending thoracic aorta. Follow-up was complete in 100% at mean 4.4 ± 2.0 years. No late death, limb ischemia, or stroke occurred. Endovascular repair was performed in 1 patient, and ascending aortic dilation occurred in 1 patient. The residual aorta remained nondilated in 33 patients. Aortic grafts were patent in 100%, with no anastomotic leak or pseudoaneurysm. At 6 years, the incidences of death, aortic events, and event-free survival were 0%, 6.5%, and 93.5%, respectively.
Open repair of CAA can achieve favorable early and midterm outcomes. Surgical accesses and procedures should be chosen based on type of CAA, anatomic variations and associated anomalies. Our alternative categorization scheme of CAA is intuitive and comprehensive, which may facilitate classification and surgical decision making.
颈总动脉弓（CAA）罕见且难以修复。临床经验有限。我们根据一种替代分类方案报告了 35 例 CAA 患者的手术技术和中期结果。
35 例 CAA 患者中，30 例（85.7%）为左侧主动脉弓，5 例（14.3%）为右侧主动脉弓（均为 5 例血管环）。平均年龄为 34.2±13.1 岁，23 例为女性（65.7%），18 例为无症状（51.4%）。根据是否存在血管环以及降主动脉与主动脉弓侧的关系，选择外科入路和手术方式。在左侧主动脉弓组中，15 例行正中开胸主动脉弓重建，15 例行左开胸降主动脉弓和降胸主动脉置换。在右侧主动脉弓组中，2 例行正中开胸升主动脉至降主动脉旁路术，1 例行右开胸，2 例行右开胸降主动脉弓和降胸主动脉置换术。
无死亡或脊髓损伤。各有 1 例发生左喉返神经损伤、长时间通气和再次探查出血。11 例合并缩窄的患者术后上下肢梯度明显下降（从 34.0±12.7mmHg 降至 10.2±2.7mmHg；P<0.01）。34 例患者排除了病变主动脉节段，1 例患者残留近端降胸主动脉瘤。100%的患者在平均 4.4±2.0 年时完成了随访。无晚期死亡、肢体缺血或中风。1 例患者行血管内修复，1 例患者升主动脉扩张。33 例患者的残余主动脉保持不扩张。100%的主动脉移植物通畅，无吻合口漏或假性动脉瘤。6 年时，死亡率、主动脉事件发生率和无事件生存率分别为 0%、6.5%和 93.5%。
CAA 的开放修复可获得良好的早期和中期结果。手术入路和手术方式应根据 CAA 类型、解剖变异和相关异常选择。我们的 CAA 替代分类方案直观而全面，有助于分类和手术决策。
