Tanaka Akiko, Ornekian Vahram, Estrera Anthony L
Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA - anthony.l.estrera@uth.
J Cardiovasc Surg (Torino). 2020 Jun;61(3):278-284. doi: 10.23736/S0021-9509.20.11259-X. Epub 2020 Jan 23.
Acute type A aortic dissection (ATAAD) remains an eminent, life-threatening disease. Although centers of excellence report mortality rate after ATAAD repair as low as 5% to 8%, data from the International Registry of Acute Aortic Dissection continue to demonstrate a high mortality rate of around 17% to 18%. Tear-oriented approach to determine the extent of repair has been widely accepted to treat ATAAD. In recent years, aggressive approach with total arch replacement - especially using hybrid procedure with the antegrade stent grafting in the proximal descending aorta - have been advocated to decrease the future downstream reoperations in younger patients or to treat malperfusion syndrome. In this article, we review outcomes comparing limited/tear-oriented approach vs. extended repair based on updated outcomes after ATAAD repair to evaluate for the indications and validity of each approach. We found that extended repair remains a high-risk operation in most hands and distal reoperation rate in contemporary series are as low as 10%. In addition, we did not find data to support concomitant antegrade stenting to improve outcomes in patients with distal malperfusion. In conclusion, we do not recommend beyond the tear-oriented approach, as any future benefit with extended repair seems outweighed by the incremental risk with the short-term risk in most hands.
急性A型主动脉夹层（ATAAD）仍然是一种严重的、危及生命的疾病。尽管卓越中心报告称ATAAD修复后的死亡率低至5%至8%，但国际急性主动脉夹层注册中心的数据仍显示死亡率高达17%至18%左右。以破口为导向的方法来确定修复范围已被广泛接受用于治疗ATAAD。近年来，有人主张采用积极的全主动脉弓置换方法——特别是在降主动脉近端采用顺行支架植入的杂交手术——以减少年轻患者未来的下游再次手术或治疗灌注不良综合征。在本文中，我们根据ATAAD修复后的最新结果，回顾了比较有限/以破口为导向的方法与扩大修复的结果，以评估每种方法的适应症和有效性。我们发现，在大多数人手中，扩大修复仍然是一项高风险手术，当代系列中的远端再次手术率低至10%。此外，我们没有找到数据支持同时进行顺行支架植入以改善远端灌注不良患者的预后。总之，我们不建议超越以破口为导向的方法，因为在大多数人手中，扩大修复带来的任何未来益处似乎都被其短期风险增加所抵消。
