Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
Division of Vascular and Endovascular Therapy, Emory University School of Medicine, Atlanta, Georgia.
Ann Thorac Surg. 2020 Sep;110(3):799-806. doi: 10.1016/j.athoracsur.2019.12.036. Epub 2020 Mar 5.
Thoracic endovascular aortic repair (TEVAR) with endograft coverage from the left subclavian artery to the celiac artery has been hypothesized to increase spinal cord ischemia. This study analyzes the impact of extended coverage on adverse outcomes and aortic remodeling in patients with complicated acute type B aortic dissection (aTBAD).
From January 2012 to October 2018, 91 patients underwent TEVAR for aTBAD. Median follow-up was 3.1 (interquartile range, 1.2-4.9) years and was complete in 94% of patients. The extent of aortic endograft coverage was categorized as standard (n = 39) or extended (n = 52). Contrast-enhanced imaging scans were analyzed to determine length of coverage, maximum aortic diameters, and false lumen (FL) status.
The mean age was 52.6 ± 13.9 years, and 66% were men. The most common indications for intervention were malperfusion (42%) and refractory pain (34%). Thirteen (14%) patients required a lumbar drain (preoperative: n = 3; postoperative: n = 10). Mean duration between scans was 2.0 ± 1.9 years. Length of aortic coverage was significantly longer in the extended group (241.7 ± 29.2 mm vs 180.8 ± 22.3 mm in the standard group; P < .001). In-hospital and overall mortality were 6% and 11%, respectively. There were no cases of paraplegia, and the incidence of spinal cord ischemia was 3%. After TEVAR, there was a higher incidence of FL obliteration or thrombosis at the distal descending thoracic aorta in the extended group (53% vs 16% in the standard group; P = .004).
Extended TEVAR carries a low risk of spinal cord ischemia and improves FL remodeling of the descending thoracic aorta in patients with aTBAD. This strategy may decrease the need for reinterventions on the thoracic aorta in the chronic phase of TBAD.
从左锁骨下动脉到腹腔动脉的胸主动脉腔内修复术（TEVAR）覆盖范围已被假设会增加脊髓缺血。本研究分析了在复杂急性 B 型主动脉夹层（aTBAD）患者中，延长覆盖范围对不良结局和主动脉重塑的影响。
2012 年 1 月至 2018 年 10 月，91 例 aTBAD 患者接受 TEVAR 治疗。中位随访时间为 3.1 年（四分位距，1.2-4.9 年），94%的患者随访完整。主动脉内移植物覆盖范围分为标准范围（n=39）和扩展范围（n=52）。通过增强对比成像扫描来确定覆盖范围的长度、最大主动脉直径和假腔（FL）状态。
患者的平均年龄为 52.6±13.9 岁，66%为男性。干预的最常见指征是灌注不良（42%）和难治性疼痛（34%）。13 例（14%）患者需要腰椎引流（术前：n=3；术后：n=10）。两次扫描之间的平均时间为 2.0±1.9 年。在扩展组中，主动脉覆盖长度明显更长（241.7±29.2mm 比标准组的 180.8±22.3mm；P<0.001）。住院期间和总死亡率分别为 6%和 11%。无截瘫病例，脊髓缺血发生率为 3%。TEVAR 后，在扩展组中，降胸主动脉远端的 FL 闭塞或血栓形成发生率更高（53%比标准组的 16%；P=0.004）。
在 aTBAD 患者中，延长 TEVAR 覆盖范围具有较低的脊髓缺血风险，并改善降胸主动脉的 FL 重塑。这种策略可能会减少 TBAD 慢性期对胸主动脉的再次干预需求。
