Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China.
Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China.
Interact Cardiovasc Thorac Surg. 2020 Aug 1;31(2):254-262. doi: 10.1093/icvts/ivaa095.
The aim of this study was to investigate the clinical outcomes and follow-up results among 5 main aortic arch surgery methods for type A aortic dissection in a single centre.
From 2002 to 2018, 958 type A aortic dissection patients who received surgical repair were divided into 5 groups according to the arch surgery method: hemiarch replacement (n = 206), island arch replacement (n = 54), total arch replacement with frozen elephant trunk (n = 425), triple-branched stent (n = 39) and fenestrated stent (n = 234). The indications for the different arch methods were related to the patient's preoperative status, the location and extent of the dissection and the surgical ability of the surgeons. A comparative study was performed to identify the differences in the perioperative data, and the Kaplan-Meier analysis was used to assess the long-term survival and reintervention rates. Thirty matched surviving patients that were included in each group completed Computed tomography angiography to determine long-term reshaping effect.
The 30-day mortality rate was 15.8%, and there was no difference among the 5 groups (P = 0.848). The follow-up survival rates were similar among the 5 groups (P = 0.130), and the same was true for patients without reintervention (P = 0.471). In the propensity matching study, patients with stents (frozen elephant trunk, triple-branched stent, fenestrated stent) had a slower aortic dilation rate and a higher ratio of thrombosis in the false lumen at the descending aortic and abdominal aortic levels than patients without stents.
No standard method is available for arch surgery, and indications and long-term effects should be identified with clinical data. In our experiences, simpler surgical procedures could reduce mortality in critically ill patients and stents in the distal aorta could improve long-term reshape effects.
本研究旨在探讨单中心 5 种主动脉弓手术方法治疗 A 型主动脉夹层的临床转归和随访结果。
2002 年至 2018 年，958 例接受手术修复的 A 型主动脉夹层患者根据弓部手术方法分为 5 组：半弓置换（n=206）、岛状弓置换（n=54）、全弓置换加冷冻象鼻（n=425）、三分支支架（n=39）和开窗支架（n=234）。不同弓部方法的适应证与患者术前状态、夹层部位和范围以及术者的手术能力有关。通过比较研究确定围手术期数据的差异，并采用 Kaplan-Meier 分析评估长期生存率和再干预率。每组纳入 30 例匹配存活患者，完成计算机断层血管造影术以确定长期重塑效果。
30 天死亡率为 15.8%，5 组间无差异（P=0.848）。5 组间随访生存率相似（P=0.130），无再干预患者亦如此（P=0.471）。在倾向评分匹配研究中，带支架（冷冻象鼻、三分支支架、开窗支架）患者的降主动脉和腹主动脉水平假腔血栓形成率较高，主动脉扩张率较慢。
弓部手术尚无标准方法，应根据临床资料确定适应证和长期效果。在我们的经验中，较简单的手术程序可降低危重症患者的死亡率，而远端主动脉支架可改善长期重塑效果。
