Jakob Heinz, Shehada Sharaf-Eldin, Dohle Daniel, Wendt Daniel, El Gabry Mohamed, Schlosser Thomas, Tsagakis Konstantinos
Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany.
Department of Cardiothoracic and Vascular Surgery, Johannes-Gutenberg University, Mainz, Germany.
J Thorac Cardiovasc Surg. 2022 Feb;163(2):568-574.e1. doi: 10.1016/j.jtcvs.2020.04.113. Epub 2020 May 6.
Acute type I aortic dissection (AAD) represents a surgical emergency with time-dependent evolving complications. Frozen elephant trunk (FET) enables false lumen exclusion downstream but is still debated in AAD due to its greater dimension of surgery. To combine the benefits of fast proximal repair with the FET benefits, a 3-zone hybrid graft was developed consisting of an ascending polyester portion, an arch noncovered stent, and a descending stent graft. Mid-term results of this new technique are presented.
A total of 6 patients (age mean 69 years) with type I AAD in critical status (Penn classification B n = 5, BC n = 1) were operated between July 2016 and April 2018 using the 3-zone hybrid graft. The device was implanted on the basis of strict compassionate use. Operations were performed under distal hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP).
Operative mortality was 17% (n = 1). Mean crossclamp and SACP time were 92 and 34 minutes, respectively, but came down in the last 2 cases to 75/65 crossclamp and 23/24 SACP minutes each. During follow up, mean 19 ± 12 months, one endovascular extension downstream was performed. Imaging control demonstrated no anastomotic-related proximal entry and no true lumen collapse downstream.
The goal to achieve fast and reliable repair of complicated type I AAD down to midthoracic level seems to be achievable. Noncovered stenting of the head vessel's origin does not cause stenosis or obstruction. A multicenter studying of this concept is next.
急性I型主动脉夹层（AAD）是一种具有时间依赖性演变并发症的外科急症。冷冻象鼻支架（FET）可实现下游假腔封闭，但由于其手术范围较大，在AAD治疗中仍存在争议。为了将快速近端修复的优点与FET的优点相结合，研发了一种三区混合移植物，其由升主动脉聚酯部分、主动脉弓裸支架和降主动脉支架移植物组成。本文介绍了这项新技术的中期结果。
2016年7月至2018年4月期间，对6例处于危急状态的I型AAD患者（平均年龄69岁）（Penn分级B级5例，BC级1例）使用三区混合移植物进行手术。该装置是在严格的同情使用基础上植入的。手术在远端低温循环停止和选择性顺行脑灌注（SACP）下进行。
手术死亡率为17%（n = 1）。平均阻断钳夹时间和SACP时间分别为92分钟和34分钟，但在最后2例中分别降至75/65分钟和23/24分钟。在平均19±12个月的随访期间，进行了1次下游血管腔内延伸治疗。影像学检查显示无吻合口相关的近端破口，下游真腔无塌陷。
实现对复杂I型AAD直至胸中段进行快速可靠修复的目标似乎是可以实现的。头臂血管起源处的裸支架置入不会导致狭窄或阻塞。接下来将对这一概念进行多中心研究。
