Vascular and Thoracic Surgery Department, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris, France; Centre de Référence pour le Syndrome de Marfan et apparentés, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris, France; Université de Paris, Paris, France; Laboratory for Vascular Translational Science, Inserm U1148, Université de Paris, Paris, France.
Vascular and Thoracic Surgery Department, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris, France; Centre de Référence pour le Syndrome de Marfan et apparentés, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris, France; Université de Paris, Paris, France.
J Vasc Surg. 2021 Jul;74(1):20-27. doi: 10.1016/j.jvs.2020.12.049. Epub 2020 Dec 16.
Open repair of type II thoracoabdominal aortic aneurysms (TAAAs) remains a challenging procedure. Staged procedures could decrease the incidence and severity of complications after complex aortic repair. In the present report, we have described a strategy using thoracic endovascular aortic repair (TEVAR) for proximal repair, followed by distal open repair.
From 2014 to 2018, 14 patients had undergone TEVAR, followed by distal open repair, for type II TAAAs. All patients should have a suitable proximal landing zone according to the current guidelines. In cases of chronic dissection, false lumen embolization was performed to achieve total exclusion.
The mean patient age was 48 ± 15 years. Of the 14 patients, 5 had had Marfan syndrome (36%) and 6 had undergone previous aortic arch repair (43%). Ten patients had had a chronic dissection. The maximal aortic diameter was 73 ± 12 mm. The TEVAR technical success rate was 100%. The aortic length coverage was 211 ± 63 mm. The number of covered segmental arteries was 6 (range, 4-13). Two endoleaks were observed, one type Ib and one type II. The delay between TEVAR and open repair was 12 ± 8 weeks. Cerebrospinal fluid drainage was used in 13 patients. Six patients had undergone segmental artery reattachment during surgery. No spinal cord ischemic event was observed. One patient had died 5 weeks after open repair of multiple organ failure. During the 32 months of follow-up, no aortic-related deaths had occurred. No new aortic procedure was needed. The type Ib endoleak had resolved during open repair, and the type II TAAA had resolved spontaneously. The mean maximal thoracic aortic diameter had significantly decreased to 49 ± 8 mm (P < .0001). Aneurysmal shrinkage of ≥5 mm was observed in 13 patients (93%).
Staged hybrid repair of type II TAAAs appears to be efficient, with low morbidity and mortality rates. This technique could improve postoperative outcomes after open repair, and TEVAR might have a role in ischemic preconditioning to protect against spinal cord ischemia.
开放修复 II 型胸腹主动脉瘤（TAAAs）仍然是一项具有挑战性的手术。分期手术可以降低复杂主动脉修复后的并发症发生率和严重程度。在本报告中，我们描述了一种使用胸主动脉腔内修复术（TEVAR）进行近端修复，然后进行远端开放修复的策略。
2014 年至 2018 年，14 例 II 型 TAAAs 患者接受了 TEVAR 治疗，随后进行了远端开放修复。所有患者均应根据现行指南具备合适的近端着陆区。对于慢性夹层，进行假腔栓塞以实现完全闭塞。
患者的平均年龄为 48±15 岁。14 例患者中，5 例患有马凡综合征（36%），6 例曾接受过主动脉弓修复（43%）。10 例患者患有慢性夹层。最大主动脉直径为 73±12mm。TEVAR 技术成功率为 100%。主动脉覆盖长度为 211±63mm。覆盖的节段性动脉数量为 6 个（范围为 4-13 个）。观察到 2 例内漏，1 例 Ib 型，1 例 II 型。TEVAR 和开放修复之间的延迟时间为 12±8 周。13 例患者使用了脑脊液引流。6 例患者在手术中进行了节段性动脉再附着。未观察到脊髓缺血事件。1 例患者在开放修复后 5 周死于多器官衰竭。在 32 个月的随访期间，无主动脉相关死亡发生。无需进行新的主动脉手术。Ib 型内漏在开放修复时得到解决，II 型 TAAA 自发性缓解。最大胸主动脉直径显著下降至 49±8mm（P<.0001）。13 例患者（93%）观察到动脉瘤缩小≥5mm。
分期杂交修复 II 型 TAAAs 似乎有效，且发病率和死亡率低。该技术可以改善开放修复后的术后结果，TEVAR 可能在缺血预处理中发挥作用，以防止脊髓缺血。
