Division of Cardiovascular Surgery, University of Toronto, Toronto, Canada
Department of Cardiac Surgery, Magdi Yacoub Heart Foundation, Aswan Heart Centre; and Department of Cardiothoracic Surgery, Alexandria University, Faculty of Medicine, Egypt.
Multimed Man Cardiothorac Surg. 2020 Nov 19;2020. doi: 10.1510/mmcts.2020.062.
Acute type A aortic dissection remains a high-risk surgical condition, and mortality among those presenting with malperfusion is up to 3-fold higher. Despite the added technical challenge of distal aortic arch interventions in the acute setting, it may be necessary to resolve distal malperfusion in patients with this disorder. The ideal arch intervention to address acute type A aortic dissection complicated by malperfusion should address the following objectives: (1) to relieve distal malperfusion by expanding the distal true lumen and depressurizing the false lumen; (2) to avoid compromising arch branches without requiring additional arch branch interventions; (3) to minimize the risk of spinal cord ischemia; and (4) to minimize the operative duration and circulatory arrest time. The use of an uncovered aortic arch stent that is delivered in an antegrade manner during circulatory arrest, concomitantly with hemiarch replacement, therefore represents an attractive solution in the management of acute type A aortic dissection complicated by malperfusion. This strategy does not require complex arch reconstruction and may thus be a feasible option among cardiac and vascular surgeons in lower volume aortic centers. Here we present a step-by-step approach to acute type A aortic dissection repair with hemiarch repair and delivery of an uncovered arch stent for a patient presenting with malperfusion.
急性A型主动脉夹层仍然是一种高风险的手术情况，出现灌注不良的患者死亡率高达 3 倍。尽管在急性情况下进行远端主动脉弓干预具有额外的技术挑战，但对于患有这种疾病的患者，可能需要解决远端灌注不良的问题。解决急性 A 型主动脉夹层合并灌注不良的理想弓部干预措施应达到以下目标：（1）通过扩张远端真腔和降低假腔压力来缓解远端灌注不良；（2）避免损害弓部分支，而无需进行额外的弓部分支干预；（3）最大限度地降低脊髓缺血的风险；（4）最大限度地减少手术时间和循环阻断时间。在循环阻断期间，顺行输送的 uncovered aortic arch stent 与半弓置换同时使用，因此代表了一种有吸引力的解决方案，可用于治疗急性 A 型主动脉夹层合并灌注不良。这种策略不需要复杂的弓部重建，因此可能是低容量主动脉中心的心脏和血管外科医生的可行选择。在此，我们介绍了一种治疗急性 A 型主动脉夹层的分步方法，即半弓修复和输送 uncovered arch stent 以治疗出现灌注不良的患者。
