Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex.
Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
J Thorac Cardiovasc Surg. 2022 Apr;163(4):1252-1264. doi: 10.1016/j.jtcvs.2020.09.148. Epub 2020 Nov 26.
The reversed elephant trunk technique permits staged repair of extensive thoracic aortic aneurysm in patients whose distal (ie, descending thoracic and thoracoabdominal) aorta is symptomatic or disproportionately large compared with their proximal aorta (ie, ascending aorta and transverse aortic arch). We present our 23-year experience with the reversed elephant trunk approach.
Between 1994 and 2017, 94 patients (median age 62 [46-69] years) underwent stage 1 reversed elephant trunk repair of the distal aorta. Fifty-three patients (56%) had aortic dissection, and 31 patients (33%) had heritable thoracic aortic disease. Eighty-eight operations (94%) were Crawford extent I or II thoracoabdominal aortic repairs. Twenty-seven patients (29%) underwent subsequent stage 2 repair of the proximal aorta; 14 patients (52%) required redo median sternotomy. The median time between the stage 1 and 2 operations was 18.8 (4.8-69.3) months.
The operative mortality was 10% (9/94) for stage 1 repairs and 4% (1/27) for stage 2 repairs; 1 patient with heritable thoracic aortic disease died after stage 1 repair (1/31, 3%), and 1 patient died after stage 2 repair (1/13, 8%). Two patients (2%) had ruptures after stage 1 repair; 1 resulted in death, and 1 precipitated emergency stage 2 repair. In total, 36 patients (38%) who survived stage 1 repair died before stage 2 reversed elephant trunk completion repair could be performed.
Managing extensive aortic aneurysm with the 2-stage reversed elephant trunk technique yields acceptable short-term outcomes. This technique is useful for the reversed elephant trunk in patients who require distal aortic repair before proximal repair and is particularly effective in patients with heritable thoracic aortic disease. The low number of patients returning for completion repair is concerning. Rigorous surveillance is needed.
反“象鼻”技术允许对远端（即降主动脉和胸腹主动脉）主动脉有症状或与近端（即升主动脉和主动脉弓）相比不成比例增大的广泛胸主动脉瘤患者进行分期修复。我们介绍了我们 23 年的反“象鼻”技术经验。
1994 年至 2017 年，94 例（中位年龄 62 [46-69] 岁）患者接受了一期反“象鼻”手术治疗远端主动脉。53 例（56%）患者患有主动脉夹层，31 例（33%）患者患有遗传性胸主动脉疾病。88 例手术（94%）为 Crawford Ⅰ型或Ⅱ型胸腹主动脉修复术。27 例患者（29%）随后接受了近端主动脉二期修复；14 例患者（52%）需要再次正中开胸。一期和二期手术之间的中位时间为 18.8（4.8-69.3）个月。
一期手术的手术死亡率为 10%（9/94），二期手术的死亡率为 4%（1/27）；1 例遗传性胸主动脉疾病患者在一期手术后死亡（1/31，3%），1 例患者在二期手术后死亡（1/13，8%）。2 例患者（2%）在一期手术后破裂；1 例导致死亡，1 例引发紧急二期修复。共有 36 例（38%）一期手术存活的患者在二期反“象鼻”完成修复前死亡。
采用两阶段反“象鼻”技术治疗广泛的主动脉瘤可获得可接受的短期结果。该技术对于需要在近端修复之前进行远端主动脉修复的患者非常有用，对于遗传性胸主动脉疾病患者尤其有效。返回完成修复的患者数量较少令人担忧。需要进行严格的监测。
