升主动脉弓部替换术在急性 A 型主动脉夹层合并弓部分支血管夹层但无脑灌注不良的患者中是否足够？
Is hemiarch replacement adequate in acute type A aortic dissection repair in patients with arch branch vessel dissection without cerebral malperfusion?
机构信息
Creighton University School of Medicine, Omaha, Neb.
Department of Cardiac Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Mich.
出版信息
J Thorac Cardiovasc Surg. 2021 Mar;161(3):873-884.e2. doi: 10.1016/j.jtcvs.2020.10.160. Epub 2020 Dec 10.
OBJECTIVE
The study objective was to determine if hemiarch replacement is an adequate arch management strategy for patients with acute type A aortic dissection and arch branch vessel dissection but no cerebral malperfusion.
METHODS
From January 2008 to August 2019, 479 patients underwent open acute type A aortic dissection repair. After excluding those with aggressive arch replacement (n = 168), cerebral malperfusion syndrome (n = 34), and indeterminable arch branch vessel dissection (n = 1), 276 patients with an acute type A aortic dissection without cerebral malperfusion syndrome who underwent hemiarch replacement comprised this study. Patients were then divided into those with arch branch vessel dissection (n = 133) and those with no arch branch vessel dissection (n = 143).
RESULTS
The median age of the entire cohort was 62 years, with the arch branch vessel dissection group being younger (60 vs 62 years, P = .048). Both groups had similar aortic arch and descending thoracic aortic diameters, with significantly more DeBakey type I dissections (100% vs 80%) in the arch branch vessel dissection group. The arch branch vessel dissection group had more aortic root replacement (36% vs 27%, P = .0035) and longer aortic crossclamp times (153 vs 128 minutes, P = .007). Postoperative outcomes were similar between the arch branch vessel dissection and no arch branch vessel dissection groups, including stroke (10% vs 5%, P = .12) and operative morality (7% vs 5%, P = .51). The arch branch vessel dissection group had a significantly greater cumulative incidence of reoperation (8-year: 19% vs 4%, P = .04) with a hazard ratio of 2.89 (95% confidence interval, 1.01-8.27; P = .048), which was similar between groups among only DeBakey type I dissections (8-year: 19% vs 5%, P = .11). The 8-year survival was similar between the arch branch vessel dissection and no arch branch vessel dissection groups (76% vs 74%, P = .30).
CONCLUSIONS
Hemiarch replacement was adequate for patients with acute type A aortic dissection with arch branch vessel dissection without cerebral malperfusion syndrome, but carried a higher risk of late reoperation.
目的
本研究旨在探讨对于无脑部低灌注的急性 A 型主动脉夹层合并弓部分支血管夹层的患者，行半弓置换术是否为一种合适的弓部处理策略。
方法
2008 年 1 月至 2019 年 8 月，共有 479 例患者接受了急性 A 型主动脉夹层开放修复手术。排除行积极的弓部置换术的患者（n=168）、有脑部低灌注综合征的患者（n=34）和弓部分支血管夹层无法明确的患者（n=1）后，本研究共纳入 276 例无脑部低灌注综合征的急性 A 型主动脉夹层患者，这些患者均接受了半弓置换术。然后将这些患者分为合并弓部分支血管夹层的患者（n=133）和不合并弓部分支血管夹层的患者（n=143）。
结果
全队列患者的中位年龄为 62 岁，其中合并弓部分支血管夹层的患者年龄更小（60 岁 vs 62 岁，P=0.048）。两组患者的主动脉弓和降主动脉直径相似，合并弓部分支血管夹层的患者中更常见 DeBakey Ⅰ型夹层（100% vs 80%）。合并弓部分支血管夹层的患者主动脉根部置换比例更高（36% vs 27%，P=0.0035），主动脉阻断时间更长（153 分钟 vs 128 分钟，P=0.007）。两组患者的术后转归相似，包括卒中（10% vs 5%，P=0.12）和手术死亡率（7% vs 5%，P=0.51）。合并弓部分支血管夹层的患者再次手术的累积发生率明显更高（8 年时：19% vs 4%，P=0.04），风险比为 2.89（95%置信区间：1.01-8.27；P=0.048），在仅为 DeBakey Ⅰ型夹层的患者中，两组之间的差异也相似（8 年时：19% vs 5%，P=0.11）。合并弓部分支血管夹层和不合并弓部分支血管夹层的患者 8 年生存率相似（76% vs 74%，P=0.30）。
结论
对于无脑部低灌注综合征的急性 A 型主动脉夹层合并弓部分支血管夹层的患者，行半弓置换术是一种合适的治疗策略，但会增加晚期再次手术的风险。
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