Creighton University School of Medicine, Omaha, Neb.
Department of Cardiac Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Mich.
J Thorac Cardiovasc Surg. 2021 Mar;161(3):873-884.e2. doi: 10.1016/j.jtcvs.2020.10.160. Epub 2020 Dec 10.
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.
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).
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).
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.
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。
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）。
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）。
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。
