Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut, USA.
Department of Internal Medicine, Saint Mary's Hospital, Waterbury, Connecticut, USA.
J Card Surg. 2021 Jun;36(6):1882-1891. doi: 10.1111/jocs.15441. Epub 2021 Feb 26.
Diffuse mega-aorta is challenging. Prior studies have raised concerns regarding the safety of the open two-stage elephant trunk (ET) approach for extensive thoracic aortic aneurysm (TAA), specifically in regard to interstage mortality. This study evaluates the safety of the two-stage ET approach for management of extensive TAA.
Between 2003 and 2018, 152 patients underwent a Stage I ET procedure by a single surgeon (mean age 64.5 ± 14.8). Second stage ET procedure was planned in 60 patients (39.4%) and to-date has been performed in 54 patients (90%). (in the remaining patients, the ET was prophylactic for the long-term, with no plan for near-term utilization).
In-hospital mortality after the Stage I procedure was 3.3% (5/152). In patients planned for Stage II, the median interstage interval was 5 weeks (range: 0-14). Of the remaining six patients with planned, but uncompleted Stage II procedures, five patients expired from various causes in the interval period (interstage mortality of 8.3%). There were no cases of aortic rupture in the interstage interval. Stage II was completed in 58 patients (including four unplanned) with a 30-day mortality of 10.3% (6/58). Seven patients developed strokes after Stage II (12%), and three patients (5.1%) developed paraplegia.
The overall mortality, including Stage I, interstage interval, and Stage II was 18.6%. This substantial cumulative mortality for the open two-staged ET approach for the treatment of extensive TAA appears commensurate with the severity of the widespread aortic disease in this patient group. Fear of interstage rupture should not preclude the aggressive Two-Stage approach to the management of extensive TAA.
弥漫性主动脉瘤较为棘手。既往研究对广泛胸主动脉瘤（TAA）的开放两阶段象鼻（ET）治疗方法的安全性提出了担忧，特别是在围手术期死亡率方面。本研究旨在评估广泛 TAA 两阶段 ET 治疗方法的安全性。
2003 年至 2018 年，由同一位外科医生对 152 名患者进行了一期 ET 手术（平均年龄 64.5±14.8 岁）。计划对 60 名患者（39.4%）进行二期 ET 手术，其中 54 名患者（90%）已进行了手术。（其余患者 ET 为长期预防，近期无使用计划）。
一期手术后院内死亡率为 3.3%（5/152）。在计划进行二期手术的患者中，围手术期中位数为 5 周（范围：0-14）。在其余 6 名计划但未完成二期手术的患者中，5 名患者在围手术期因各种原因死亡（围手术期死亡率为 8.3%）。围手术期内无主动脉破裂病例。58 名患者（包括 4 名非计划手术）完成了二期手术，30 天死亡率为 10.3%（6/58）。二期手术后 7 名患者发生中风（12%），3 名患者（5.1%）发生截瘫。
包括一期、围手术期和二期在内的总死亡率为 18.6%。对于广泛 TAA，开放两阶段 ET 治疗方法的这种累积死亡率相当高，这与该患者群体中广泛主动脉疾病的严重程度相符。对围手术期破裂的担忧不应阻止对广泛 TAA 进行积极的两阶段治疗。
