采用一体化冰冻象鼻装置的改良“三明治”主动脉弓置换术治疗急性A型主动脉夹层。
Modified "" arch replacement with an integrative frozen elephant trunk device for acute type A aortic dissection.
作者信息
Xue Yunxing, Cao Hailong, Zhou Qing, Pan Jun, Fan Fudong, Zhang Bomin, Wang Dongjin
机构信息
Department of Thoracic and Cardiovascular Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.
Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China.
出版信息
J Thorac Dis. 2021 Sep;13(9):5448-5457. doi: 10.21037/jtd-21-75.
BACKGROUND
Total arch replacement (TAR) and frozen elephant trunk (FET) has been proposed as the primary arch repair method for acute type A aortic dissection (aTAAD). We introduce a modified "" arch replacement with an integrative FET device for aTAAD.
METHODS
From January 2018 to December 2019, 507 aTAAD patients from Nanjing Drum Tower Hospital received surgical therapy; among them, 57 patients with modified island total arch replacement (MiTAR) and 138 patients with TAR were enrolled. Marfan syndrome, primary intimal tears located in the large curve of aortic arch +/- or supra-arch vessels and dilated aortic arch (≥45 mm) were contraindications for MiTAR. MiTAR involves two steps: first, insert a FET device into the descending aorta during the hypothermic circulation arrest period; second, anastomose the remaining "island" arch with the prosthetic vessel and the proximal part of the FET.
RESULTS
MiTAR patients were older than those receiving TAR (52.1 48.9 years; P=0.078), but their baseline demographics and manifestations of organ ischaemia were nearly the same. The times of cardiopulmonary bypass (CPB), aortic clamp and hypothermic circulation arrest were significantly shorter with MiTAR (209.3 267.1 minutes, P=0.000; 147.9 190.0 minutes, P=0.000; 34.0 39.4 minutes, P=0.003, respectively). The volumes of intraoperative transfusions of red blood cells (RBCs), fresh frozen plasma (FFP), platelets and cryoprecipitates were significantly lower in MiTAR (5.9 8.5 units, P=0.000; 758.3 930.4, P=0.000; 12.5 17.5 mL, P=0.000; 9.4 16.6 units, P=0.000). The 30-day mortality was 7.0% (4/57) for MiTAR and 11.6% (16/138) for TAR. One patient died and no patient received reintervention during the follow-up period, while the size of several levels of aorta showed a decreasing trend.
CONCLUSIONS
MiTAR is a simplified approach to TAR that reduces the surgical trauma while achieving aortic reshaping effects.
背景
全弓置换术（TAR）和冰冻象鼻支架植入术（FET）已被提议作为急性A型主动脉夹层（aTAAD）的主要弓部修复方法。我们介绍一种用于aTAAD的改良“一体化FET装置的弓部置换术”。
方法
2018年1月至2019年12月，来自南京鼓楼医院的507例aTAAD患者接受了手术治疗；其中，57例行改良岛状全弓置换术（MiTAR），138例行TAR。马凡综合征、原发性内膜破口位于主动脉弓大弯处±或弓上血管以及主动脉弓扩张（≥45mm）是MiTAR的禁忌证。MiTAR包括两个步骤：首先，在低温循环停搏期将FET装置插入降主动脉；其次，将剩余的“岛状”主动脉弓与人工血管和FET的近端进行吻合。
结果
MiTAR患者比接受TAR的患者年龄更大（52.1对48.9岁；P=0.078），但他们的基线人口统计学特征和器官缺血表现几乎相同。MiTAR的体外循环（CPB）、主动脉阻断和低温循环停搏时间明显更短（分别为209.3对267.1分钟，P=0.000；147.9对190.0分钟，P=0.000；34.0对39.4分钟，P=0.003）。MiTAR术中红细胞（RBC）、新鲜冰冻血浆（FFP）、血小板和冷沉淀的输血量明显更低（分别为5.9对8.5单位，P=0.000；758.3对930.4，P=0.000；12.5对17.5mL，P=0.000；9.4对16.6单位，P=0.000）。MiTAR的30天死亡率为7.0%（4/57），TAR为11.6%（16/138）。随访期间1例患者死亡，无患者接受再次干预，同时主动脉几个节段的大小呈下降趋势。
结论
MiTAR是一种简化的TAR方法，在实现主动脉重塑效果的同时减少了手术创伤。
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