Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany.
Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany.
Eur J Cardiothorac Surg. 2022 Mar 24;61(4):869-876. doi: 10.1093/ejcts/ezab444.
The aim of this study was to assess preoperative dissection flap motility and to evaluate its impact on the aortic remodelling and the development of distal stent-induced new entry after thoracic endovascular aneurysm repair (TEVAR)/frozen elephant trunk (FET).
Patients with primary or residual type B dissections were included in a retrospective study with transoesophageal echocardiography analysis of the preoperative dissection flap motility assessed by the true lumen (TL) strain. Three-dimensional computing tomography centreline reconstructions before TEVAR/FET and during the follow-up were conducted to measure aortic remodelling: false lumen thrombosis, TL expansion and aortic diameters at 10 and 20 cm downstream the left subclavian artery, at the coeliac trunk and in the infrarenal aorta. All continuous variables are reported as median with first and third quartiles.
Fifty-six consecutive patients were treated with TEVAR (n = 45) or FET (n = 11) in the acute (n = 16), subacute (n = 16) and chronic (n = 24) dissection phase. At a median follow-up of 6 (3-12) months, they showed a favourable TL expansion in the descending aorta, significantly higher in the acute [+9 mm (5-12); P < 0.001] and subacute groups [+5 mm (3-8); P = 0.039] than in the chronic group [+2 mm (0-5)]. The dissection flap motility parameter TL strain was superior in the acute (P = 0.006) and subacute (P = 0.035) groups in comparison to the chronic group. The motile flap [TL strain >22.5% (median)] was associated with a higher TL expansion rate in the thoracic aorta (P = 0.009) and a comparable distal stent-induced new entry incidence (overall: 16%) in comparison to the immobile flap (P = 0.89).
The intraoperative assessment and the inclusion of the dissection flap motility parameters in the decision-making during TEVAR/FET may refine the distal endograft sizing for an improved remodelling of the TL.
本研究旨在评估术前夹层瓣活动度，并评估其对胸主动脉腔内修复术（TEVAR）/冷冻象鼻（FET）后主动脉重塑和远端支架诱导新入口的发展的影响。
本回顾性研究纳入了原发性或残留型 B 型夹层患者，通过经食管超声心动图分析真腔（TL）应变评估术前夹层瓣活动度。在 TEVAR/FET 术前和随访期间进行三维计算断层中心线重建，以测量主动脉重塑：假腔血栓形成、TL 扩张以及左锁骨下动脉下游 10cm 和 20cm、腹腔干和肾下主动脉处的主动脉直径。所有连续变量均以中位数（第一四分位数和第三四分位数）表示。
56 例连续患者接受 TEVAR（n=45）或 FET（n=11）治疗，分别处于急性（n=16）、亚急性（n=16）和慢性（n=24）夹层期。中位随访时间为 6（3-12）个月，他们在降主动脉中显示出有利的 TL 扩张，在急性组[+9mm（5-12）；P<0.001]和亚急性组[+5mm（3-8）；P=0.039]显著高于慢性组[+2mm（0-5）]。与慢性组相比，急性（P=0.006）和亚急性（P=0.035）组的夹层瓣活动度参数 TL 应变更好。活动瓣[TL 应变>22.5%（中位数）]与胸主动脉 TL 扩张率更高相关（P=0.009），与固定瓣（总体：16%）相比，远端支架诱导新入口发生率相当（P=0.89）。
在 TEVAR/FET 期间进行术中评估并将夹层瓣活动度参数纳入决策中，可能会改善 TL 的重塑，从而使远端内支架的尺寸更精确。
