Tanaka Akiko, Oderich Gustavo S, Estrera Anthony L
Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Tex.
JTCVS Tech. 2021 Aug 8;10:28-33. doi: 10.1016/j.xjtc.2021.08.002. eCollection 2021 Dec.
Open thoracoabdominal aortic aneurysm (TAAA) repair remains a surgical challenge. Hybrid and total endovascular repair have emerged as alternatives in treating TAAA. Total endovascular TAAA repair may be best performed with branched/fenestrated stent grafts. However, these technologies are not yet widely available. Thus, currently total endovascular TAAA repair using the chimney/snorkel techniques is considered a viable option in many centers. In this article, we briefly review 2 readily available techniques with off-the-shelf devices, hybrid procedure using total abdominal debranching, and total endovascular repair using chimney/snorkel procedures. The hybrid TAAA repair avoids thoracotomy but requires laparotomy and carries high morbidity and mortality (eg, operative mortality, 4%-26% and renal failure, 4%-26%), comparable to traditional open repair. The staged hybrid approach has been proposed to minimize the invasiveness of the procedure, whereas the associated risk of interval aortic deaths is not negligible. Total endovascular repair reduces the morbidity and mortality after TAAA repair (eg, operative mortality, 3%-20% and renal failure, 0%-20%). However, it is technically demanding and the risks of future reinterventions-and need for repetitive surveillance-is inevitable (eg, immediate type I endoleak, 7%-16% and 1-year branch patency, 93%-98%). Currently, there are not enough data to determine which less-invasive option for open repair in patients with TAAA is superior. These alternatives should complement each other and be applied to carefully selected populations as a part of the overall toolbox in treating TAAA.
开放性胸腹主动脉瘤（TAAA）修复术仍然是一项外科挑战。杂交修复术和完全腔内修复术已成为治疗TAAA的替代方法。完全腔内TAAA修复术最好使用分支/开窗支架型人工血管来进行。然而，这些技术尚未广泛应用。因此，目前在许多中心，使用烟囱/ snorkel技术进行完全腔内TAAA修复术被认为是一种可行的选择。在本文中，我们简要回顾两种使用现成设备的简便技术、采用全腹去分支的杂交手术以及使用烟囱/ snorkel手术的完全腔内修复术。杂交TAAA修复术避免了开胸手术，但需要开腹手术，且发病率和死亡率较高（例如，手术死亡率为4%-26%，肾衰竭为4%-26%），与传统开放修复术相当。已提出分期杂交手术方法以尽量减少手术的侵入性，而其间主动脉死亡的相关风险不可忽视。完全腔内修复术降低了TAAA修复术后的发病率和死亡率（例如，手术死亡率为3%-20%，肾衰竭为0%-20%）。然而，该技术要求较高，未来再次干预的风险以及重复监测的必要性是不可避免的（例如，即刻I型内漏为7%-16%，1年分支通畅率为93%-98%）。目前，尚无足够数据确定哪种TAAA患者的微创开放修复选择更具优势。这些替代方法应相互补充，并作为治疗TAAA的整体工具的一部分应用于精心挑选的人群。
