First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan.
Asian Cardiovasc Thorac Ann. 2023 Jan;31(1):26-31. doi: 10.1177/02184923211069812. Epub 2022 Feb 15.
Vital organ malperfusion in acute type A aortic dissection is associated with worse outcomes, especially when multiple organ systems are involved, and when coronary or mesenteric malperfusion is present. To achieve the two goals of central aortic repair and adequate and timely reperfusion, mechanism and organ-specific strategy in the methods and sequence of repair should be considered. For dynamic aortic malperfusion, reperfusion can be quickly achieved by femoral artery perfusion, and the fenestrated frozen elephant trunk operation, in which the proximal end of device is secured to zone 1 or 2 and distal 1 or 2 supra-aortic vessels are preserved by fenestration of the fabric, seems optimal as a method of central aortic repair. For coronary malperfusion, percutaneous coronary intervention before central aortic repair may have a role. However, it should be kept in mind that the door-to-unloading time is also important to reduce the area of myocardial infarction, and retrograde cardioplegia is not distributed to most of the right ventricle, which can be critical when right coronary malperfusion is present. Static mesenteric malperfusion should be addressed first, and second-look laparotomy should not be hesitated after central aortic repair. The use of a hybrid operating room may be an optimal solution to achieve both goals.
急性 A 型主动脉夹层的重要器官灌注不良与较差的预后相关，尤其是当涉及多个器官系统时，以及当存在冠状动脉或肠系膜灌注不良时。为了实现中央主动脉修复和充分、及时再灌注的两个目标，应考虑修复方法和顺序中的机制和器官特异性策略。对于动态主动脉灌注不良，通过股动脉灌注可快速实现再灌注，并且分叉冷冻象鼻手术似乎是一种最佳的中央主动脉修复方法，其中装置的近端固定在 1 区或 2 区，并且通过织物的开窗保留近端 1 区或 2 区的主动脉上血管。对于冠状动脉灌注不良，在进行中央主动脉修复之前进行经皮冠状动脉介入治疗可能具有一定作用。然而，应该记住，门到卸载时间对于减少心肌梗死面积也很重要，并且逆行心脏停搏液不能分布到大多数右心室，当存在右冠状动脉灌注不良时，这可能是至关重要的。应首先解决静态肠系膜灌注不良问题，并且在中央主动脉修复后不应犹豫进行再次剖腹探查。杂交手术室的使用可能是实现这两个目标的最佳解决方案。
