Serviço de Cirurgia Cardiotorácica do Hospital de Santa Marta.
Port J Card Thorac Vasc Surg. 2022 Jan 4;28(4):21-24. doi: 10.48729/pjctvs.219.
Thoracic Endovascular Aortic Repair (TEVAR) has enabled the treatment of aortic pathology that previously required open surgery, with higher morbidity and mortality. The need for a favorable landing zone (Lz), without compromising the patency of the supra-aortic vessels meant that Ishimaru Lz 2 was the most proximal technically feasible Lz. We developed a hybrid technique for the creation of a more proximal Lz in high risk patients - in the first stage, debranching/ rerouting of the supra-aortic vessels, with or without ascending aorta replacement, was performed; a few weeks later, a TEVAR with a LZ in the distal ascending aorta was performed. This technique allowed the avoidance of the more aggressive total arch and proximal descending aorta replacement (Elephant Trunk or Frozen Elephant Trunk - FET) in high risk patients. We reviewed all patients who underwent hybrid arch surgery in our Department to create a more proximal Lz that allowed safe TEVAR stent placement. From November 2007 to October 2019, 15 patients required hybrid surgery to achieve treatment - 9 by replacing the ascending aorta and debranching supra-aortic vessels and 6 by debranching and re-routing supra-aortic vessels to the native ascending aorta. All underwent computed tomography angiography within 30 days of surgery and had follow-up with annual appointments and imaging control. Patients average age was 65.5 (+/- 11.5) years, 73.3% being male. Average follow-up was 54.7 (+/- 46.2) months. The most common diagnosis was thoracic aortic aneurysm (66.7%), followed by chronic type B aortic dissection (20.0%), pen- etrating atherosclerotic ulcer (6.7%) and reintervention due to endoleak (EL, 6.7%). No in-hospital mortality was registered. ICU and hospital stay was 1.3 (0.8) days and 9.8 (10.3) days, respectively. Survival at 1- and 5- years was 84.6% and 65.8%, respectively. No EL was detected in 66.7% (n=10) of patients. Incidence of early EL was 20.0% (n=3), of which two-thirds had spontaneous resolution, and late EL was 13.3% (n=2). Endovascular reintervention was required in one patient. TEVAR in the context of hybrid surgery is associated with low morbidity and mortality, with a low incidence of EL and good early and long term survival.
胸主动脉腔内修复术（TEVAR）使以前需要开放性手术治疗的主动脉病变得到了治疗，其发病率和死亡率更高。需要一个有利的着陆区（Lz），而不影响主动脉以上血管的通畅性，这意味着 Ishimaru Lz 2 是技术上最可行的近端 Lz。我们为高危患者开发了一种创建更靠近近端 Lz 的杂交技术 - 在第一阶段，进行了主动脉以上血管的分支/再循环，可伴或不伴升主动脉置换；几周后，在远端升主动脉进行了 TEVAR。该技术可避免在高危患者中进行更激进的全弓和降主动脉近端置换（象鼻或冷冻象鼻 - FET）。我们回顾了在我院接受杂交弓手术以创建更靠近近端 Lz 的所有患者，以确保安全放置 TEVAR 支架。从 2007 年 11 月到 2019 年 10 月，有 15 名患者需要接受杂交手术来实现治疗 - 9 名患者通过置换升主动脉和分支主动脉以上血管，6 名患者通过分支和重新引导主动脉以上血管至原生升主动脉。所有患者均在术后 30 天内行计算机断层血管造影检查，并进行年度预约和影像学控制随访。患者平均年龄为 65.5（+/-11.5）岁，73.3%为男性。平均随访时间为 54.7（+/-46.2）个月。最常见的诊断是胸主动脉瘤（66.7%），其次是慢性 B 型主动脉夹层（20.0%）、穿透性粥样硬化性溃疡（6.7%）和因内漏（EL）而再次介入（6.7%）。无院内死亡。重症监护病房和住院时间分别为 1.3（0.8）天和 9.8（10.3）天。1 年和 5 年的生存率分别为 84.6%和 65.8%。66.7%（n=10）的患者未检测到 EL。早期 EL 的发生率为 20.0%（n=3），其中三分之二自发缓解，晚期 EL 的发生率为 13.3%（n=2）。一名患者需要进行血管内再介入治疗。杂交手术背景下的 TEVAR 与较低的发病率和死亡率相关，EL 发生率较低，早期和长期生存率较好。
