Yuan Xun, Mitsis Andreas, Mozalbat David, Nienaber Christoph A
Cardiology and Aortic Centre, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, SW3 6NP UK.
National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK.
Indian J Thorac Cardiovasc Surg. 2022 Apr;38(Suppl 1):183-192. doi: 10.1007/s12055-021-01281-3. Epub 2021 Dec 13.
Open surgery remains the mainstay of treatment for acute type A aortic dissection and should be offered to most patients. However, there are elderly patients in which surgical treatment may be deemed extremely high risk or futile. Endovascular treatment approaches have been applied to a small number of these patients and data are limited to case reports and small series. The application of endovascular therapies to ascending aorta is currently limited by anatomical and technical challenges posed by the dynamic motion of the ascending aorta and the proximity of vital structures to intended landing zones (aortic valve, coronary arteries, and supra-aortic branches) and lack of specially designed endografts to address these issues. While thoracic endovascular aortic repair (TEVAR) has replaced open aortic repair for a suitable lesion in distal aortic dissection, some selected patients with type A aortic dissection at high surgical may be candidates. Hence, there is potential because, in proximal (Stanford type A) dissections, 10-30% of patients are not accepted for surgery, and 30-50% are technically amenable for TEVAR. Recent experience has shown that carefully selected patients with favorable anatomical characteristics may be subject to endovascular stent-graft treatment as a last resort with mixed results. Technical improvement is necessary to offer. satisfactory endovascular options in non-surgical candidates.
开放手术仍然是急性A型主动脉夹层治疗的主要手段，应为大多数患者提供该治疗方式。然而，有部分老年患者，其手术治疗可能被认为风险极高或徒劳无益。血管内治疗方法已应用于少数这类患者，相关数据仅限于病例报告和小样本系列研究。目前，升主动脉血管内治疗的应用受到升主动脉动态运动以及重要结构与预期着陆区（主动脉瓣、冠状动脉和主动脉弓上分支）距离较近所带来的解剖学和技术挑战的限制，并且缺乏专门设计的腔内移植物来解决这些问题。虽然胸主动脉腔内修复术（TEVAR）已取代开放主动脉修复术用于治疗合适的远端主动脉夹层病变，但一些手术风险高的A型主动脉夹层特定患者可能是TEVAR的候选对象。因此，存在潜力，因为在近端（斯坦福A型）夹层中，10% - 30%的患者不适合接受手术，30% - 50%的患者在技术上适合TEVAR。最近的经验表明，经过精心挑选、具有有利解剖特征的患者可能作为最后手段接受血管内支架移植物治疗，结果不一。需要技术改进以提供令人满意的血管内治疗选择给非手术候选患者。
