Martens Andreas, Beckmann Erik, Kaufeld Tim, Arar Morsi, Natanov Ruslan, Fleissner Felix, Korte Wilhelm, Krueger Heike, Boethig Dietmar, Haverich Axel, Shrestha Malakh
Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
J Thorac Cardiovasc Surg. 2024 Aug;168(2):477-487.e9. doi: 10.1016/j.jtcvs.2023.01.014. Epub 2023 Jan 23.
The frozen elephant trunk is a standard treatment method for aortic arch pathologies extending into the descending aorta. We previously described the phenomenon of early postoperative intraluminal thrombosis within the frozen elephant trunk. We investigated the features and predictors of intraluminal thrombosis.
A total of 281 patients (66% male, mean age 60 ± 12 years) underwent frozen elephant trunk implantation between May 2010 and November 2019. In 268 patients (95%), early postoperative computed tomography angiography was available to assess intraluminal thrombosis.
The incidence of intraluminal thrombosis after frozen elephant trunk implantation was 8.2%. Intraluminal thrombosis was diagnosed early after the procedure (4.6 ± 2.9 days) and could be successfully treated with anticoagulation in 55% of patients. A total of 27% developed embolic complications. Mortality (27% vs 11%, P = .044) and morbidity were significantly higher in patients with intraluminal thrombosis. Our data showed a significant association of intraluminal thrombosis with prothrombotic medical conditions and anatomic slow flow features. The incidence of heparin-induced thrombopenia was higher in patients with intraluminal thrombosis (18% vs 3.3%, P = .011). Stent-graft diameter index, anticipated endoleak Ib, and degenerative aneurysm were significant independent predictors of intraluminal thrombosis. Therapeutic anticoagulation was a protective factor. Glomerular filtration rate, extracorporeal circulation time, postoperative rethoracotomy, and intraluminal thrombosis (odds ratio, 3.19, P = .047) were independent predictors of perioperative mortality.
Intraluminal thrombosis is an underrecognized complication after frozen elephant trunk implantation. In patients with risk factors of intraluminal thrombosis indication for frozen elephant trunk should be carefully evaluated and postoperative anticoagulation considered. Early thoracic endovascular aortic repair extension should be considered in patients with intraluminal thrombosis to prevent embolic complications. Stent-graft designs should be improved to prevent intraluminal thrombosis after frozen elephant trunk implantation.
冷冻象鼻技术是治疗累及降主动脉的主动脉弓病变的标准方法。我们之前描述过冷冻象鼻术后早期腔内血栓形成的现象。我们研究了腔内血栓形成的特征及预测因素。
2010年5月至2019年11月期间，共有281例患者（66%为男性，平均年龄60±12岁）接受了冷冻象鼻植入术。268例患者（95%）术后早期接受了计算机断层扫描血管造影以评估腔内血栓形成情况。
冷冻象鼻植入术后腔内血栓形成的发生率为8.2%。腔内血栓形成在术后早期被诊断出来（4.6±2.9天），55%的患者通过抗凝治疗成功治愈。共有27%的患者发生了栓塞并发症。腔内血栓形成患者的死亡率（27%对11%，P = 0.044）和发病率显著更高。我们的数据显示腔内血栓形成与血栓形成倾向的内科疾病及解剖学上的血流缓慢特征显著相关。腔内血栓形成患者肝素诱导的血小板减少症的发生率更高（18%对3.3%，P = 0.011）。支架移植物直径指数、预期的Ⅰb型内漏及退行性动脉瘤是腔内血栓形成的显著独立预测因素。治疗性抗凝是一个保护因素。肾小球滤过率、体外循环时间、术后再次开胸及腔内血栓形成（比值比，3.19，P = 0.047）是围手术期死亡率的独立预测因素。
腔内血栓形成是冷冻象鼻植入术后一种未被充分认识的并发症。对于有腔内血栓形成危险因素的患者，应仔细评估冷冻象鼻植入的指征并考虑术后抗凝。对于腔内血栓形成的患者，应考虑早期进行胸段血管腔内主动脉修复术以预防栓塞并发症。应改进支架移植物设计以预防冷冻象鼻植入术后腔内血栓形成。
