Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
J Vasc Surg. 2024 Aug;80(2):323-335. doi: 10.1016/j.jvs.2024.03.026. Epub 2024 Mar 25.
Aortic dissection is common in patients undergoing open surgical repair of thoracoabdominal aortic aneurysms (TAAAs). Most often, dissection is chronic and is associated with progressive aortic dilatation. Because contemporary outcomes in chronic dissection are not clearly understood, we compared patient characteristics and outcomes after open TAAA repair between patients with chronic dissection and those with non-dissection aneurysm.
We retrospectively analyzed data from 3470 open TAAA repairs performed in a single practice. Operations were for non-dissection aneurysm in 2351 (67.8%) and chronic dissection in 1119 (32.2%). Outcomes included operative mortality and adverse events, a composite variable comprising operative death and persistent (present at discharge) stroke, paraplegia, paraparesis, and renal failure necessitating dialysis. Logistic regression identified predictors of operative mortality and adverse events. Time-to-event analyses examined survival, death, repair failure, subsequent progressive repair, and survival free of failure or subsequent repair.
Compared with patients with non-dissection aneurysm, those with chronic dissection were younger, had fewer atherosclerotic risk factors, and were more likely to have heritable thoracic aortic disease and undergo extent II repair. The operative mortality rate was 8.5% (n = 296) overall and was higher in non-dissection aneurysm patients (n = 217; 9.2%) than in chronic dissection patients (n = 79; 7.1%; P = .03). Adverse events were less frequent (P = .01) in patients with chronic dissection (n = 145; 13.0%), 22 (2.0%) of whom had persistent paraplegia. Chronic dissection was not predictive of operative mortality (P = .5) or adverse events (P = .6). Operative mortality and adverse events, respectively, were independently predicted by emergency repair (odds ratio [OR], 3.46 and 2.87), chronic kidney disease (OR, 1.74 and 1.81), extent II TAAA repair (OR, 1.44 and 1.73), increasing age (OR, 1.04/year and 1.04/year), and increasing aortic cross-clamp time (OR, 1.02/minutes and 1.02/minutes). Patients with chronic dissection had lower 10-year unadjusted mortality (42% vs 69%) but more frequent repair failure (5% vs 3%) and subsequent repair for progressive aortic disease (11% vs 5%) than patients with non-dissection aneurysm (P < .001); these differences were no longer statistically significant after adjustment.
Outcomes of open TAAA repair vary by aortic disease type. Emergency repairs and atherosclerotic diseases most commonly occur in patients with non-dissection aneurysm and independently predict operative mortality. Repair of chronic dissection is associated with low rates of adverse events, including operative mortality and persistent paraplegia, along with reasonable late survival and good durability. However, patients with chronic dissection tend to more commonly undergo subsequent repair to treat progressive aortic disease, which emphasizes the need for robust long-term imaging surveillance protocols.
主动脉夹层在接受胸腹主动脉瘤（TAAA）开放手术修复的患者中很常见。大多数情况下，夹层是慢性的，与主动脉进行性扩张有关。由于目前对慢性夹层的结果尚不清楚，我们比较了慢性夹层和非夹层动脉瘤患者接受开放 TAAA 修复后的患者特征和结果。
我们回顾性分析了在一个实践中进行的 3470 例开放 TAAA 修复的数据。手术为非夹层动脉瘤 2351 例（67.8%），慢性夹层 1119 例（32.2%）。结果包括手术死亡率和不良事件，不良事件是指手术死亡和持续性（出院时存在）中风、截瘫、不全截瘫和需要透析的肾衰竭的复合变量。Logistic 回归确定了手术死亡率和不良事件的预测因素。时间事件分析检查了生存、死亡、修复失败、随后的渐进性修复以及无失败或随后修复的生存。
与非夹层动脉瘤患者相比，慢性夹层患者更年轻，有较少的动脉粥样硬化危险因素，并且更可能患有遗传性胸主动脉疾病并进行 II 型修复。总的手术死亡率为 8.5%（n=296），非夹层动脉瘤患者（n=217；9.2%）高于慢性夹层患者（n=79；7.1%；P=0.03）。慢性夹层患者不良事件发生率较低（P=0.01）（n=145；13.0%），其中 22 例（2.0%）存在持续性截瘫。慢性夹层并不预示手术死亡率（P=0.5）或不良事件（P=0.6）。手术死亡率和不良事件分别独立地由急诊修复（比值比[OR]，3.46 和 2.87）、慢性肾脏病（OR，1.74 和 1.81）、II 型 TAAA 修复（OR，1.44 和 1.73）、年龄增加（OR，每年 1.04/年和每年 1.04/年）和主动脉阻断时间增加（OR，每增加 1 分钟 1.02/分钟和 1.02/分钟）预测。慢性夹层患者的 10 年未调整死亡率较低（42% vs 69%），但修复失败率较高（5% vs 3%），随后因进行性主动脉疾病进行修复的频率也较高（11% vs 5%），而非夹层动脉瘤患者（P<0.001）；在调整后，这些差异不再具有统计学意义。
开放 TAAA 修复的结果因主动脉疾病类型而异。非夹层动脉瘤患者最常发生紧急修复和动脉粥样硬化疾病，这独立预测手术死亡率。慢性夹层的修复与不良事件发生率低相关，包括手术死亡率和持续性截瘫，以及合理的晚期生存率和良好的耐久性。然而，慢性夹层患者往往更常进行随后的修复以治疗进行性主动脉疾病，这强调了需要强有力的长期影像学监测方案。
