Crawford E S, Crawford J L, Safi H J, Coselli J S
Ann Thorac Surg. 1985 Nov;40(5):439-55. doi: 10.1016/s0003-4975(10)60099-9.
Sixty-seven operations were performed in 59 patients for aneurysmal disease occurring after previous operations involving the ascending aorta and transverse aortic arch. The initial aortic pathological condition included the following: fusiform aneurysm due to medial degenerative disease in 34 patients, 12 of whom had Marfan's syndrome; aortic dissection in a previously undilated aorta in 23; and aneurysm persisting or occurring after brachiocephalic bypass in 2. One of the latter had an aneurysm because of aortitis. Various operations initially performed did not completely treat the disease, and certain complications occurred spontaneously, including infection and dissection. The residual pathological condition led to the development of aortic insufficiency, aortic dissection, coronary artery insufficiency, and progressive aneurysmal dilatation. These complications were treated by composite valve graft replacement of the aortic valve and ascending aorta or the transverse aortic arch or both, simple aortic valve replacement, graft replacement of the ascending aorta or arch or both, and suture of false aneurysm with viable tissue wrap. Twenty patients (34%) had an aneurysm of the distal aorta. The entire aorta was replaced in 3, thoracoabdominal segments in 9, and the abdominal aorta in 1. Of the 59 patients, 49 (83%) were early survivors and 40 (68%) were alive on January 1, 1985. Principles of therapy that may have prevented the complications leading to reoperation include aneurysm replacement at the time of aortic valve replacement and coronary artery bypass; total replacement of the ascending aorta and aortic valve in patients with Marfan's syndrome; the same procedure or aortic valve replacement and separate graft replacement in patients with non-Marfan's medial degenerative disease; ascending aortic replacement in all patients with dissection combined with valve resuspension, aortic valve replacement, or composite valve graft depending on the involvement of the aortic sinuses and the presence of aortic insufficiency.
59例患者共接受了67次手术，以治疗既往升主动脉和主动脉弓手术后继发的动脉瘤性疾病。最初的主动脉病理状况如下：34例患者因中层退行性病变导致梭形动脉瘤，其中12例患有马方综合征；23例患者在先前未扩张的主动脉中发生主动脉夹层；2例患者在头臂旁路术后动脉瘤持续存在或新发，其中1例因主动脉炎导致动脉瘤。最初进行的各种手术未能完全治愈疾病，且出现了一些自发并发症，包括感染和夹层。残留的病理状况导致主动脉瓣关闭不全、主动脉夹层、冠状动脉供血不足和动脉瘤进行性扩张。这些并发症通过主动脉瓣和升主动脉或主动脉弓或两者的复合瓣膜移植置换、单纯主动脉瓣置换、升主动脉或弓或两者的移植置换以及用活组织包裹缝合假性动脉瘤来治疗。20例患者（34%）存在主动脉远端动脉瘤。3例患者接受了全主动脉置换，9例患者接受了胸腹段主动脉置换，1例患者接受了腹主动脉置换。59例患者中，49例（83%）为早期幸存者，40例（68%）在1985年1月1日仍存活。可能预防导致再次手术的并发症的治疗原则包括在主动脉瓣置换和冠状动脉搭桥时进行动脉瘤置换；马方综合征患者进行升主动脉和主动脉瓣的全置换；非马方中层退行性病变患者进行相同手术或主动脉瓣置换及单独的移植置换；所有夹层患者进行升主动脉置换，并根据主动脉窦的受累情况和主动脉瓣关闭不全的存在情况，联合瓣膜悬吊、主动脉瓣置换或复合瓣膜移植。
