Shah Aakash, Robinson Justin, Chahal Diljan, Kang Jeanwan, Toursavadkohi Shahab, Taylor Bradley S, Ghoreishi Mehrdad
Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Md.
Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Md.
J Thorac Cardiovasc Surg. 2025 Sep;170(3):650-658.e1. doi: 10.1016/j.jtcvs.2024.12.031. Epub 2025 Jan 15.
More than 30% of patients presenting with acute type A aortic dissection are considered high risk or inoperable. This study aims to investigate the early and midterm outcomes of complex endovascular aortic repair of aortic root, ascending aorta, and aortic arch among patients with acute type A aortic dissection.
From January 2018 to January 2023, 29 patients who were considered high risk for open operation underwent endovascular aortic repair. Patients were considered high risk because of frailty (n = 14), severe malperfusion (n = 5), chronic obstructive pulmonary disease and on home oxygen (n = 4), frozen chest (n = 3), metastatic cancer (n = 3), ejection fraction <20% (n = 4), and cirrhosis (n = 2). For an isolated tear in the ascending aorta (zone 0), ascending stent graft placement was performed using commercially available aortic stent grafts. For patients with a tear in the aortic root, Endo-Bentall was performed using a physician-modified modular device composed of a self-expanding transcatheter aortic valve incorporated inside an aortic stent graft. For patients with a tear in the ascending aorta as well as the aortic arch (zone 0, zone 1, 2), ascending stent graft placement and endovascular arch repair was performed. Follow-up electrocardiogram-gated computed tomography was performed to evaluate aortic remodeling.
The mean age for this cohort was 76.3 ± 11.1 years. Endovascular repairs included isolated ascending stent placement in 65.5% (19/29), endo-Bentall in 6.9% (2/29), endo-Bentall plus endo arch in 6.9% (2/29), and ascending thoracic endovascular repair + endo arch in 20.7% (6/29). The operative mortality was 10.3% (3/29). Stroke rate was 10.3% (3/29). During the follow-up time of a median of 6.25 months (range, 0.85-64.6 months), an endoleak was observed in 42.3% (11/26) patients (80% among patients with a tear <2 cm of sinotubular junction). Seven patients had a type 1a endoleak, whereas 4 patients had a type 1b endoleak on follow-up computed tomography angiography. Three patients required reintervention. The Kaplan-Meier 5-year probability of survival for the entire cohort post-intervention was 35%.
Early outcomes of complex endovascular repair of ascending aortic dissection are promising with acceptable mortality and stroke rate. However, the rate of endoleak after isolated ascending thoracic endovascular repair with a tear within 2 cm of the aortic root is high with poor long-term survival.
超过30%的急性A型主动脉夹层患者被认为是高危或无法手术的。本研究旨在调查急性A型主动脉夹层患者中主动脉根部、升主动脉和主动脉弓复杂血管腔内主动脉修复的早期和中期结果。
2018年1月至2023年1月，29例被认为开放手术高危的患者接受了血管腔内主动脉修复。患者因身体虚弱（n = 14）、严重灌注不良（n = 5）、慢性阻塞性肺疾病且在家吸氧（n = 4）、冻结胸（n = 3）、转移性癌症（n = 3）、射血分数<20%（n = 4）和肝硬化（n = 2）而被认为是高危患者。对于升主动脉孤立性撕裂（0区），使用市售主动脉覆膜支架进行升主动脉覆膜支架置入。对于主动脉根部撕裂的患者，使用由置于主动脉覆膜支架内的自膨胀经导管主动脉瓣膜组成的医生改良模块化装置进行Endo-Bentall手术。对于升主动脉和主动脉弓均有撕裂的患者（0区、1区、2区），进行升主动脉覆膜支架置入和血管腔内主动脉弓修复。进行随访心电图门控计算机断层扫描以评估主动脉重塑。
该队列的平均年龄为76.3±11.1岁。血管腔内修复包括65.5%（19/29）的孤立升主动脉支架置入、6.9%（2/29）的Endo-Bentall手术、6.9%（2/29）的Endo-Bentall加血管腔内主动脉弓修复以及20.7%（6/29）的胸段升主动脉血管腔内修复+血管腔内主动脉弓修复。手术死亡率为10.3%（3/29）。卒中发生率为10.3%（3/29）。在中位随访时间6.25个月（范围0.85 - 64.6个月）内，42.3%（11/26）的患者观察到内漏（在窦管交界撕裂<2 cm的患者中占80%）。7例患者随访计算机断层扫描血管造影显示为1a型内漏，4例为1b型内漏。3例患者需要再次干预。整个队列干预后5年的Kaplan-Meier生存概率为35%。
升主动脉夹层复杂血管腔内修复的早期结果令人鼓舞，死亡率和卒中发生率可接受。然而，主动脉根部2 cm内有撕裂的孤立胸段升主动脉血管腔内修复术后内漏发生率高，长期生存率低。
