Iba Yutaka, Nakajima Tomohiro, Nakazawa Junji, Shibata Tsuyoshi, Miura Shuhei, Kawaharada Nobuyoshi
Department of Cardiovascular Surgery, Sapporo Medical University, Sapporo, Hokkaido, Japan.
EJVES Vasc Forum. 2024 Dec 31;63:32-40. doi: 10.1016/j.ejvsvf.2024.12.001. eCollection 2025.
Thoracic endovascular aortic repair (TEVAR) is widely used in thoracic aortic surgery. However, for various reasons some patients require secondary open aortic repair. Herein, the surgical outcomes and problems of such open conversion surgery after TEVAR are investigated.
This was a retrospective and observational study. From January 2010 to June 2022, 20 patients who underwent open aortic repair after TEVAR were included. The indications for open conversion surgery were as follows: aortic enlargement due to endoleak (EL) in seven patients (type Ia: = 4, type II: = 1, type V: = 2; 35%), stent graft infection including aorto-oesophageal fistula (AEF) in six (30%), retrograde type A aortic dissection (RTAD) in three (15%), and dilatation of adjacent distal aorta or false lumen in four (20%).
Seven patients with type Ia EL or RTAD required open aortic arch repair. Four underwent thoraco-abdominal aortic repair for distal aortic enlargement. Descending thoracic aortic replacement was performed in all six infection cases and two patients with type V EL. Furthermore, three patients with AEF received concomitant oesophagectomy. One patient with persistent type II EL underwent intercostal artery ligation and aneurysmorrhaphy via thoracotomy. There were two in hospital deaths (10%), all with AEF. Thus, the rates of in hospital death were 0% in non-infected cases, 33% in graft infections, with 66% in those with AEF. Stroke and paraplegia were observed in two patients (10%).
When open conversion surgery is required after TEVAR, the indications are complex, often associated with infectious pathology, and are necessarily high risk particularly in patients with AEF. Surgical strategy has to be individualised based on the nature or cause of the complication and extent of aortic involvement.
胸主动脉腔内修复术（TEVAR）在胸主动脉手术中被广泛应用。然而，由于各种原因，一些患者需要进行二次开放性主动脉修复。在此，对TEVAR术后这种开放性转换手术的手术结果及问题进行研究。
这是一项回顾性观察研究。纳入2010年1月至2022年6月期间接受TEVAR术后开放性主动脉修复的20例患者。开放性转换手术的指征如下：7例患者因内漏（EL）导致主动脉扩张（Ia型：=4例，II型：=1例，V型：=2例；35%），6例（30%）为支架移植物感染，包括主动脉-食管瘘（AEF），3例（15%）为逆行A型主动脉夹层（RTAD），4例（20%）为相邻远端主动脉扩张或假腔。
7例Ia型EL或RTAD患者需要进行开放性主动脉弓修复。4例因远端主动脉扩张接受胸腹主动脉修复。所有6例感染病例和2例V型EL患者均进行了降主动脉置换。此外，3例AEF患者同时接受了食管切除术。1例持续性II型EL患者通过开胸进行肋间动脉结扎和动脉瘤缝合术。住院死亡2例（10%），均为AEF患者。因此，非感染病例的住院死亡率为0%，移植物感染病例为33%，AEF患者为66%。2例患者（10%）出现中风和截瘫。
TEVAR术后需要进行开放性转换手术时，指征复杂，常与感染性病变相关，尤其是AEF患者，必然具有高风险。手术策略必须根据并发症的性质或原因以及主动脉受累程度进行个体化制定。
