de Oliveira Marreiros Delano J, Arabkhani Bardia, Verhoef Jos L, Keekstra Niels, van der Vorst Joost R, van Schaik Jan, Braun Jerry, Klautz Robert J M, Groenwold Rolf H H, Hjortnaes Jesper
Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands.
Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands.
JTCVS Open. 2024 Dec 4;23:69-80. doi: 10.1016/j.xjon.2024.11.014. eCollection 2025 Feb.
Optimal surgical management of the aortic arch for acute type A aortic dissection remains contentious. We assessed clinical outcomes after total arch replacement and proximal aortic repair (ascending aortic ± hemiarch replacement) for acute type A aortic dissection.
All patients surgically treated for acute type A aortic dissection at our institution between 1992 and 2021 were included. Study end points included all-cause mortality, distal aortic reintervention, stroke, and malperfusion syndrome.
A total of 357 patients underwent surgery for acute type A aortic dissection; 76 (21.3%) received total arch replacement, and 281 (78.7%) received proximal aortic repair. The frequency of total arch replacement increased over time (01). In-hospital mortality was higher for total arch replacement between 1992 and 2009 (39.2% vs 20.3%, 03), but became more comparable to proximal aortic repair from 2010 onward (16.7% vs 13.0%, 53). For total arch replacement and proximal aortic repair, 10-year cumulative survival was 64.3% (95% CI, 52.3-76.2) and 54.3% (95% CI, 47.6-61.0), respectively. After initial 30-day postoperative survival, long-term mortality risk appeared lower for total arch replacement (hazard ratio, 0.49, 95% CI, 0.23-1.07), although not statistically significant. No significant differences in distal aortic reinterventions were observed (hazard ratio, 1.38; 95% CI, 0.67-2.82). The incidence of in-hospital stroke (17.1% vs 17.1%, = 1.00) and malperfusion syndrome (28.9% vs 28.2%, = .90) was comparable between both groups.
In-hospital mortality after acute type A aortic dissection decreased over time despite the implementation of an aggressive approach to the dissected aortic arch. Long-term survival appears favorable after total arch replacement, but remains contingent on early postoperative survival. The surgical approach should be based on the patient's clinical presentation, while considering total arch replacement in patients at risk of aortic arch reinterventions.
急性A型主动脉夹层的主动脉弓最佳手术管理仍存在争议。我们评估了急性A型主动脉夹层全弓置换和近端主动脉修复（升主动脉±半弓置换）后的临床结果。
纳入1992年至2021年间在我院接受急性A型主动脉夹层手术治疗的所有患者。研究终点包括全因死亡率、远端主动脉再次干预、中风和灌注不良综合征。
共有357例患者接受了急性A型主动脉夹层手术；76例（21.3%）接受了全弓置换，281例（78.7%）接受了近端主动脉修复。全弓置换的频率随时间增加（01）。1992年至2009年间，全弓置换的住院死亡率较高（39.2%对20.3%，03），但从2010年起与近端主动脉修复的死亡率更接近（16.7%对13.0%，53）。对于全弓置换和近端主动脉修复，10年累积生存率分别为64.3%（95%CI，52.3 - 76.2）和54.3%（95%CI，47.6 - 61.0）。术后最初30天存活后，全弓置换的长期死亡风险似乎较低（风险比，0.49，95%CI，0.23 - 1.07），尽管无统计学意义。远端主动脉再次干预未观察到显著差异（风险比，1.38；95%CI，0.67 - 2.82）。两组住院中风发生率（17.1%对17.1%，= 1.00）和灌注不良综合征发生率（28.9%对28.2%，= 0.90）相当。
尽管对夹层主动脉弓采取了积极的治疗方法，但急性A型主动脉夹层后的住院死亡率随时间下降。全弓置换后长期生存率似乎良好，但仍取决于术后早期存活情况。手术方法应基于患者的临床表现，同时考虑对有主动脉弓再次干预风险的患者进行全弓置换。
