Ohira Suguru, Malekan Ramin, Kai Masashi, Tavolacci Sooyun Caroline, Gregory Vasiliki, Shimamura Junichi, Laskowski Igor, Lansman Steven L, Spielvogel David
Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY.
New York Medical College, Valhalla, NY.
JTCVS Tech. 2025 Mar 28;31:1-10. doi: 10.1016/j.xjtc.2025.03.015. eCollection 2025 Jun.
We sought to review the outcomes of our arch-first total aortic arch repair (TAR) using a trifurcated graft after previous acute type A aortic dissection (ATAD) repair.
From February 2006 to June 2024, 62 patients underwent reoperative TAR after ATAD repair. The first-stage TAR includes axillary artery cannulation, minimal dissection without aortic crossclamping, myocardial protection using systemic potassium and retrograde blood cardioplegia, an arch-first technique with deep hypothermia (20 °C), and construction of a classical elephant trunk through a partial transverse incision distally or proximally to old distal aortic anastomosis.
The median age at reoperative TAR was 63.5 years. The median interval from initial ATAD repair to reoperative TAR was 3 years. A concomitant procedure was performed in 20 patients (32.3%). The median cardiopulmonary bypass and lower body circulatory arrest times were 227.5 and 97 minutes, respectively. Operative mortality was 1.6% (n = 1/62), as was the incidence of stroke (1.6%) and renal-replacement therapy (3.2%). Stage II repair was performed or planned in 49 patients (open repair [above the celiac axis in most patients], n = 42; endovascular, n = 3; endovascular converted to open repair, n = 2; and waiting for repair, n = 2). Median interval between staged procedures was 63 days [interquartile range, 36, 134]. Mortality of stage II procedure was 4.3% (n = 2/47) with no spinal cord injury. Kaplan-Meier analysis showed that estimated survival at 5 years was 82.7 ± 6.7%.
Our reoperative TAR is safe in the setting of residual dissection that minimizes dissection of the cardiac structures, simplifies the distal anastomosis, and protects vital organs.
我们试图回顾在先前急性A型主动脉夹层（ATAD）修复术后使用三分叉移植物进行先弓部全主动脉弓修复（TAR）的结果。
2006年2月至2024年6月，62例患者在ATAD修复术后接受再次手术TAR。一期TAR包括腋动脉插管、不进行主动脉阻断的最小限度分离、使用全身钾和逆行血液心脏停搏液进行心肌保护、采用深低温（20℃）的先弓部技术，以及通过在旧的远端主动脉吻合口远端或近端的部分横向切口构建经典象鼻。
再次手术TAR时的中位年龄为63.5岁。从初次ATAD修复到再次手术TAR的中位间隔时间为3年。20例患者（32.3%）进行了同期手术。中位体外循环和下半身循环停止时间分别为227.5分钟和97分钟。手术死亡率为1.6%（n = 1/62），卒中发生率（1.6%）和肾脏替代治疗发生率（3.2%）也是如此。49例患者进行了或计划进行二期修复（开放修复[大多数患者在腹腔干轴上方]，n = 42；血管腔内修复，n = 3；血管腔内修复转为开放修复，n = 2；等待修复，n = 2）。分期手术之间的中位间隔时间为63天[四分位间距，36, 134]。二期手术的死亡率为4.3%（n = 2/47），无脊髓损伤。Kaplan-Meier分析显示，5年时的估计生存率为82.7±6.7%。
我们的再次手术TAR在残余夹层情况下是安全的，可最大限度减少心脏结构的分离，简化远端吻合，并保护重要器官。
