Bachet J E, Termignon J L, Dreyfus G, Goudot B, Martinelli L, Piquois A, Brodaty D, Dubois C, Delentdecker P, Guilmet D
Service de Chirurgie Cardio-vasculaire, Hôpital Foch, Universite de Paris-Ouest, Suresnes, France.
J Thorac Cardiovasc Surg. 1994 Aug;108(2):199-205; discussion 205-6.
From January 1977 to September 1992, 143 patients underwent an emergency operation for type A acute aortic dissection. Because of the location of the intimal tear, the replacement of the ascending aorta was extended to the transverse arch in 42 patients (29.3%). One hundred ten patients (78%) survived the operation. During the same period, 32 patients had to be reoperated on once (n = 24) twice (n = 6), or three times (n = 2) for a total of 42 reoperations. Nineteen patients had had the initial repair in our institution, and 13 had been operated on elsewhere. Reoperation was indicated for aortic valve disease (n = 4), recurring dissection (n = 7) threatening aneurysmal evolution of a persisting dissection (n = 28), or false aneurysm (n = 3). The redo procedure involved the aortic root and/or ascending aorta in 15 cases (group I), the transverse arch alone in 7 cases (group II), the transverse arch and the descending aorta or the descending aorta alone in 10 cases (group III), or the thoracoabdominal aorta in 10 cases (group IV). The risk factors for reoperation have been analyzed in the 110 survivors initially operated on in our institution. Seven of 18 patients with Marfan's syndrome (38.8%) versus 12 of 92 without Marfan's syndrome (13%) were reoperated on (p = 0.023). None of the 30 patients surviving arch replacement at initial repair required a reoperation, versus 19 of 80 (23.7%) patients surviving a replacement limited to the ascending aorta (p = 0.013). The overall mortality rate of reoperation was 21.8% (7/32) with a risk of 16.6% (7/42) at each procedure (group I, 13.3%; group II, 0%; group III, 20%; group IV, 30%). Hospital mortality was influenced by emergency operation (5/10) (p < 0.005) and thoracoabdominal replacement (3/10) (p < 0.035). The late survivals after reoperation are 65.1% +/- 17.6% at 1 year and 55% +/- 19.63% at 5 years (Kaplan-Meier, confidence interval 95%). The late survivals, after the initial repair, of the patients undergoing reoperation are 89.6% +/- 11.0%, 79.3% +/- 14.7%, 53.9% +/- 18.1%, and 35.9% +/- 21.8% at 1, 5, 10, and 12 years, respectively. In conclusion, aortic dissection is an evolving process that may require one or several reoperations after the initial repair. At initial emergency operation, the resection of the entry site, when located on or extending to the transverse arch, has reduced the risk of reoperation, in our experience. Elective reoperation must be considered before the occurrence of complications, especially in patients with Marfan's syndrome.(ABSTRACT TRUNCATED AT 400 WORDS)
1977年1月至1992年9月，143例患者因A型急性主动脉夹层接受了急诊手术。由于内膜撕裂的位置，42例患者（29.3%）的升主动脉置换延伸至横弓。110例患者（78%）术后存活。同期，32例患者因各种原因接受了再次手术，其中24例接受1次再次手术，6例接受2次再次手术，2例接受3次再次手术，共进行了42次再次手术。19例患者在本机构接受了初次修复，13例在其他地方接受了手术。再次手术的指征包括主动脉瓣疾病（4例）、复发性夹层（7例）、持续夹层的动脉瘤样演变（28例）或假性动脉瘤（3例）。再次手术过程中，15例涉及主动脉根部和/或升主动脉（I组），7例仅涉及横弓（II组），10例涉及横弓和降主动脉或仅降主动脉（III组），10例涉及胸腹主动脉（IV组）。对本机构初次手术的110例存活患者的再次手术风险因素进行了分析。18例马凡综合征患者中有7例（38.8%）接受了再次手术，而92例非马凡综合征患者中有12例（13%）接受了再次手术（p = 0.023）。初次修复时接受弓部置换的30例存活患者均无需再次手术，而仅接受升主动脉置换的80例患者中有19例（23.7%）需要再次手术（p = 0.013）。再次手术的总体死亡率为(7/32)21.8%，每次手术的风险为(7/42)16.6%（I组13.3%；II组0%；III组20%；IV组30%）。医院死亡率受急诊手术（5/10）（p < 0.005）和胸腹主动脉置换（3/10）（p < 0.035）影响。再次手术后1年的晚期生存率为65.1%±17.6%，5年为55%±19.63%（Kaplan-Meier法，95%置信区间）。初次修复后接受再次手术的患者在1年、5年、10年和12年的晚期生存率分别为89.6%±11.0%、79.3%±14.7%、53.9%±18.1%和35.9%±21.8%。总之，主动脉夹层是一个动态演变的过程，初次修复后可能需要一次或多次再次手术。根据我们的经验，在初次急诊手术时，当入口部位位于或延伸至横弓时，切除该部位可降低再次手术的风险。在并发症出现之前，尤其是马凡综合征患者，必须考虑择期再次手术。（摘要截断于400字）
