Carrel T, Pasic M, Jenni R, Tkebuchava T, Turina M I
Clinic for Cardiovascular Surgery, University Hospital Zürich, Switzerland.
Ann Thorac Surg. 1993 Aug;56(2):259-68; discussion 269. doi: 10.1016/0003-4975(93)91157-i.
Recurrent aortic aneurysms, persistent or new dissection, new onset of valvular and coronary artery disease, graft infection, and prosthetic endocarditis are not rare after thoracic aortic operations; they can be difficult to diagnose and represent a formidable surgical challenge. Between 1977 and 1991, 876 operations were performed on the thoracic aorta in our institution: 340 in dissections, 299 in true aneurysms, 150 for aortic remodeling and external wall support during aortic valve replacement, and 87 for miscellaneous causes. During the same period, there were 193 additional reoperations. Vascular reoperations on abdominal aorta and peripheral arteries accounted for 73 cases and are not further discussed in this study. The reasons for reoperation (n = 130) in 120 patients were: failure of biologic valves (n = 23); aneurysm recurrence in a proximal or distal aortic segment (n = 21); pseudoaneurysm formation at suture lines (n = 13); new dissection or dilatation involving ascending aorta (n = 11), aortic arch (n = 13), and descending aorta (n = 10); aneurysm after aortic remodeling (n = 13); new onset of valvular disease (n = 5); and new onset of coronary disease (n = 5). Infected aortic graft and prosthetic endocarditis accounted for 10 reoperations, and a planned two-staged procedure was performed in 6 patients. Omitting the failed biologic valves, reoperations were performed on the aortic segment previously operated on in 69.3% of the cases and on other thoracic segments in 30.7%. Overall hospital mortality rate after reoperation was 5.8%. A significant decrease in operative mortality was observed in the most recent period (3.0% between 1989 and 1991). Reoperations are technically demanding, and some of them are preventable; therefore (1) graft inclusion technique should be abandoned in ascending aortic operation due to formation of false aneurysms; (2) in patients with Marfan syndrome, complete repair of the diseased aorta should be attempted during the initial operation; (3) aortic arch dissection should be repaired definitively during the first operation in low-risk patients; (4) biological valves should be avoided in aneurysm operations; and (5) homograft replacement is the treatment of choice in prosthetic endocarditis or in infected composite graft after an aortic valve or ascending aortic operation.
复发性主动脉瘤、持续性或新发夹层、瓣膜和冠状动脉疾病的新发、移植物感染以及人工瓣膜心内膜炎在胸主动脉手术后并不罕见；它们可能难以诊断，并且是一项艰巨的外科挑战。1977年至1991年期间，我们机构对胸主动脉进行了876例手术：340例为夹层手术，299例为真性动脉瘤手术，150例为主动脉瓣置换期间的主动脉重塑和外壁支撑手术，87例为其他原因手术。同期，还有193例再次手术。腹主动脉和外周动脉的血管再次手术占73例，本研究不再进一步讨论。120例患者再次手术的原因（n = 130）为：生物瓣膜功能衰竭（n = 23）；主动脉近端或远端节段动脉瘤复发（n = 21）；缝合线处假性动脉瘤形成（n = 13）；累及升主动脉（n = 11）、主动脉弓（n = 13）和降主动脉（n = 10）的新发夹层或扩张；主动脉重塑后动脉瘤（n = 13）；瓣膜疾病新发（n = 5）；冠状动脉疾病新发（n = 5）。感染性主动脉移植物和人工瓣膜心内膜炎占10例再次手术，6例患者进行了计划性两阶段手术。不包括功能衰竭的生物瓣膜，69.3%的病例在先前手术的主动脉节段进行了再次手术，30.7%的病例在其他胸段进行了再次手术。再次手术后的总体医院死亡率为5.8%。在最近时期观察到手术死亡率显著下降（1989年至1991年期间为3.0%）。再次手术技术要求高，其中一些是可以预防的；因此，（1）由于假性动脉瘤形成，升主动脉手术应放弃移植物植入技术；（2）对于马方综合征患者，初次手术时应尝试对病变主动脉进行完全修复；（3）低风险患者的主动脉弓夹层应在首次手术时进行确定性修复；（4）动脉瘤手术应避免使用生物瓣膜；（5）同种异体移植物置换是人工瓣膜心内膜炎或主动脉瓣或升主动脉手术后感染复合移植物的首选治疗方法。
