Okita Y, Takamoto S, Ando M, Morota T, Yamaki F, Kawashima Y, Nakajima N
Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan.
Eur J Cardiothorac Surg. 1996;10(9):784-90. doi: 10.1016/s1010-7940(96)80340-x.
This study reports surgical experience of 72 cases of aortic dissection with intimal tear in the transverse aortic arch.
Of 325 patients with aortic dissection, 72 (22.2%) had a tear in the arch, including 27 with acute dissection and 45 with chronic dissection. Mean age at surgery was 60.8 +/- 14.1 years. The dissection was localized from the ascending aorta to the arch in 30 patients and extensive from the ascending aorta to the descending aorta in 42. Surgeries consisted of total arch replacement in 50 patients, hemiarch replacement in 20, and extra-anatomical bypass in 1. In the initial series, cardiopulmonary bypass for brain protection during arch procedures was selective cerebral perfusion (61 patients), but since July 1993 deep hypothermic circulatory arrest with retrograde cerebral perfusion was exclusively utilized (8 patients).
Hospital mortality was 9.7%, 11.1% of the patients who had acute dissection and 8.8% with chronic dissection. There has been no mortality since February 1993. The mean follow-up period was 51 +/- 37 months, and there were 3 late deaths. The 5 and 10 year survival rate was 85.3 +/- 4.8 in all patients, 84.3 +/- 8.9% with acute dissection, and 85.5 +/- 5.7% with chronic dissection. The 5 and 10 year survival was 79.8 +/- 7.1 with extensive dissection, and 93.5 +/- 6.5% with localized dissection. During follow-up, 6 patients underwent subsequent aortic surgeries. The freedom from reoperation at 5 years and at 10 years was 91.4 +/- 4.8% and 65.6 +/- 14.4%, respectively. In patients with acute dissection it was 92.3 +/- 7.4% and 61.5 +/- 25.6% at 5 years and 10 years, while with chronic dissection it was 87.0 +/- 7.0% and 44.0 +/- 17.3% at 5 years and 10 years, respectively (n.s.). The freedom from subsequent reoperation for the aorta in all patients was 91.4 +/- 4.8% at 5 years and 10 years was 65.6 +/- 14.4%. With acute dissection it was 92.3 +/- 7.4% at 5 years and 61.5 +/- 25.6% at 10 years, while that with chronic dissection it was 91.3 +/- 5.9% and 65.7 +/- 16.8% at 5 years and 10 years respectively (n.s.). The freedom from all reoperations with extensive dissection at 5 years and 10 years was 86.6% +/- 7.2% and 34.2 +/- 17.3%, respectively, moreover, the freedom from reoperations with localized dissection at 5 and at 10 years was 90.0 +/- 9.5% (n.s.). However, the freedom from subsequent aorta reoperation with extensive dissection at 5 years and 10 years was 86.6 +/- 7.2% and 56.0 +/- 16.0%, respectively, while with localized dissection it was 100% at 10 years (P < 0.01).
Early and late surgical result for arch dissection was satisfactory with a surgical principle of resecting the aortic segment that contains the initial intimal tear and graft replacement.
本研究报告72例升主动脉弓部内膜撕裂型主动脉夹层的外科治疗经验。
325例主动脉夹层患者中，72例（22.2%）升主动脉弓部有撕裂，其中急性夹层27例，慢性夹层45例。手术时平均年龄为60.8±14.1岁。夹层局限于升主动脉至主动脉弓者30例，累及升主动脉至降主动脉者42例。手术方式包括全弓置换50例，半弓置换20例，解剖外旁路1例。在最初阶段，主动脉弓部手术中用于脑保护的体外循环是选择性脑灌注（61例），但自1993年7月起，仅采用深低温停循环加逆行脑灌注（8例）。
住院死亡率为9.7%，急性夹层患者死亡率为11.1%，慢性夹层患者死亡率为8.8%。自1993年2月以来无死亡病例。平均随访时间为51±37个月，有3例晚期死亡。所有患者5年和10年生存率分别为85.3±4.8%，急性夹层患者为84.3±8.9%，慢性夹层患者为85.5±5.7%。广泛型夹层患者5年和10年生存率为79.8±7.1%，局限型夹层患者为93.5±6.5%。随访期间，6例患者接受了再次主动脉手术。5年和10年免于再次手术的比例分别为91.4±4.8%和65.6±14.4%。急性夹层患者5年和10年分别为92.3±7.4%和61.5±25.6%，慢性夹层患者5年和10年分别为87.0±7.0%和44.0±17.3%（无显著性差异）。所有患者5年和10年免于主动脉再次手术的比例分别为91.4±4.8%和65.6±14.4%。急性夹层患者5年为92.3±7.4%，10年为61.5±25.6%，慢性夹层患者5年和10年分别为91.3±5.9%和65.7±16.8%（无显著性差异）。广泛型夹层患者5年和10年免于所有再次手术的比例分别为86.6%±7.2%和34.2±17.3%，局限型夹层患者5年和10年免于再次手术的比例为90.0±9.5%（无显著性差异）。然而，广泛型夹层患者5年和10年免于主动脉再次手术的比例分别为86.6±7.2%和56.0±16.0%，局限型夹层患者10年为100%（P<0.01）。
主动脉弓部夹层的早期和晚期手术效果满意，手术原则是切除包含初始内膜撕裂的主动脉段并进行人工血管置换。
