Great vessel management for endovascular exclusion of aortic arch aneurysms and dissections.

OBJECTIVES: To evaluate a recent approach for the endovascular repair of thoracic aortic aneurysms and dissections involving the aortic arch in high risk patients (HRP). METHODS: Amongst 102 thoracic aortic aneurysms and dissections, we treated 25 patients for aortic arch endovascular exclusion after transposition of the great vessels, of which 14 (56%) had thoracic aortic arch aneurysms and 11 type A and B chronic aortic dissections. Total transpositions were done in 15 cases (60%) and hemi-arch transpositions in 10. We then used Talent, Excluder and Zenith endografts in 12, seven and six cases, respectively. RESULTS: Surgical transpositions were complicated by one minor stroke, which worsened to a major stroke (4%) after endovascular exclusion. After endovascular exclusions, two patients (8%) died from catheterization related complications. One patient had a delayed minor stroke (4%). The successful exclusion rate was 92%. During follow-up (15+/-5.8 months), one patient (4%) developed unilateral limb palsy, successfully treated by CSF drainage. The late exclusion rate remained 92%. No stent-related complications were seen. CONCLUSIONS: Transposition of supra-aortic vessels allows the endovascular exclusion of the aortic arch in HRP. Aortic endografting after surgical transposition proved to be feasible and offers good mid-term results. Specialized surgical centers with both endovascular and surgical expertise are required to treat these patients.     

Staged hybrid repair of thoracoabdominal aortic aneurysm after chronic type B aortic dissection

The purpose of this study was to evaluate clinical outcomes of combined endovascular and open techniques to eradicate false lumen dilatation in the visceral aortic segment after type B aortic dissection associated with aortic aneurysm. We reviewed eight patients with distal thoracic and abdominal false lumen dilatation treated with a staged procedure. These included arch debranching as needed, proximal thoracic endovascular repair, and open surgical correction with abdominal aortic replacement of the visceral and infrarenal aorta. False lumen eradication was successful in all patients. There were no operative deaths, and paraplegia or paraparesis occurred in two patients. During a mean follow-up of 30 months, no complications or secondary interventions were necessary. The thoracic false lumen remained thrombosed in all patients, with no evidence of aortic dilatation or stent graft complications. Complete thrombosis and eradication of the false lumen can be achieved through a three-stage repair of chronic type B aortic dissection with aneurysmal dilatation. A prospective randomized trial is needed to establish the viability of this approach versus standard open repair of type II thoracoabdominal aortic aneurysms.     

Novel technique: staged hybrid surgical and endovascular treatment of acute Type A aortic dissections with aortic arch involvement

AIM: The standard approach for treating acute Type A aortic dissections (TAD) is replacement of the ascending aorta utilizing hypothermic circulatory arrest (HCA), which is associated with significant morbidity and frequently leaves a residual aortic arch dissection. We describe a staged surgical and endovascular technique of ascending aorta replacement and simultaneous aorto-innominate artery bypass without HCA, followed 4 weeks later by carotid-carotid bypass and endovascular exclusion of the remaining arch dissection with a thoracic endograft. METHODS: From December 2004 to December 2005, 5 consecutive patients (mean age 58 +/- 6.9 years) with TADs underwent the staged procedure. All patients underwent replacement of the ascending aorta and aorto-innominate bypass. Two patients subsequently underwent the second endovascular stage. In one patient the aortic false lumen completely thrombosed following the first surgical stage and two patients are currently awaiting the endovascular stage. RESULTS: There were no major adverse events (death, cerebrovascular accident or paraplegia) following the first surgical stage. One patient suffered a transient minor stroke. The 2 patients who underwent the second endovascular stage showed no immediate adverse events. Postoperative CT scans have demonstrated that the false channel was excluded from the aortic arch down to the distal end of the endograft in the descending aorta in each case, but became patent further downstream. CONCLUSIONS: This procedure appears safe and feasible. It may allow for a more definitive treatment of TADs than the standard surgical approach. It can be adapted by low volume centers, surgeons untrained in aortic arch repair, and in high risk patients.     

Hybrid aortic procedures for endoluminal arch replacement in thoracic aneurysms and type B dissections

The aim of this study was to report our clinical experience with and review current literature on endoluminal aortic hybrid techniques and to evaluate outcome in high-risk patients treated for complex aortic arch lesions combining conventional supra-aortic debranching bypasses with subsequent or staged thoracic endovascular grafting. Of 172 patients treated with thoracic endografts for different thoracic aortic pathologies within the last 8 years, the mid-aortic arch was involved in 25, i.e. at least the left common carotid artery had to be overstented and revascularized to provide a proper proximal landing zone. These debranching bypasses were performed as a simultaneous or a staged procedure. All patients were at high-risk and were excluded by cardiac surgeons as ineligible for conventional arch repair. After partial (n=16) or complete (n=9) supra-aortic transposition, 4 different commercially available endografts (80% TAG, WL Gore) were implanted transfemorally or via iliac conduit. Deployment success was 100% in 25 patients after simultaneous or staged supra-aortic transposition; in 32% an emergency procedure was performed due to contained rupture; in 36% more than 1 endograft system was implanted (2 in 20%, 3 in 8% und 4 in 8%). The overall perioperative thirty-day mortality was 5 of 25 (20%) due to interoperative proximal bare stent perforation (n=1), transfusion related acute lung injury (TRALI n=1), cardiac failure (n=1), embolic stroke (n=1) and pneumonia (n=1). The mean follow-up was 21 months. All endoleaks type I (n=3) were corrected with another endograft; the 2 endoleaks type II sealed spontaneously. The major adverse events were: prolonged ventilation in 5 (20%), temporary renal insufficiency with hemodialysis (n=2), bypass infection (n=1), without any complications (n=9). No cases of paraplegia were recorded. Hybrid aortic arch repair is technically challenging but feasible. This novel approach may be an alternative to standard open procedures in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger series.     

Endovascular treatment of aortic arch aneurysms.

INTRODUCTION: The aim of this study was to review our clinical experience with endovascular treatment of aortic arch aneurysms using different commercially available grafts (Gore, Talent, Endomed, Cook). METHODS: From 1999 to 2004, 97 patients received endovascular treatment for diseases of the thoracic aorta. In 30 cases (26 males, 4 females) the aortic arch was involved. The left subclavian artery was overstented (Ishimaru zone '2') in 18 cases (60%). Only in the first three cases had the subclavian artery been revascularized. The left common and subclavian arteries were covered (zone '1') in 6 (20%) cases-all had the carotid artery reconstructed, either simultaneously (five cases) or as a staged procedure (one case). Finally, the whole aortic arch was over-stented (zone '0') in 6 (20%) cases, with simultaneous (five cases) or staged (one case) grafting of the supra-aortic vessels from the ascending aorta. RESULTS: Perioperative mortality was 2/30 (7%), due to graft migration (zone '2') and intra-operative stroke (zone '0'), respectively. One minor stroke was observed. No cases of paraplegia were recorded. Three type I endoleaks were observed. Two resolved at 6 months follow-up; one zone '0' graft is still being followed. There was one surgical conversion for endograft failure 2 weeks after implantation. Thus, the technical success rate was 87% (26/30) cases. The mean follow-up time was 23+/-17 months. No new onset endoleaks or aneurysm-related deaths were recorded. CONCLUSIONS: Currently available grafts may be deployed in the aortic arch in most instances. De-branching of the aortic arch with surgical revascularization for zone '0' and '1' seems to be adequate to obtain a satisfactory proximal landing zone.     

Long term outcome for extra-anatomic arch reconstruction. An analysis of 143 procedures.

PURPOSE: With the FDA approval of thoracic endografts, extra-anatomic reconstruction of the aortic arch has allowed for more suitable proximal landing zones and increased applicability of thoracic endovascular procedures. We evaluated our short term and long term results of extra-anatomic reconstruction of the carotid and subclavian vessels. METHODS: One hundred and forty three (143) procedures were performed for extra-anatomic carotid and subclavian reconstruction. Of these 143 operations: 85 were carotid subclavian reconstructions, 22 were carotid crossover bypasses, 30 were subclavian carotid reconstructions and 6 were carotid subclavian transpositions. Sixty (42%) were male, 20 (14%) were diabetic, and 63 (44%) were current smokers. Mean age was 63 (SD +/- 12.3). Indication for surgery was primarily for occlusive or embolic disease (97%). In those patients undergoing bypass graft, prosthetic (ePTFE) was used in 93%. Follow-up was performed at 3 and 6 month intervals by ultrasound and pulse volume recordings where indicated. Life table analyses were used to analyze patency. RESULTS: Of the 143 reconstructions operative mortality was 1 (0.7%). Non-fatal complications included 3 (2.1%) for bleeding, 1 (0.7%) wound infection, 2 (1.4%) TIA, 1 (0.7%) suffered a non-fatal stroke, 2 (1.4%) had postoperative myocardial infarctions, and 6 (4.3%) late (>30-day) occlusions. Follow-up was 1 to 124 months (mean: 39 months). Primary patency at 1 year was 98%, 3 years 96%, and 5 years was 92%. CONCLUSION: Extra-anatomic arch reconstruction can be performed safely and appears to be durable over long term follow-up. Its use with endovascular grafting should provide a durable reconstruction for patients who require aortic "debranching" prior endovascular thoracic aortic aneurysm repair.     

Endovascular treatment of arch and proximal thoracic aortic lesions

OBJECTIVE: To analyze at one institution the endovascular treatment for aortic arch and proximal thoracic aortic lesions, categorize open arch reconstruction, and make preliminary recommendations based on pathology (dissection vs aneurysm), and anatomical extent of disease. METHODS: A retrospective review of aortic arch and descending thoracic aortic lesions managed with endovascular treatment between June 2002 and June 2007. RESULTS: Thirty-four patients received endovascular repair for aortic dissection (n = 28) and aneurysm (n = 6). Open supra-aortic transposition or debranching of the great vessels was performed in 14 cases of dissection (50%) and six cases (100%) of aneurysm. In 14 dissections, the entry tear was located in the distal aortic arch, enabling the left subclavian artery to be sealed without reconstruction. The procedures were successful in 33 patients (97.1%); one intraoperative death occurred. Type I endoleaks were found intraoperatively in eight cases. After management with balloon angioplasty and by extending the stent implantation, the endoleaks resolved in four cases and decreased in four cases. One patient with Stanford type A dissection died from an unknown cause 3 months after treatment. The overall survival rate was 94.1% (32/34), and all bypass grafts remained patent during the follow-up period. CONCLUSIONS: Endovascular stent grafting is a safe and effective method for the treatment of aortic arch lesions. Transposition of the supra-aortic great vessels can be effectively combined with endovascular stent grafting to ensure both cerebral blood supply and enough landing area for the stent graft.     

Aortendissektion Stanford Typ A nach supraaortalem Debranching und endovaskulärem Stenting des Aortenbogens

Combined procedures involving an endovascular stenting technique and transposition of the supra-aortic arteries have been proposed for the treatment of aneurysms or chronic dissections involving the descending thoracic aorta and the aortic arch. This novel concept abandons the use of extracorporeal circulation and can be applied without a full length sternotomy. Thus the reduction in surgical trauma and peri-proce-dural morbidity and mortality have been proposed as advantages of this novel technique. Here, we report on two cases of acute aortic dissection Stanford type A that occurred during supra-aortic debranching and endovascular stenting of the aortic arch and the descending aorta. Both cases emphasize that despite preliminary encouraging results cautious patient selection is still mandatory for supraaortic debranching and implantation of a stent graft into the aortic arch in view of different therapeutic options that are available today, including the frozen elephant trunk technique. Procedure adhering risks deserve further attention and need to be re-evaluated.     

Collective experience with hybrid procedures for suprarenal and thoracoabdominal aneurysms

Not every patient is fit for open thoracoabdominal aortic aneurysm (TAAA) repair, nor is every TAAA or juxtarenal abdominal aortic aneurysm suitable for branched or fenestrated endovascular exclusion. The hybrid procedure consists of debranching of the renal and visceral arteries followed by endovascular exclusion of the aneurysm and might be an alternative in these patients. Between May 2004 and March 2006, 16 patients were treated with a hybrid procedure. The indications were recurrent suprarenal or thoracoabdominal aneurysms after previous abdominal and/or thoracic aortic surgery (n = 8), type I to III TAAAs (n = 3), proximal type I endoleak after endovascular repair (n = 2), penetrating ulcer of the juxtarenal aorta (n = 1), visceral patch aneurysm after type IV open repair (n = 1), and primary suprarenal aneurysm (n = 1). Eight (50%) of 16 patients were judged to be unfit for open TAAA repair. The hospital mortality rate was 31% (5 of 16). Four of five deceased patients were unfit for thoracophrenic laparotomy. Two patients died from cardiac complications and three from visceral ischemia. No spinal cord ischemia was detected, and temporary renal failure occurred in four patients (25%). The mean follow-up was 13 months (range 6-28 months). During follow-up, no additional grafts occluded and no patients died. Hybrid procedures are technically feasible but have substantial mortality (31%), especially in patients unfit for open repair (80%). They might be indicated when urgent TAAA surgery is required or when vascular anatomy is unfavorable for fenestrated endografts in patients with extensive previous open aortic surgery.     

Surgical bypass procedures to facilitate endovascular repair of aortic arch pathology

Thoracic aortic aneurysms and other thoracic aortic lesions may become life-threatening conditions if they remain untreated. Conventional open surgical reconstruction with placement of an interposition graft is regarded as a definitive form of treatment, but is associated with considerable operative morbidity and mortality. Thoracic aortic lesions involving the aortic arch require more complex surgical interventions necessitating cardiopulmonary bypass, and hypothermic circulatory arrest. Outcomes from this form of treatment have a reported early stroke and death rate of up to 25%. Thoracic endovascular aortic repair is a less invasive alternative for the treatment of many thoracic aortic lesions. The application of a thoracic endoprosthesis may be limited by the extent of involvement of the proximal thoracic aorta as coverage of arch vessel ostia may be necessary to obtain adequate proximal endograft fixation and aneurysm exclusion. In an effort to overcome proximal landing zone limitations imposed by arch vessel involvement, hybrid surgical-endovascular reconstructive and debranching bypass procedures have been performed to create a proximal landing zone of adequate length. Although these adjunctive techniques incorporate invasive surgical procedures, it is believed that minimizing the procedural invasiveness, by avoiding aortic cross-clamping and/or hypothermic circulatory arrest, morbidity and mortality outcomes can be improved especially in high-risk patients. Several surgical approaches and techniques have been described for various levels of aortic arch involvement with encouraging early and mid-term results, although the long-term durability of these hybrid surgical-endovascular procedures remains to be defined.     

The strategy of thoracic endovascular repair for aortic arch aneurysms

Thoracic endovascular aneurysm repair (TEVAR) has gained wide acceptance because of its minimal invasiveness and effectiveness for thoracic aortic aneurysms. However, the endovascular technique alone is often not applicable to arch aneurysms due to their anatomical complexity, such as aortic curve and presense of neck branches. The development of branched stent graft that allows total endovascular approach has been slow. Therefore open surgical technique is still needed to obtain an adequate landing zone. Prior total arch replacement with elephant trunk and debranching neck vessels including partial debranching such as carotid-carotid crossover bypass, and total debranching from the ascending aorta were able to create a suitable proximal landing zone. Chimney technique using covered stent for the neck vessels is also effective for arch aneurysms. Here, we report the strategies of TEVAR for aortic arch aneurysms.     

Initial Experience of Modified Four-Branched Graft Technique and Antegrade TEVAR in Acute Type A Aortic Dissection

Background: We report the initial experience of modified four-branched graft technique for proximal aorta and arch repair, feasibly combined with antegrade thoracic endovascular aortic repair (TEVAR) to extend distal aortic reconstruction in acute type A aortic dissection.Methods: From 2011 to 2013, 12 consecutive patients with acute type A aortic dissection were indicated for arch surgery and underwent surgical replacement of proximal aorta, arch replacement or debranching procedure, and concomitant TEVAR for distal aortic repair.Results: A good surgical field was obtained in all patients. No major complications developed but two hospital deaths were attributed to end-organs damage preoperatively. Good and fast remodeling of thoracic descending aorta was demonstrated in 11 patients in postoperative CT imaging and no aneurysmal dilatation of visceral aorta had been observed in 10 patients during follow-up periods.Conclusion: Modified four-branched graft technique facilitated proximal aorta and arch repair, and provided excellent neurological outcome and favorable short-term results. Single-stage operation combined with antegrade TEVAR is feasible and effective to extend the repair down to the descending aorta, and thus achieved good remodeling of thoracic descending aorta.     

Early and mid-term results of endovascular stent grafting for aortic aneurysms]

Early and mid-term clinical results of 28 cases of endovascular stent grafting for descending thoracic aortic aneurysms and 11 cases of abdominal aortic aneurysms are reported. Early clinical results: Among 28 patients (7 true thoracic aortic aneurysms, 3 pseudothoracic aortic aneurysms and 8 acute, 4 subacute, and 6 chronic aortic dissections), two patients (7.1%) with ruptured acute aortic dissection or ruptured infected pseudoaneurysm died in the perioperative period. Two of the remaining 26 patients experienced minor complications. Aneurysmal sacs or false lumens at the descending thoracic aorta were completely thrombosed in the 26 patients. One patient (9.1%) with a ruptured abdominal aneurysm died, and one of the remaining 10 patients had renal and peripheral emboli and peripheral vascular trauma. Inadvertent covering of the renal arteries occurred in another patient. Unless one patient had persistent endoleak, aneurysmal sacs in the 10 surviving patients were thrombosed. Mid-term clinical results: One aortic dissection at a different section of the descending aorta occurred 6 months after stent grafting for aortic dissection, and one patient died of pneumonia 3 months after stent grafting for an abdominal aortic aneurysm. CT scanning 6 months after stent grafting revealed a decrease in maximal aneurysmal size in 3 of 9 patients with true or pseudothoracic aneurysms and in 2 of 5 patients with abdominal aortic aneurysms. Five of 9 patients with stent grafting for acute or subacute dissection showed elimination of the false lumen in the descending thoracic aorta in a CT scan 6 months after grafting. One patient with a true thoracic aneurysm and one patient with an abdominal aortic aneurysm showed an increase in aneurysmal size in a CT scan 2 years and one year after treatment, respectively.     

Hybrid Aortic Arch Repair Procedure: Reinforcement of the Aorta for a Safe and Durable Landing Zone

ObjectivesHybrid aortic arch repair procedure was introduced to reduce invasiveness in high-risk patients with aortic arch pathology. The good results are expanding its application, but endoleak, particularly type I, remains its Achilles’ heel.DesignWe describe our experience with hybrid treatment of aortic arch diseases focussing on techniques and results to avoid type I endoleak.Materials and MethodsA total of 15 high-risk patients with zone 0–2 aortic arch pathology underwent supra-aortic debranching on ascending aorta and proximal aortic arch reinforcement with a Dacron prosthesis. Metachronously, the procedure was completed with endovascular stent grafting (ESG).ResultsMedian age was 70 years with a mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) of 12.7 ± 6.8. One patient died between aortic debranching and ESG. Mean time between surgical debranching and ESG was 32 ± 27.7 days. No major neurological events occurred. Mean length of the landing zone for ESG was 3.8 ± 0.8 cm. Computed tomography (CT) angiography scan performed soon after operation, and at 3, 6, and 12 months did not show any type I endoleak.ConclusionsSupra-aortic debranching on ascending aorta with proximal aortic arch reinforcement is a useful step to ensure a safe landing zone for ESG, reducing risk early to midterm of endoleak. Longer term follow-up is required to confirm the viability of this technique.     

Use of the abdominal aorta as an alternative access site for thoracic aortic stent graft placement

The treatment of thoracic aortic pathology has undergone a paradigm shift in recent years, with a trend toward less invasive endovascular techniques and away from open surgical repair. Reports on the successful use of endografts in the thoracic aorta have demonstrated decreased morbidity and mortality of these procedures compared with traditional open repair. However, some patients are not candidates for an endovascular approach because of a short proximal landing zone, arch angulation, luminal irregularities, or a large diameter of the transverse arch and the proximal descending aorta. Other patients are excluded because of distal pathology or anatomic irregularities. This article presents 2 patients with thoracic aortic pathology, and both had inadequate proximal landing zones and small, calcified iliac arteries prohibiting femoral or iliac access. Successful repair of these patients was achieved by a staged procedure using a brachiocephalic debranching technique, followed by direct infrarenal aortic cannulation through a limited celiotomy.     

主动脉弓部病变杂交手术后并发症的原因分析及处理

目的 对主动脉弓部病变杂交手术后常见并发症的发生原因进行分析.方法 对2001年1月至2008年12月接受杂交手术的34例主动脉弓部病变患者的资料进行回顾性分析.其中男性28例,女性6例,年龄34～75岁,平均年龄56.7岁.主动脉央层27例,其中A型21例,B型6例;主动脉弓部真性动脉瘤7例.杂交手术包括升主动脉-无名动脉-左颈总动脉Y形旁路3例,升主动脉-左颈总动脉-左锁骨下动脉Y形旁路2例,升主动脉-左颈总动脉旁路连同冠状动脉旁路移植1例,左颈总动脉-右颈总动脉旁路13例,右颈总动脉-左颈总动脉及左颈总动脉-左锁骨下动脉旁路3例,左锁骨下动脉-左颈总动脉-右颈总动脉Y形旁路2例,左颈总动脉-左锁骨下动脉旁路9例.一期行腔内修复26例,分期行腔内修复8例.结果 总的并发症发生率为32.4%(11/34),其中致死性并发症发生率11.8%(4/34).并发症包括主动脉央层破裂1例,脑卒中2例,吻合口漏并假件动脉瘤2例,心肌梗死1例,肺栓塞1例,颈部血肿1例,内漏3例.除4例围手术期死亡外,其余病例随访6～50个月,平均28.6个月,均健康生存.结论 肤主动脉弓部病变杂交手术后的并发症较一般腔内修复术更为多见,降低致死性并发症的发生率是该手术获得进一步推广的关键.     

Retrograde Typ-A-Dissektion nach „debranching“ und endovaskulärer Stentgraft-Therapie des Aortenbogens

This article describes the hybrid repair of a large thoracic aneurysm of the transverse arch and the descending aorta in an 81-year-old patient using the debranching technique with subsequent thoracic endovascular aortic repair (TEVAR). On postoperative day 10 the patient suffered a retrograde type A aortic dissection – involving the ascending aorta and the aortic root – with acute tamponade. After stabilization the patient successfully underwent emergency supracoronary ascending aortic replacement by performing of a distal elephant trunk anastomosis.     

Single Center Experience with a New Commercially Available Thoracic Endovascular Graft

PURPOSE: To evaluate the intra-operative performance and clinical outcome of a new commercially available stent-graft for the treatment of thoracic aortic diseases. METHODS AND PATIENTS: From January 2003 to October 2004, 45 consecutive patients received endovascular treatment with the Zenith TX1 device for diseases of the thoracic aorta at a single center in northern Italy. Indications included disease of the descending thoracic aorta in 26 cases, of the aortic arch in 17 cases and of the thoraco-abdominal aorta in two cases. We treated 38 atherosclerotic aneurysms, two post-traumatic aortic ruptures, two penetrating ulcers, two chronic dissections and one case was treated for aortic bleeding after voluntary acid ingestion for attempted suicide. General anesthesia was used in 20 cases. Combined or hybrid endovascular and open surgical repair was performed in 11 patients. Mean follow-up was 7 months (range 1-22 months). RESULTS: Technical success was obtained in 44 patients (98%). One primary type I endoleak occurred (2%). ICU was used in 12 cases with a mean stay of 1 day. The mean hospital stay was 6 days (range 4-13 days). There were no hospital deaths or strokes but one transient paraplegia (2%). A type II endoleak was observed in one case and resolved spontaneously 1 month later. No aneurysm enlargement, endograft migration or structural failures were observed during follow-up. Two late unrelated-deaths were observed. CONCLUSIONS: This stent-graft does not fulfill all the characteristics of the ideal graft, however, it proved to be safe and allowed satisfactory short term results in this group of patients treated at a single center.     

Stent-grafting of a dissected aortic arch and descending aorta after debranching of the supra-aortic vessels: case-presentation,indications, technique

Endovascular repair of thoracic aorta pathology is emerging as the preferred treatment strategy in high risk patients. Hybrid techniques with debranching of the supra-aortic vessels extend indications for endovascular repair of the aortic arch and descending aorta.

After a brief case-presentation, we describe these procedures, outline the indications and discuss the outcomes and results available in present literature.     

"杂交"手术治疗DeBakey Ⅰ型主动脉夹层

目的 总结应用无深低温停循环的升主动脉置换、升主动脉-主动脉弓分支血管旁路、腔内隔绝的"杂交"手术治疗DeBakey Ⅰ型主动脉夹层的方法和经验.方法 2009年1月至2010年6月,39例、平均年龄(55±16)岁的DeBakey Ⅰ型主动脉夹层病人进行无深低温停循环的"杂交"手术.病人经股动脉、右腋动脉插管灌注,先于常规体外循环下行升主动脉和主动脉瓣置换,再采用四分支人工血管、"Y"形人工血管或单根人工血管行升主动脉-主动脉弓分支血管旁路手术,再经股动脉逆行径路数字减影血管造影(DSA)下或术中顺行径路食管超声定位下行主动脉弓-降主动脉腔内隔绝术.结果 全组均手术成功,升主动脉处理时8例行单纯升主动脉人工血管置换,20例行Bentall手术(其中冠状动脉移位采用Carbrol法11例),11例行Wheat手术;升主动脉-主动脉弓分支血管旁路手术采用四分支人工血管16例、"Y"形人工血管15例、单根人工血管序贯法8例;主动脉弓-降主动脉腔内隔绝术采用DSA下股动脉逆行径路36例,术中人工血管分支顺行径路3例,均使用1枚支架.体外循环(61±22)min,主动脉阻断(48±18)min.术后(30±9)h拔除气管插管,24 h胸液小于300 ml,无偏瘫、截瘫、严重感染、凝血障碍等并发症.所有病人均治愈出院,平均术后(21±6)天出院.术后随访1～15个月,平均(8.4±7.2)个月,病人均健康生存,无脏器功能不全.术后3个月行CT主动脉血管成像检查,显示膈肌水平假腔闭合率为91.2%.结论 常温体外循环下升主动脉置换、升主动脉-弓部血管旁路、腔内隔绝的"杂交"手术治疗DeBakey Ⅰ型主动脉夹层,简化了DeBakey Ⅰ型主动脉夹层外科治疗方法,该手术方法避免了深低温停循环,减少了术后并发症,提高了外科治疗效果.

Abstract：

Objective Some major procedures for DeBakey type Ⅰ aortic dissection used to be performed with deep hypothermic circulatory arrest, which had been associated with more complications than seen with standard extracorporeal circulation. We reviewed the cases who received the treatment for DeBakey type Ⅰ aortic dissection by hybrid procedure without deep hypothermic circulatory arrest. The procedure consisted of ascending aorta replacement, ascending aorta-aortic arch branch vascular bypass reconstruction and endovascular graft exclusion. Methods From January 2009 to June 2010, 39 patients [mean age (55 ±16) years] who had DeBakey Ⅰ aortic dissection underwent hybrid procedure without deep hypothermic circulatory arrest. The femoral artery and right axillary artery were cannulated for perfusion. The ascending aorta and/or aortic valves were replaced under conventional extracorporeal circulation with Bentall procedure or Wheat procedure. The aortic arch branch vessels were dissected and the proximal part was sealed. Then the ascending aorta-aortic arch branch vascular bypasses were constructed with 4-bifurcation vascular grafts, Y-shape bifurcated vascular grafts or artificial vessels. Finally the endovascular grafts were deployed via the femoral incisions monitored dynamically with DSA, or via the ascending aortic bifurcated vessels monitored with transesophageal echocardiography. Results The operation succeeded in all 39 patients. Eight patients underwent ascending aorta replacement without aortic valve replacement or prosthesis, 20 patients underwent Bentall procedure ( Carbrol procedure were used in 11 cases), and 11 underwent Wheat procedure. For ascending aorta-aortic branch vascular bypass reconstruction, sequential anastomoses were performed in 8, Y-shaped bifurcated grafts were used in 15, and 4-bifurcated grafts were employed in 16 patients. The endovascular stent grafts were deployed via the former femoral incisions in 36 patients and via ascending aortic bifurcated vessels in 3. The cardiopulmonary bypass time was (61 ±22) minutes, the aortic crossclamp time was (48 ±18) minutes, and the post-operative intubation time was (30 ±9) hours. The thoracic drainage from each patient was less than 300 ml in 24 hours. No complication, such as hemiplegia, paraplegia, severe infections, renal failure or coagulation disorder, was observed. The duration of hospitalization was (21 ±6) days. No hospital death occurred. Follow-up was performed 1 to 15 months [mean (8.4 ±7.2) months] postoperatively. All patients survived without any organ dysfunction at follow up. The CTA examination 3 months after operation revealed that the false lumens had been closed in 91.2% of the patients. Conclusion Our findings indicated that the hybrid procedure, which combining ascending aorta replacement,ascending aorta-aortic arch branch vascular bypass reconstruction and endovascular graft exclusion under conventional extracorporeal circulation, may be an option for avoiding the possible complications associated with profound hypothermic circulatory arrest. The novel hybrid operation may improve the surgical outcomes and provide a simplified surgical approach for the treatment of DeBakey Ⅰ aortic dissection.