外科治疗国人A型主动脉夹层和支架象鼻手术治疗主动脉夹层的随访研究
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摘要
目的：总结单中心A型主动脉夹层的外科治疗经验,评价细化分型的临床应用价值；评价全主动脉弓替换加支架象鼻技术治疗马凡综合征和非马凡病人主动脉夹层的效果；观察瓣膜置换后的抗凝治疗对主动脉夹层远端残余假腔的影响。
方法：(1)834例A型主动脉夹层病人按照细化分型分组,总结各亚组的手术方法、死亡率及并发症并进行生存分析。(2)83例经历全弓替换+支架象鼻技术的主动脉夹层病人,按病因分为马凡综合征组(n=24)和非马凡组(n=59),比较两组术后的恢复情况及随访结果。(3)181例主动脉夹层病人经支架象鼻技术治疗后按照是否有瓣膜置换分为瓣膜置换组(n=55)和非瓣膜置换组(n=126)瓣膜置换组术后需长期口服华法林钠抗凝。回顾性整理病人临床及随访资料,采用计算机软件建立数据库。选取CT断层测量计算真腔与主动脉直径的比值作为CT变量,对行支架象鼻术的病人进行组间及不同时间段的横向纵向比较。所有数据经统计学分析后评价其临床意义。
结果：A型夹层病人总的院内死亡率为3.24%,严重的并发症发生率为6.9%,二次开胸止血占8.5%,各亚组随访生存率均>90%。CT显示马凡组和非马凡组的院内死亡率、术后4年生存率、在支架段水平1年后支架内径与主动脉直径比及远端主动脉残余假腔的血栓化程度差异均无统计学意义(p=0.506,0.341,0.336和0.468),马凡组的二次手术率较高。瓣膜置换组和非瓣膜置换组术后1年的CT显示支架段水平支架内径与主动脉直径比及假腔的血栓化程度差异有明显的统计学意义(P＜0.05),瓣膜置换组支架段的假腔血栓化明显迟于非瓣膜置换组。
结论：细化分型对A型主动脉夹层的外科治疗有临床应用价值；全弓替换加支架象鼻技术对马凡综合征和非马凡的主动脉夹层病人均能起到良好的治疗效果,有利于远端残余假腔的闭合；与瓣膜相关的抗凝治疗能延迟主动脉夹层术后残余假腔的血栓化进程,从而增加术后早期再次手术的风险。
Objective:(1) To clarify if our surgical strategy according to further subdivision is justified for patients with type-A aortic dissection (AAD). (2) To assess the outcome of stented elephant trunk (SET) surgical approach for aortic dissection in Marfan and non-Marfan patients. (3) To assess the influence of anticoagulation treatment on the evolvement of residual false lumen after SET procedure with mechanical prosthetic valve replacement for aortic dissection patient.
Methods:(1) AAD patients of 834 from 1997 to 2008 were further divided into subgroups according to the pathology of aortic root, aortic arch and descending aorta. Supra-commissural replacement of the ascending aorta was applied to 517 patients, two hundred and eighty-six patients received a composite replacement, one hundred and eight patients were treated with the aorta valve-sparing technique, hemi or total arch replacement was performed in 720 patients with 316 patients undergoing the concomitant conventional or SET procedure, and fifteen patients were accomplished with total aortic replacement.
(2) Between 2003 and 2008, twenty-four patients were made definite diagnosis of Marfan among eighty-three aortic dissection patients undergoing the total arch replacement and SET procedure. All the patients were not accompanied with other clear systematic diseases. Twenty-three patients received aortic root procedure combined with aortic valve replacement.
(3) Between 2003 and 2008, one hundred and eighty-one aortic dissection patients undergoing the open SET procedure concomitant with arch and/or proximal surgery were enrolled in this study. Fifty-five patients received an aortic valve replacement (AVR) with mechanical prosthesis. According to whether mechanical valve was implanted (namely long-term anticoagulation was necessary or not), patients were divided into two groups with and without AVR.
The aorta was measured using enhanced computed tomography (CT), and the diameter ratios between the true lumen and aorta were calculated and the thrombosis extent of false lumen was quantified.
Results:(1) Overall hospital mortality was 3.24%(27) and severe morbidity excluding rethoractomy for bleeding was 6.9%. Survival was>90%in all subtypes to the last date of visit. Two patients required reoperation for failure of the reconstructed valve and nineteen patients needed aortic reoperation. Follow-up CT study of 201 (67.7%) patients undergoing the stented elephant trunk procedure showed significant difference in the diameter ratios of the stent and the aorta at the carina level at different periods.
(2) Follow-up CT study over one year postoperative showed no difference about the diameter ratios of stent and aorta at the same level between groups (Marfan 0.78±0.21 versus non-Marfan 0.87±0.24,p=0.336, at the coryna level). The residual false lumen in the distal descending aorta remained patent in 33.3%of Marfan and 30.5%of non-Marfan. Hospital and late mortality at follow-up time did not show significant differences between groups (4.2%versus 1.7%,p=0.506; 8.3%versus 8.5%,p=0.983). Survival at four years was no significantly different with 85.2+10.7%for Marfan, and 89.6+5.2%for non-Marfan (p-0341). Four patients from Marfan and two patients in non-Marfan required reoperation for distal dissection or aneurysm (16.7% versus 3.4%;p=0.055).
(3) Follow-up CT study at one year showed significant difference between groups, mainly in the diameter ratios of the stent and aorta at the same level (p=0.005, at the carina; p=0.003, at the stent end). Accordingly CT data after discharge were significantly different in the extent of false lumen thrombosis at the carina (p=0.018, at 3-6 months;p=0.020, at one year). Over one year after surgery, the residual false lumen around the stent graft achieved complete thrombosis in 87.3%of patients with AVR and 98.4%without AVR (p=0.005). One patient with AVR and three patients without AVR required re-operation on the descending aorta.
Conclusions:This subtype classification is useful in determining the indication and optimal surgical strategy for AAD. The SET technique is an effective way of closing the false lumen in proximal descending aorta and might contribute to the comparable and favorable long-term outcome for aortic dissection in Marfan and non-Marfan patients. Valve-related anticoagulation can slow down the remodeling of proximal descending aorta of aortic dissection after SET implantation.
方法：(1)834例A型主动脉夹层病人按照细化分型分组,总结各亚组的手术方法、死亡率及并发症并进行生存分析。(2)83例经历全弓替换+支架象鼻技术的主动脉夹层病人,按病因分为马凡综合征组(n=24)和非马凡组(n=59),比较两组术后的恢复情况及随访结果。(3)181例主动脉夹层病人经支架象鼻技术治疗后按照是否有瓣膜置换分为瓣膜置换组(n=55)和非瓣膜置换组(n=126)瓣膜置换组术后需长期口服华法林钠抗凝。回顾性整理病人临床及随访资料,采用计算机软件建立数据库。选取CT断层测量计算真腔与主动脉直径的比值作为CT变量,对行支架象鼻术的病人进行组间及不同时间段的横向纵向比较。所有数据经统计学分析后评价其临床意义。
结果：A型夹层病人总的院内死亡率为3.24%,严重的并发症发生率为6.9%,二次开胸止血占8.5%,各亚组随访生存率均>90%。CT显示马凡组和非马凡组的院内死亡率、术后4年生存率、在支架段水平1年后支架内径与主动脉直径比及远端主动脉残余假腔的血栓化程度差异均无统计学意义(p=0.506,0.341,0.336和0.468),马凡组的二次手术率较高。瓣膜置换组和非瓣膜置换组术后1年的CT显示支架段水平支架内径与主动脉直径比及假腔的血栓化程度差异有明显的统计学意义(P＜0.05),瓣膜置换组支架段的假腔血栓化明显迟于非瓣膜置换组。
结论：细化分型对A型主动脉夹层的外科治疗有临床应用价值；全弓替换加支架象鼻技术对马凡综合征和非马凡的主动脉夹层病人均能起到良好的治疗效果,有利于远端残余假腔的闭合；与瓣膜相关的抗凝治疗能延迟主动脉夹层术后残余假腔的血栓化进程,从而增加术后早期再次手术的风险。
Objective:(1) To clarify if our surgical strategy according to further subdivision is justified for patients with type-A aortic dissection (AAD). (2) To assess the outcome of stented elephant trunk (SET) surgical approach for aortic dissection in Marfan and non-Marfan patients. (3) To assess the influence of anticoagulation treatment on the evolvement of residual false lumen after SET procedure with mechanical prosthetic valve replacement for aortic dissection patient.
Methods:(1) AAD patients of 834 from 1997 to 2008 were further divided into subgroups according to the pathology of aortic root, aortic arch and descending aorta. Supra-commissural replacement of the ascending aorta was applied to 517 patients, two hundred and eighty-six patients received a composite replacement, one hundred and eight patients were treated with the aorta valve-sparing technique, hemi or total arch replacement was performed in 720 patients with 316 patients undergoing the concomitant conventional or SET procedure, and fifteen patients were accomplished with total aortic replacement.
(2) Between 2003 and 2008, twenty-four patients were made definite diagnosis of Marfan among eighty-three aortic dissection patients undergoing the total arch replacement and SET procedure. All the patients were not accompanied with other clear systematic diseases. Twenty-three patients received aortic root procedure combined with aortic valve replacement.
(3) Between 2003 and 2008, one hundred and eighty-one aortic dissection patients undergoing the open SET procedure concomitant with arch and/or proximal surgery were enrolled in this study. Fifty-five patients received an aortic valve replacement (AVR) with mechanical prosthesis. According to whether mechanical valve was implanted (namely long-term anticoagulation was necessary or not), patients were divided into two groups with and without AVR.
The aorta was measured using enhanced computed tomography (CT), and the diameter ratios between the true lumen and aorta were calculated and the thrombosis extent of false lumen was quantified.
Results:(1) Overall hospital mortality was 3.24%(27) and severe morbidity excluding rethoractomy for bleeding was 6.9%. Survival was>90%in all subtypes to the last date of visit. Two patients required reoperation for failure of the reconstructed valve and nineteen patients needed aortic reoperation. Follow-up CT study of 201 (67.7%) patients undergoing the stented elephant trunk procedure showed significant difference in the diameter ratios of the stent and the aorta at the carina level at different periods.
(2) Follow-up CT study over one year postoperative showed no difference about the diameter ratios of stent and aorta at the same level between groups (Marfan 0.78±0.21 versus non-Marfan 0.87±0.24,p=0.336, at the coryna level). The residual false lumen in the distal descending aorta remained patent in 33.3%of Marfan and 30.5%of non-Marfan. Hospital and late mortality at follow-up time did not show significant differences between groups (4.2%versus 1.7%,p=0.506; 8.3%versus 8.5%,p=0.983). Survival at four years was no significantly different with 85.2+10.7%for Marfan, and 89.6+5.2%for non-Marfan (p-0341). Four patients from Marfan and two patients in non-Marfan required reoperation for distal dissection or aneurysm (16.7% versus 3.4%;p=0.055).
(3) Follow-up CT study at one year showed significant difference between groups, mainly in the diameter ratios of the stent and aorta at the same level (p=0.005, at the carina; p=0.003, at the stent end). Accordingly CT data after discharge were significantly different in the extent of false lumen thrombosis at the carina (p=0.018, at 3-6 months;p=0.020, at one year). Over one year after surgery, the residual false lumen around the stent graft achieved complete thrombosis in 87.3%of patients with AVR and 98.4%without AVR (p=0.005). One patient with AVR and three patients without AVR required re-operation on the descending aorta.
Conclusions:This subtype classification is useful in determining the indication and optimal surgical strategy for AAD. The SET technique is an effective way of closing the false lumen in proximal descending aorta and might contribute to the comparable and favorable long-term outcome for aortic dissection in Marfan and non-Marfan patients. Valve-related anticoagulation can slow down the remodeling of proximal descending aorta of aortic dissection after SET implantation.
引文
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