Straight incision for extended descending and thoracoabdominal aortic replacement: novel and simple exposure with rib-cross thoracotomy
Straight incision for extended descending and thoracoabdominal aortic replacement: novel and simple exposure with rib-cross thoracotomy
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DOI：
10.1093/icvts/ivw140
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发表时间：
2016-09-01
影响因子：
--
通讯作者：
Kobayashi, Junjiro
中科院分区：
文献类型：
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作者：
Minatoya, Kenji;Seike, Yoshimasa;Kobayashi, Junjiro
目的：朝向肩胛骨尖端螺旋切开胸壁并通过第六肋间空间入路已经成为置换胸腹和降主动脉瘤的标准方法。然而，螺旋切口暴露主动脉近端病变并不总是足以治疗病变延伸到主动脉弓的患者。马凡氏综合征患者往往胸部平坦，使用左胸切口暴露通常会导致主动脉弓手术困难。自2012年5月以来，47名患者（平均年龄51.2 ± 16.1岁，范围9-79岁，33名男性）接受了新型切口，以更好地暴露扩展的降动脉瘤和胸腹动脉瘤。从腋部到脐部做直切口而不是传统的螺旋切口，并切断第四至第六肋骨。保留背阔肌和胸背动脉，可作为Adamkiewicz动脉侧支循环的来源。有两次急性主动脉夹层的紧急手术。24例（51%）患者既往接受过近端主动脉手术，2例患者接受过去分支胸主动脉瘤腔内修复术。16例（34.0%）患者诊断为结缔组织疾病（Marfan综合征13例，Loeys-Dietz综合征3例）。结果：10例患者均行全降主动脉置换术，其余均行Ⅱ型胸腹主动脉置换术。3例行部分主动脉弓置换术，5例行全主动脉弓置换术，3例行腹主动脉Y型移植术。手术时间为567 +/- 141 min，心肺转流时间为259 +/- 60 min。3例患者发生严重卒中（6.4%），1例发生轻微卒中。存活者无脊髓并发症。住院死亡率为4.3%（2/47）。这2例患者进行了胸腹主动脉置换术，并有重大stroke.CONCLUSIONS：这种新的暴露与直切口肋骨交叉开胸术提供了良好的暴露胸腹主动脉的长段，它使延长更换从升主动脉到腹主动脉。
OBJECTIVES: piral incision of the thoracic wall towards the tip of a scapula and approach through the sixth intercostal space has been a standard method for the replacement of thoracoabdominal and descending aortic aneurysms. However, the exposure of the proximal lesion of the aorta with the spiral incision is not always sufficient for patients with a lesion extending into the aortic arch. Patients with Marfan syndrome tend to have a flat chest, and exposure using left thoracotomy generally causes difficulty to operate on the aortic arch.METHODS: ince May 2012, 47 patients (mean age 51.2 +/- 16.1, range 9-79, 33 males) have received a novel incision for better exposure of the extended descending and thoracoabdominal aneurysm. A straight incision instead of the traditional spiral one was made from the axilla to the umbilical region and the fourth to sixth ribs were transected. The latissimus dorsi muscle and thoracodorsal artery were preserved, which could be a source for collateral circulation to the Adamkiewicz artery. There were two emergent operations for acute aortic dissection. Twenty-four patients (51%) had undergone previous proximal aortic operation, and 2 patients undergone debranched thoracic endovascular aneurysm repair of the aortic arch. Connective tissue disorders were diagnosed in 16 (34.0%) patients (Marfan syndrome 13, Loeys-Dietz syndrome 3). All surgeries were performed under profound hypothermia.RESULTS: even patients underwent total descending aortic replacement, and the others had Type II thoracoabdominal aortic replacements. Three had partial aortic arch replacement, 5 had total aortic arch replacement and 3 had Y-grafting for the abdominal aorta concomitantly. Operation time was 567 +/- 141 min and cardiopulmonary bypass time was 259 +/- 60 min. Three patients had a major stroke (6.4%), and 1 had a minor stroke. There was no spinal cord complication among survivors. Hospital mortality rate was 4.3% (2/47). These 2 patients underwent thoracoabdominal aortic replacement, and had a major stroke.CONCLUSIONS: This new exposure with straight incision with rib-cross thoracotomy provided excellent exposures for the long segment of the thoracoabdominal aorta, and it enabled extended replacement from the ascending aorta to the abdominal aorta.