Complementary roles of open and hybrid approaches to thoracoabdominal aortic aneurysm repair
Complementary roles of open and hybrid approaches to thoracoabdominal aortic aneurysm repair
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DOI：
10.1016/j.jvs.2016.04.022
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发表时间：
2016-11-01
影响因子：
4.3
通讯作者：
Hughes, G. Chad
中科院分区：
文献类型：
--
作者：
Benrashid, Ehsan;Wang, Hanghang;Hughes, G. Chad
目的：胸腹主动脉瘤（TAAA）修复术仍然是一项重大挑战，具有相当高的围手术期发病率和死亡率。利用内脏去分支和动脉瘤腔内隔绝术的混合方法已用于治疗高风险患者，因此允许更多患者进行修复。关于该手术的长期结局以及与传统开放修复术的比较，数据有限。这项研究描述了我们的机构算法的方法，TAAA修复使用开放和混合techniques.Methods：混合和开放TAAA修复之间进行2005年7月和2015年8月，从一个前瞻性维护的机构主动脉手术数据库中确定。围手术期的发病率和死亡率，从再干预自由，长期和特定的生存率进行了计算和比较between the two group.Results：在研究期间，165个连续TAAA修复进行，包括84开放修复和81混合修复。混合修复组的患者年龄明显较大，女性更常见，并且通常具有更大的共病疾病负担，包括明显更多的慢性肾脏疾病。尽管年龄较大且病情较重，但两组之间的住院死亡率没有差异（混合型9.9% vs开放型7.1%; P = 0.59）。不同手术的主要发病率不同，接受开放性修复术的患者术后卒中发生率显著更高（开放性9.5% vs混合型0%; P = 0.017），而接受混合型修复术的患者新的永久性透析发生率更高（混合型14.8% vs开放性3.6%; P = 0.043）。两组术后永久性截瘫/轻瘫的发生率无差异（开放型8.3% vs混合型7.4%; P = 0.294）。混合修复组的再介入率显著增加（混合组12.3% vs开放组1.2%，P = 0.004），所有混合再介入均因内漏而进行。两组的一年生存率相似，混合修复组为69%，开放修复组为77%。混合组的长期生存率更差（5年生存率，32%混合型vs 56%开放型），尽管晚期生存率似乎主要受共病疾病负担的影响，但两组之间的长期特异性生存率相似。使用算法方法，即采用混合方法治疗TAAA的高风险患者，采用传统开放修复术治疗低风险患者，短期和长期的结果。在一家临床试验机构内提供TAAA修复术的多种选择可能允许更多患者接受修复术，从而降低了与TAAA相关的死亡风险，但增加了内漏的再干预。
Objective: Thoracoabdominal aortic aneurysm (TAAA) repair remains a significant challenge with considerable perioperative morbidity and mortality. A hybrid approach utilizing visceral debranching with endovascular aneurysm exclusion has been used to treat high-risk patients and therefore allow repair in more patients. Limited data exist regarding long-term outcomes with this procedure as well as comparison to conventional open repair. This study describes our institutional algorithmic approach to TAAA repair using both open and hybrid techniques.Methods: Hybrid and open TAAA repairs performed between July 2005 and August 2015 were identified from a prospectively maintained institutional aortic surgery database. Perioperative morbidity and mortality, freedom from reintervention, and long-term and aorta-specific survival were calculated and compared between the two groups.Results: During the study period, 165 consecutive TAAA repairs were performed, including 84 open repairs and 81 hybrid repairs. Patients in the hybrid repair group were significantly older, were more frequently female, and had a generally greater comorbid disease burden, including significantly more chronic kidney disease. Despite the older and sicker cohort, there was no difference in in-hospital mortality between the two groups (9.9% hybrid vs 7.1% open; P =.59). Major morbidity rates differed by procedure, with patients undergoing open repair having a significantly higher rate of postoperative stroke (9.5% open vs 0% hybrid; P =.017), whereas patients undergoing hybrid repair had a higher rate of new permanent dialysis (14.8% hybrid vs 3.6% open; P =.043). There was no difference between groups in the rate of postoperative permanent paraplegia/paresis (8.3% open vs 7.4% hybrid; P =.294). There was a significantly increased rate of reintervention in the hybrid repair group (12.3% hybrid vs 1.2% open, P =.004), with all hybrid reinterventions performed because of endoleak. One-year survival was similar between groups at 69% in hybrid repairs vs 77% in open repairs. Long-term survival was worse in the hybrid group (5-year survival, 32% hybrid vs 56% open), although late survival appeared to be influenced mainly by comorbid disease burden, given the similar long-term aorta-specific survival between groups.Conclusions: Use of an algorithmic approach whereby higher risk patients with TAAA are treated by a hybrid approach and lower risk patients with conventional open repair yields satisfactory short-and long-term outcomes. The availability of multiple options for TAAA repair within a single center likely allows repair in more patients with consequent decrease in the risk of aorta-related death, at the expense of increased reinterventions for endoleak.