Reoperations after operation on the thoracic aorta: etiology, surgical techniques, and prevention.
Reoperations after operation on the thoracic aorta: etiology, surgical techniques, and prevention.
复制标题
胸主动脉术后再次手术：病因、手术技术和预防。
DOI：
10.1016/0003-4975(93)91157-i
复制
发表时间：
1993
期刊：
影响因子：
--
通讯作者：
Marko I. Turina
中科院分区：
文献类型：
--
作者：
Thierry Carrel;M. Pasic;R. Jenni;T. Tkebuchava;Marko I. Turina
胸主动脉手术后，复发性主动脉瘤、持续性或新发夹层、新发瓣膜和冠状动脉疾病、移植物感染和人工心内膜炎并不少见；它们可能很难诊断，并且是一项艰巨的手术挑战。 1977年至1991年间，我们机构进行了876例胸主动脉手术：340例夹层手术，299例真性动脉瘤手术，150例主动脉重塑和主动脉瓣置换术期间的外壁支撑，87例因其他原因。同期，又进行了 193 例再手术。腹主动脉和周围动脉的血管再手术占73例，本研究不再进一步讨论。 120 名患者再次手术的原因（n = 130）是： 生物瓣膜失效（n = 23）；近端或远端主动脉段动脉瘤复发（n = 21）；缝合线处假性动脉瘤形成（n = 13）；新的夹层或扩张涉及升主动脉 (n = 11)、主动脉弓 (n = 13) 和降主动脉 (n = 10)；主动脉重塑后动脉瘤（n = 13）；新发瓣膜病（n = 5）；和新发冠心病（n = 5）。感染的主动脉移植物和人工心内膜炎导致 10 例再次手术，6 例患者按计划进行了两阶段手术。排除失效的生物瓣膜，69.3%的病例对之前接受手术的主动脉段进行了再次手术，30.7%的病例对其他胸段进行了再次手术。再次手术后总体医院死亡率为5.8%。最近一段时期观察到手术死亡率显着下降（1989 年至 1991 年期间为 3.0%）。再次手术在技术上要求很高，其中一些是可以预防的；因此（1）升主动脉手术中应放弃移植物包涵技术，因为会形成假性动脉瘤； (2)对于马凡综合征患者，初次手术时应尝试完全修复病变主动脉； (3)低危患者首次手术时应明确主动脉弓夹层修复术； (4)动脉瘤手术中应避免使用生物瓣膜； (5)同种移植物置换是人工心内膜炎或主动脉瓣或升主动脉手术后感染的复合移植物的首选治疗方法。
Recurrent aortic aneurysms, persistent or new dissection, new onset of valvular and coronary artery disease, graft infection, and prosthetic endocarditis are not rare after thoracic aortic operations; they can be difficult to diagnose and represent a formidable surgical challenge. Between 1977 and 1991, 876 operations were performed on the thoracic aorta in our institution: 340 in dissections, 299 in true aneurysms, 150 for aortic remodeling and external wall support during aortic valve replacement, and 87 for miscellaneous causes. During the same period, there were 193 additional reoperations. Vascular reoperations on abdominal aorta and peripheral arteries accounted for 73 cases and are not further discussed in this study. The reasons for reoperation (n = 130) in 120 patients were: failure of biologic valves (n = 23); aneurysm recurrence in a proximal or distal aortic segment (n = 21); pseudoaneurysm formation at suture lines (n = 13); new dissection or dilatation involving ascending aorta (n = 11), aortic arch (n = 13), and descending aorta (n = 10); aneurysm after aortic remodeling (n = 13); new onset of valvular disease (n = 5); and new onset of coronary disease (n = 5). Infected aortic graft and prosthetic endocarditis accounted for 10 reoperations, and a planned two-staged procedure was performed in 6 patients. Omitting the failed biologic valves, reoperations were performed on the aortic segment previously operated on in 69.3% of the cases and on other thoracic segments in 30.7%. Overall hospital mortality rate after reoperation was 5.8%. A significant decrease in operative mortality was observed in the most recent period (3.0% between 1989 and 1991). Reoperations are technically demanding, and some of them are preventable; therefore (1) graft inclusion technique should be abandoned in ascending aortic operation due to formation of false aneurysms; (2) in patients with Marfan syndrome, complete repair of the diseased aorta should be attempted during the initial operation; (3) aortic arch dissection should be repaired definitively during the first operation in low-risk patients; (4) biological valves should be avoided in aneurysm operations; and (5) homograft replacement is the treatment of choice in prosthetic endocarditis or in infected composite graft after an aortic valve or ascending aortic operation.