Evolution of surgical therapy for Stanford acute type A aortic dissection
Evolution of surgical therapy for Stanford acute type A aortic dissection
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DOI：
10.21037/acs.2016.05.05
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发表时间：
2016-07-01
影响因子：
3.1
通讯作者：
Miller, D. Craig
中科院分区：
文献类型：
--
作者：
Chiu, Peter;Miller, D. Craig
急性A型主动脉夹层(ACA-AOD)是一种发病率和死亡率都很高的外科急症。不幸的是，在过去的20年里，紧急手术修复的早期结果并没有实质性的改善。许多同样的争论反复发生在手术范围和手术的最佳实施上。问题仍然是：患者接受的手术是太大还是太小？在可行的情况下，有利于常规主动脉瓣再悬浮的钟摆已经转向了频繁的主动脉根部置换。这种已经很积极的方法现在正受到挑战，在选定的患者中进行更广泛的保留瓣膜的主动脉根部置换术(V-SARR)。在远端，大部分横弓的开放置换在大多数患者中是最好的。更广泛的远端手术操作并未显示出晚期再介入主动脉的必要性，但当代对远端冷冻象鼻(FET)的热情似乎只是建立起来的。必须记住，行动的首要目标是有一名手术幸存者；减少晚期发病率的额外措施是次要的愿望。随着经验的增加，急诊手术的真正禁忌症已经减少，但高龄、多重合并症和严重神经功能障碍的患者情况不佳。此外，血管内革命催生了现代实践的创新选择，包括上升支架移植和对旧的瓣膜开窗技术的改造。尽管手术越来越复杂，治疗方法也在不断扩大，但这种危及生命的疾病仍然是所有心血管外科医生面临的一项顽强挑战。发展专门的胸主动脉团队和对ACA-AOD患者进行地区性护理提供了改善总体结果的最大希望。
Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small? The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results.