Öz
Amaç: Akut tip A aort
diseksiyonlarının yaklaşık %10’u, semptomların olmaması veya tanı
konulamamasına bağlı olarak kronikleşmektedir. Bu hastalarda klinik gidiş, cerrahi
strateji ve sonuçlar farklılıklar göstermektedir. Bu çalışmada amaç kronik tip
A aort diseksiyonu nedeniyle opere edilen hastaların erken dönem sonuçlarını
analiz etmektir.
Gereç ve Yöntem: Çalışmaya 2001-2014
yılları arasında, kronik tip A aort diseksiyonu nedeniyle ameliyat edilen
toplam 41 hastanın verileri retrospektif olarak analiz edildi. Bu hastaların
28’ i erkek (%68) ve yaş ortalaması 55.9±13 yıl idi. Hastaların öyküsünde en
sık saptanan risk faktörleri hipertansiyon (%65), koroner arter hastalığı (%22)
idi. Tüm hastaların 13 tanesinde (%31.7) geçirilmiş aort veya diğer kardiyak
cerrahi öyküsü mevcuttu. Cerrahi insizyon olarak hastaların çoğunda (%95)
median sternotomi uygulandı.
Bulgular: Cerrahi teknik olarak
20 hastaya basit tüp greft replasmanı, 15 hastada aort kökü kondüit greft
replasmanı, 6 hastada total arkus replasmanı uygulandı. Beyin koruma stratejisi
olarak derin hipotermik sirkülatuar arrest (%82.9), ve antegrad serebral
perfüzyon (%17.1) uygulandı. Tüm hastalarda saptanan ortalama kardiyopulmoner by-pass süresi 210.1±67 dk, miyokard
iskemi süresi ise 116.3±43 dk olarak saptandı. Ortalama serebral iskemi süresi
27.6±9 dakika olarak bulundu. Postoperatif 3 hastada reeksplorasyon gerektiren
kanama, 5 hastada uzamış mekanik ventilatör desteği gerekmiştir. Hastaların
ortalama yoğun bakım kalış süresi 4.1±5 gün iken hastanede kalış süresi 9.8±8
gün olarak bulundu. Bir hastada multipl embolilere bağlı kalıcı strok gelişti.
Mortalite bir hastada (%2) görülmüş olup bu hastada ölüm nedeni embolik strok
olarak kaydedilmiştir.
Sonuç: Kronik tip A aort
diseksiyonlu hastaların cerrahi tedavisinde düşük mortalite oranı uygun
strateji ile sağlanabilir. Strok en önemli mortalite nedeni olarak göze
çarpmaktadır.
Anahtar Kelimeler
Kaynakça
- Hynes CF, Greenberg MD, Sarin S, Trachiotis GD. Chronic type A aortic dissection: Two cases and a review of current management strategies. Aorta (Stamford) 2016;4(1):16-21.
- Cabasa A, Pochettino A. Surgical management and outcomes of type A dissection: The Mayo Clinic experience. Ann Cardiothorac Surg 2016; 5(4):296-309.
- Peterss S, Mansour AM, Ross JA, et al. Changing pathology of the thoracic aorta from acute to chronic dissection: Literature review and insights. J Am Coll Cardiol 2016;68(10):1054-65.
- Rylski B, Milewski RK, Bavaria JE, et al. Outcomes of surgery for chronic type A aortic dissection. Ann Thorac Surg 2015;99(1):88-93.
- Hirst AE Jr, Johns VJ Jr, Kime SW Jr. Dissecting aneurysm of the aorta: A review of 505 cases. Medicine (Baltimore) 1958;37(3):217-79.
- Yuan Q, Yu H, Karmacharya U, et al. Comparison of chronic type A aortic dissection with acute type A dissection of short-term and long-term survival rate. Int J Cardiol 2014;175(2):363-5.
- Roselli EE, Idrees J, Greenberg RK, Johnston DR, Lytle BW. Endovascular stent grafting for ascending aorta repair in high-risk patients. J Thorac Cardiovasc Surg 2015;149(1):144-51.
- Harky A, Fok M, Bashir M, Estrera AL. Brain protection in aortic arch aneurysm: Antegrade or retrograde? Gen Thorac Cardiovasc Surg 2018;3. doi: 10.1007/s11748-017-0879-5. [Epub ahead of print]
- UrbanskiPP, Lenos A, Bougioukakis P, Neophytou I, Zacher M, Diegeler A. Mild-to-moderate hypothermia in aortic arch surgery using circulatory arrest: A change of paradigm? Eur J Cardiothoracic Surg 2012; 41(1):185-91.
- Keeling WB, Tian DH, Leshnower BG. Safety of moderate hypothermia with antegrade cerebral perfusion in total aortic arch replacement. Ann Thorac Surg 2018;105(1):54-61.
- Tian DH, Wan B, Bannon PG, et al. A meta-analysis of deep hypothermic circulatory arrest versus moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion. Ann Cardiothorac Surg 2013;2(2):148-58.
- Kouchoukos NT. Straight deep hypothermic circulatory arrest for aortic arch surgery: Going the way of the dinosaurs? J Thorac Cardiovasc Surg 2017;154(6):1840-1.
Öz
Aim: Approximately
10% of acute type A aortic dissections become chronic due to lack of symptoms
or non-diagnosis. Clinical course, surgical strategy and outcomes differ. This
study aims to analyze early outcomes of surgical treatment for chronic type A
aortic dissection.
Materials and Methods: Forty-one patients operated for chronic type A aortic
dissection between 2001 and 2014, were included in this study and the data were
analyzed retrospectively. Mean age 55.9±13 years and 68% were male. The common
risk factors for aortic dissection were hypertension (65%) and coronary artery
disease (22%). Thirteen patients (31%) were previously operated for aortic or
other cardiac procedure. Surgical incision was median sternotomy in most of
patients (95%).
Results: The
common procedures were tube graft replacement (20 patients), valved-conduit
graft replacement for aortic root (15 patients) and total arch replacement (6
patients). Deep hypothermic circulatory arrest was used in 34 patients and
additional antegrad cerebral perfusion in 7 patients, as brain protection
strategy. The mean duration of cardiopulmonary bypass, myocardial ischemia time
and cerebral ischemia were 210.1±67, 116.3±43 and 27.6±9 min, respectively. The
common complications were re-exploration for bleeding in 3 patients, need for
prolonged ventilator
support in 5 patients. Mean intensive care unit and hospital stay was found
4.1±5 days and 9.8±8 days, respectively. Permanent stroke was observed in one
patient because of multiple embolisms. Mortality was observed in one patient
(%2) due to embolic stroke.
Conclusion: A low
mortality rate can be achieved with appropriate strategy in the surgical
treatment of chronic type A aortic dissection. Stroke seems to be the common
cause of mortality.
Anahtar Kelimeler
Chronic aortic dissection aortic replacement stroke mortality.
Kaynakça
- Hynes CF, Greenberg MD, Sarin S, Trachiotis GD. Chronic type A aortic dissection: Two cases and a review of current management strategies. Aorta (Stamford) 2016;4(1):16-21.
- Cabasa A, Pochettino A. Surgical management and outcomes of type A dissection: The Mayo Clinic experience. Ann Cardiothorac Surg 2016; 5(4):296-309.
- Peterss S, Mansour AM, Ross JA, et al. Changing pathology of the thoracic aorta from acute to chronic dissection: Literature review and insights. J Am Coll Cardiol 2016;68(10):1054-65.
- Rylski B, Milewski RK, Bavaria JE, et al. Outcomes of surgery for chronic type A aortic dissection. Ann Thorac Surg 2015;99(1):88-93.
- Hirst AE Jr, Johns VJ Jr, Kime SW Jr. Dissecting aneurysm of the aorta: A review of 505 cases. Medicine (Baltimore) 1958;37(3):217-79.
- Yuan Q, Yu H, Karmacharya U, et al. Comparison of chronic type A aortic dissection with acute type A dissection of short-term and long-term survival rate. Int J Cardiol 2014;175(2):363-5.
- Roselli EE, Idrees J, Greenberg RK, Johnston DR, Lytle BW. Endovascular stent grafting for ascending aorta repair in high-risk patients. J Thorac Cardiovasc Surg 2015;149(1):144-51.
- Harky A, Fok M, Bashir M, Estrera AL. Brain protection in aortic arch aneurysm: Antegrade or retrograde? Gen Thorac Cardiovasc Surg 2018;3. doi: 10.1007/s11748-017-0879-5. [Epub ahead of print]
- UrbanskiPP, Lenos A, Bougioukakis P, Neophytou I, Zacher M, Diegeler A. Mild-to-moderate hypothermia in aortic arch surgery using circulatory arrest: A change of paradigm? Eur J Cardiothoracic Surg 2012; 41(1):185-91.
- Keeling WB, Tian DH, Leshnower BG. Safety of moderate hypothermia with antegrade cerebral perfusion in total aortic arch replacement. Ann Thorac Surg 2018;105(1):54-61.
- Tian DH, Wan B, Bannon PG, et al. A meta-analysis of deep hypothermic circulatory arrest versus moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion. Ann Cardiothorac Surg 2013;2(2):148-58.
- Kouchoukos NT. Straight deep hypothermic circulatory arrest for aortic arch surgery: Going the way of the dinosaurs? J Thorac Cardiovasc Surg 2017;154(6):1840-1.
Ayrıntılar
| Birincil Dil | Türkçe |
|---|---|
| Konular | Sağlık Kurumları Yönetimi |
| Bölüm | Araştırma Makaleleri |
| Yazarlar | |
| Yayımlanma Tarihi | 14 Mart 2019 |
| Gönderilme Tarihi | 25 Mart 2018 |
| Yayımlandığı Sayı | Yıl 2019 |