Kaan KIRALİ, Suat Nail ÖMEROĞLU, Füsun GÜZELMERİÇ, Bahadır DAĞLAR, Ömer IŞIK, Hasan ARDAL, Turan BERKİ, Esat AKINCI, Cevat YAKUT, Gökhan İPEK, Mustafa GÜLER, Ali GÜRBÜZ, Mehmet BALKANAY, Denyan MANSUROĞLU

Aort disseksiyonu tedavisinde fil hortumu prosedürünün kullanımı ve klinik sonuçları

Amaç: Aortik arkı da tutan aort disseksiyonlarının cerrahi tedavisinde transvers aortanın replasmanı için tercih edilen fil hortumu tekniği, son on yıldır oldukça geniş bir kullanım alanı bulmuştur. Bu retrospektif çalışmanın amacı kliniğimizde uygulanan fil hortumu tekniğinin klinik sonuçlarını gözden geçirmektir. Materyal ve Metot: Koşuyolu Kalp Eğitim ve Araştırma Hastanesi'nde 1993 ile Ekim 2000 tarihleri arasında aort disseksiyonu bulunan hastalardan 28'ine fil hortumu tekniği kullanılarak aortik ark replasmanı uygulandı. Hastaların 27'si (%96.4) erkek iken bir hasta (%3.6) kadın idi. Hastaların yaş ortalaması 50.3$pm$ 9.3 yıl (33-70) idi. Hastaların 14'ünde (%50) akut aort disseksiyonu mevcutken, geri kalan 14 hastada (%50) kronik disseksiyon vardı. Yaşayan hastalar 1-7 yıl arasında, ortalama 3.3 $pm$1 yıl süreyle takip edildi. Bulgular: Hastane mortalitesi 9 hasta ile %32.1 idi. Ölüm nedenleri düşük kalp debisi, akut tubuler nekroz, erişkinde sıkıntılı solunum sendromu, multi-organ yetmezliği, aşırı kanama ve serebrovasküler olay idi. Tüm hastalar için erken mortaliteyi etkileyebileceği düşünülen 18 değişken multivaryans analiz ile incelendi ve kronik obstruktif akciğer hastalığı (KOAH) (p < 0.001), ek aortik kapak replasmanı (p = 0.0276) ve perfüzyon zamanı (p = 0.0008) erken dönem mortalite üzerinde anlamlı faktörler olarak saptandı. Geç dönem mortalite 2 hastada (%10.5) görüldü; ölüm nedenleri greft endokarditi ve anevrizma rüptürü idi. Hastaların sağ kalım oranı 5 yıl için %55.1$pm$ 11.5 olarak bulundu. En sık rastlanan morbiditeler nörolojik komplikasyonlar (%21.4), pulmoner komplikasyonlar (%14.3) ve ritm problemleri (%7.4) idi. Hastalar disseksiyon tipine (p = 0.8), aciliyetine (p = 0.9) ve anevrizma mevcudiyetine (p = 0.5) göre gruplara ayrıldığında sağ kalım açısından aralarında bir farka rastlanmadı. Sonuç: Transvers aortanın replasmanını gerektiren aort disseksiyonlarının cerrahi tedavisinde uygulanan elafant trank tekniği ile arkus elemanlarının grefte anastomozu ve serebral kan akımının devamlılığı sağlanırken, gerektiğinde ikinci bir seansta desandan aortanın replasmanı kolaylıkla uygulanabilir.

The clinical results of elephant trunk technique in the treatments of aortic dissection

The elephant trunk technique, which is used for the surgical treatment of aortic dissections involving the arcus aorta by replacing the transverse aorta, is widespread popularized in the last decade. The purpose of this retrospective study is to assess the clinical results of elephant trunk technique performed in our clinic. Methods: Between 1993 and December 2000, elephant trunk technique was performed in 28 of all patients with aortic dissection in Koşuyolu Heart and Research Hospital. Twenty-seven patients (96.4%) were male and one patient (3.6%) was female. The mean age of the patients was 50.3 ± 9.3 years (range, 33 to 70 years). Acute aortic dissection developed in 14 patients (50%), while chronic dissection was observed in 14 patients (50%). The survivors were followed up for a mean of 3.3 $pm$ 1 years (range, 1 to 7 years). Results: The hospital mortality was 32.1% with 9 patients. The reasons were low cardiac output, acute tubular necrosis, ARDS, multiorgan failure, massive hemorrhage and CVA. In the multivariante analysis of 18 possible determinants of the early mortality, chronic obstructive pulmonary disease (p < 0.001), associated aortic valve replacement (p = 0.0276) and perfusion time (p = 0.0008) were the only significant risk factors. Late mortality was 10.5% with two patients, and the causes were graft endocarditis and rupture of the aneurysm. The survival rate was 55.1% $pm$11.5% at 5 years. The most common morbidities were neurologic complications (21.4%), pulmonary complications (14.3%) and ryhthm disturbances (7.4%). Actuarial freedom from death showed no difference for type of dissection (p = 0.8), emergency pattern of the dissection (p = 0.9) or associated aortic aneurysm (p = 0.5). Conclusions: Anastomosis of the arch branches to the graft, which is used for the elephant trank procedure during replacement of the transverse aorta, is keeping up the cerebral blood flow, and it is an effective technique that facilitates the replacement of the descending aorta in a second stage.

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