全弓部置換手術におけるエレファントトランクの有用性
要 旨：遠位弓部大動脈瘤において遠位側吻合部が深い場合，および急性解離(AAD)に対する全弓部置換手術(TAR)の際には，elephant trunk(ET)を用いてきた．今回，その手術成績と対麻痺の発生，およびET周囲の血栓化からその有用性を検討した．【方法】2004～2012年に行ったTAR 122例のうち，ETを併用した40例．原因疾患は遠位弓部大動脈瘤27例，AAD 13例．2007年以降遠位弓部大動脈瘤全例(n=15)で術前CTにてAdamkiewicz動脈(AKA)を同定．【結果】全体の手術死亡1例(2.5%)．ET長は平均11.4(7-22)cm．ET長と対麻痺の関連を検討した...
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| Published in | 日本血管外科学会雑誌 Vol. 22; no. 2; pp. 77 - 84 |
|---|---|
| Main Authors | , , , , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
特定非営利活動法人 日本血管外科学会
2013
日本血管外科学会 |
| Subjects | |
| Online Access | Get full text |
| ISSN | 0918-6778 1881-767X |
| DOI | 10.11401/jsvs.22.77 |
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| Abstract | 要 旨：遠位弓部大動脈瘤において遠位側吻合部が深い場合，および急性解離(AAD)に対する全弓部置換手術(TAR)の際には，elephant trunk(ET)を用いてきた．今回，その手術成績と対麻痺の発生，およびET周囲の血栓化からその有用性を検討した．【方法】2004～2012年に行ったTAR 122例のうち，ETを併用した40例．原因疾患は遠位弓部大動脈瘤27例，AAD 13例．2007年以降遠位弓部大動脈瘤全例(n=15)で術前CTにてAdamkiewicz動脈(AKA)を同定．【結果】全体の手術死亡1例(2.5%)．ET長は平均11.4(7-22)cm．ET長と対麻痺の関連を検討したところ，15 cm以上の15例中4例(27%)に対麻痺を認め，12 cm以下の25例では対麻痺はなかった(p<0.01)．AKAを同定温存した14例で対麻痺はなかった．遠位弓部大動脈瘤でET周囲の血栓化により一期的根治を期待した21例中16例(76.2%)で瘤は血栓化し縮小．AADではET長は7-10 cmで対麻痺はなく，13例中2例で完全に解離腔が消失，8例で平均T8まで血栓化．【結論】TAR+ETの手術成績は良好であった．遠位弓部大動脈瘤ではETにより瘤の血栓化が得られるが，その長さが15 cm以上で対麻痺の危険が高く，ET長の決定には充分な注意が必要である．よって，現在ではETによる瘤の血栓化を期待するのではなく計画的二期手術(hybrid手術)を基本方針としている．またAADではET長が7-10 cmで良好な血栓化が得られ，対麻痺もなかったことから妥当な長さであると考える． |
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| AbstractList | 「要旨」: 遠位弓部大動脈瘤において遠位側吻合部が深い場合, および急性解離 (AAD) に対する全弓部置換手術 (TAR) の際には, elephant trunk (ET) を用いてきた. 今回, その手術成績と対麻痺の発生, およびET周囲の血栓化からその有用性を検討した. 【方法】2004～2012年に行ったTAR122例のうち, ETを併用した40例. 原因疾患は遠位弓部大動脈瘤27例, AAD13例. 2007年以降遠位弓部大動脈瘤全例 (n=15) で術前CTにてAdamkiewicz動脈 (AKA) を同定. 【結果】全体の手術死亡1例 (2.5%) . ET長は平均11.4 (7-22) cm. ET長と対麻痺の関連を検討したところ, 15cm以上の15例中4例 (27%) に対麻痺を認め, 12cm以下の25例では対麻痺はなかった (p<0.01) . AKAを同定温存した14例で対麻痺はなかった. 遠位弓部大動脈瘤でET周囲の血栓化により一期的根治を期待した21例中16例 (76.2%) で瘤は血栓化し縮小. AADではET長は7-10cmで対麻痺はなく, 13例中2例で完全に解離腔が消失, 8例で平均T8まで血栓化. 【結論】TAR+ETの手術成績は良好であった. 遠位弓部大動脈瘤ではETにより瘤の血栓化が得られるが, その長さが15cm以上で対麻痺の危険が高く, ET長の決定には充分な注意が必要である. よって, 現在ではETによる瘤の血栓化を期待するのではなく計画的二期手術 (hybrid手術) を基本方針としている. またAADではET長が7-10cmで良好な血栓化が得られ, 対麻痺もなかったことから妥当な長さであると考える. 要 旨：遠位弓部大動脈瘤において遠位側吻合部が深い場合，および急性解離(AAD)に対する全弓部置換手術(TAR)の際には，elephant trunk(ET)を用いてきた．今回，その手術成績と対麻痺の発生，およびET周囲の血栓化からその有用性を検討した．【方法】2004～2012年に行ったTAR 122例のうち，ETを併用した40例．原因疾患は遠位弓部大動脈瘤27例，AAD 13例．2007年以降遠位弓部大動脈瘤全例(n=15)で術前CTにてAdamkiewicz動脈(AKA)を同定．【結果】全体の手術死亡1例(2.5%)．ET長は平均11.4(7-22)cm．ET長と対麻痺の関連を検討したところ，15 cm以上の15例中4例(27%)に対麻痺を認め，12 cm以下の25例では対麻痺はなかった(p<0.01)．AKAを同定温存した14例で対麻痺はなかった．遠位弓部大動脈瘤でET周囲の血栓化により一期的根治を期待した21例中16例(76.2%)で瘤は血栓化し縮小．AADではET長は7-10 cmで対麻痺はなく，13例中2例で完全に解離腔が消失，8例で平均T8まで血栓化．【結論】TAR+ETの手術成績は良好であった．遠位弓部大動脈瘤ではETにより瘤の血栓化が得られるが，その長さが15 cm以上で対麻痺の危険が高く，ET長の決定には充分な注意が必要である．よって，現在ではETによる瘤の血栓化を期待するのではなく計画的二期手術(hybrid手術)を基本方針としている．またAADではET長が7-10 cmで良好な血栓化が得られ，対麻痺もなかったことから妥当な長さであると考える． |
| Author | 梶山, 哲也 辻家, 紀子 山村, 光弘 光野, 正孝 福井, 伸哉 宮本, 裕治 田中, 宏衞 良本, 政章 |
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| References | 2)Borst HG, Frank G, Schaps D. Treatment of extensive aortic aneurysms by a new multiple-stage approach. J Thorac Cardiovasc Surg 1988;95:11-13. 22)Jacobs MJ, Elenbaas TW, Schurink GW, et al. Assessment of spinal cord integrity during thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 2002;74:S1864-S1866; discussion S1892-S1898. 8)Ando M, Takamoto S, Okita Y, et al. Elephant trunk procedure for surgical treatment of aortic dissection. Ann Thorac Surg 1998;66:82-87. 23)Kawaharada N, Morishita K, Fukada J, et al. Thoracoabdominal or descending aortic aneurysm repair after preoperative demonstration of the Adamkiewicz artery by magnetic resonance angiography. Eur J Cardiothorac Surg 2002;21:970-974. 12)Heinemann MK, Buehner B, Jurmann MJ, et al. Use of the "elephant trunk technique" in aortic surgery. Ann Thorac Surg 1995;60:2-6; discussion 7. 11)Coselli JS, LeMaire SA, Carter SA, et al. The reversed elephant trunk technique used for treatment of complex aneurysms of the entire thoracic aorta. Ann Thorac Surg 2005;80:2166-2172; discussion 2172. 5)Le Maire SA, Carter SA, Coselli JS. The elephant trunk technique for staged repair of complex aneurysms of entire thoracic aorta. Ann Thorac Surg 2006; 81:1561-1569. 21)Griepp RB, Ergin MA, Galla JD, et al. Looking for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of descending thoracic and thoracoabdominal aorta. J Thorac Cardiovasc Surg 1996;112:1202-1213. 25)Etz CD, Halstead JC, Spielvogel D, et al. Thoracic and thoracoabdominal aneurysm repair: is reimplantation of spinal cord arteries a waste of time? Ann Thorac Surg 2006;82:1670-1677. 1)Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg 1983;31:37-40. 28)Di Eusanio M, Armaro A, Di Marco L, et al. Short- and midterm results after hybrid treatment of chronic aortic dissection with the frozen elephant trunk technique. Eur J Cardiothorac Surg 2011;40:875-880. 20)Takase K, Sawamura Y, Igarashi, et al. Demonstration of the artery of Adamkiewicz at multi-detector row helical CT. Radiology 2002;223:39-45. 13)Nishi H, Mitsuno M, Tanaka H, et all. Spinal cord injury in patients undergoing total arch replacement: a cautionary note for use of the long elephant technique. J Thorac Cardiovasc Surg 2011;142:1084-1089. 29)Obitsu Y, Koizumi N, Iida Y, et al. Long-term results of second-stage thoracic endovascular aortic repair following total aortic arch replacement. Gen Thorac Cardiovasc Surg 2010;58:501-505. 19)Kubo K, Terae S, Asano T, et al. Anterior spinal artery and artery of Adamkiewicz detected by using multi-detector row CT. AJNR Am J Neuroradiol 2003;24:13-17. 9)Toda K, Taniguchi K, Masai T, et al. Arch aneurysm repair with long elephant trunk: a 10-year experience in 111 patients. Ann Thorac Surg 2009;88:16-22. 18)Flores J, Kunihara T, Shiiya N, et al. Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury. J Thorac Cadiovasc Surg 2006;131:336-342. 17)Uchida N, Shibamura H, Katayama A, et al. Long-term results of the frozen elephant trunk technique for the extensive arteriosclerotic aneurysm. J Thorac Cardiovasc Surg 2010;139:913-917. 27)Pacini D, Tsagakis K, Jakob H, et al. The frozen elephant trunk for treatment of chronic dissection of the thoracic aorta: a multicenter experience. Ann Thorac Surg 2011;92:1663-1670. 6)Safi HJ, Miller CC III, Estrera AL, et al. Optimization of aortic arch replacement: two-stage approach. Ann Thorac Surg 2007; 83: S815-S818. 7)Etz CD, Plestis KA, Kari FA, et al. Staged repair of thoracic and thoracoabdominal aortic aneurysms using the elephant trunk technique: a consecutive series of 215 first stage and 120 complete repairs. Eur J Cardiothorac Surg 2008;34:605-615. 4)Svensson LG. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Card Surg 1992;7:301-312. 10)Watanuki H, Ogino H, Minatoya K, et al. Is emergency total arch replacement with a modified elephant trunk technique justified for acute type A aortic dissection? Ann Thorac Surg 2007;84:1585-1591. 14)Kato M, Ohnishi K, Kaneko M, et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stentted graft. Circulation 1996;94(9 Suppl):II188-II1193. 24)Safi HJ, Estrera AL, Miller CC, et al. Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair. Ann Thorac Surg 2005;80:2173-2179; discussion 2179. 26)Pochettino A, Brinkman WT, Moeller P, et al. Antegrade thoracic stent grafting during repair of acute DeBakey I dissection prevents development of thoracoabdominal aortic aneurysms. Ann Thorac Surg 2009;88:482-489; discussion 489-490. 3)Crawford ES, Coselli JS, Svensson LG, et al. Diffuse aneurysmal disease (chronic aortic dissection, Marfan, and mega aorta syndromes) and multiple aneurysm. Treatment by subtotal and total aortic replacement emphasizing the elephant trunk operation. Ann Surg 1990;211:521-537. 16)Gorlitzer M, Weiss G, Thalmann M, et al. Combined surgical and endovascular repair of complex aortic pathologies with a new hybrid prosthesis. Ann Thorac Surg 2007;84:1971-1976. 15)Di Bartolomeo R, Di Marco L, Armaro A, et al. Treatment of complex disease of the thoracic aorta: the frozen elephant trunk technique with the E-vita open prosthesis. Eur J Cardiothorac Surg 2009;35:671-676. |
| References_xml | – reference: 23)Kawaharada N, Morishita K, Fukada J, et al. Thoracoabdominal or descending aortic aneurysm repair after preoperative demonstration of the Adamkiewicz artery by magnetic resonance angiography. Eur J Cardiothorac Surg 2002;21:970-974. – reference: 6)Safi HJ, Miller CC III, Estrera AL, et al. Optimization of aortic arch replacement: two-stage approach. Ann Thorac Surg 2007; 83: S815-S818. – reference: 16)Gorlitzer M, Weiss G, Thalmann M, et al. Combined surgical and endovascular repair of complex aortic pathologies with a new hybrid prosthesis. Ann Thorac Surg 2007;84:1971-1976. – reference: 15)Di Bartolomeo R, Di Marco L, Armaro A, et al. Treatment of complex disease of the thoracic aorta: the frozen elephant trunk technique with the E-vita open prosthesis. Eur J Cardiothorac Surg 2009;35:671-676. – reference: 2)Borst HG, Frank G, Schaps D. Treatment of extensive aortic aneurysms by a new multiple-stage approach. J Thorac Cardiovasc Surg 1988;95:11-13. – reference: 11)Coselli JS, LeMaire SA, Carter SA, et al. The reversed elephant trunk technique used for treatment of complex aneurysms of the entire thoracic aorta. Ann Thorac Surg 2005;80:2166-2172; discussion 2172. – reference: 4)Svensson LG. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Card Surg 1992;7:301-312. – reference: 18)Flores J, Kunihara T, Shiiya N, et al. Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury. J Thorac Cadiovasc Surg 2006;131:336-342. – reference: 14)Kato M, Ohnishi K, Kaneko M, et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stentted graft. Circulation 1996;94(9 Suppl):II188-II1193. – reference: 1)Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg 1983;31:37-40. – reference: 8)Ando M, Takamoto S, Okita Y, et al. Elephant trunk procedure for surgical treatment of aortic dissection. Ann Thorac Surg 1998;66:82-87. – reference: 20)Takase K, Sawamura Y, Igarashi, et al. Demonstration of the artery of Adamkiewicz at multi-detector row helical CT. Radiology 2002;223:39-45. – reference: 12)Heinemann MK, Buehner B, Jurmann MJ, et al. Use of the "elephant trunk technique" in aortic surgery. Ann Thorac Surg 1995;60:2-6; discussion 7. – reference: 27)Pacini D, Tsagakis K, Jakob H, et al. The frozen elephant trunk for treatment of chronic dissection of the thoracic aorta: a multicenter experience. Ann Thorac Surg 2011;92:1663-1670. – reference: 29)Obitsu Y, Koizumi N, Iida Y, et al. Long-term results of second-stage thoracic endovascular aortic repair following total aortic arch replacement. Gen Thorac Cardiovasc Surg 2010;58:501-505. – reference: 9)Toda K, Taniguchi K, Masai T, et al. Arch aneurysm repair with long elephant trunk: a 10-year experience in 111 patients. Ann Thorac Surg 2009;88:16-22. – reference: 26)Pochettino A, Brinkman WT, Moeller P, et al. Antegrade thoracic stent grafting during repair of acute DeBakey I dissection prevents development of thoracoabdominal aortic aneurysms. Ann Thorac Surg 2009;88:482-489; discussion 489-490. – reference: 22)Jacobs MJ, Elenbaas TW, Schurink GW, et al. Assessment of spinal cord integrity during thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 2002;74:S1864-S1866; discussion S1892-S1898. – reference: 17)Uchida N, Shibamura H, Katayama A, et al. Long-term results of the frozen elephant trunk technique for the extensive arteriosclerotic aneurysm. J Thorac Cardiovasc Surg 2010;139:913-917. – reference: 24)Safi HJ, Estrera AL, Miller CC, et al. Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair. Ann Thorac Surg 2005;80:2173-2179; discussion 2179. – reference: 3)Crawford ES, Coselli JS, Svensson LG, et al. Diffuse aneurysmal disease (chronic aortic dissection, Marfan, and mega aorta syndromes) and multiple aneurysm. Treatment by subtotal and total aortic replacement emphasizing the elephant trunk operation. Ann Surg 1990;211:521-537. – reference: 13)Nishi H, Mitsuno M, Tanaka H, et all. Spinal cord injury in patients undergoing total arch replacement: a cautionary note for use of the long elephant technique. J Thorac Cardiovasc Surg 2011;142:1084-1089. – reference: 5)Le Maire SA, Carter SA, Coselli JS. The elephant trunk technique for staged repair of complex aneurysms of entire thoracic aorta. Ann Thorac Surg 2006; 81:1561-1569. – reference: 19)Kubo K, Terae S, Asano T, et al. Anterior spinal artery and artery of Adamkiewicz detected by using multi-detector row CT. AJNR Am J Neuroradiol 2003;24:13-17. – reference: 7)Etz CD, Plestis KA, Kari FA, et al. Staged repair of thoracic and thoracoabdominal aortic aneurysms using the elephant trunk technique: a consecutive series of 215 first stage and 120 complete repairs. Eur J Cardiothorac Surg 2008;34:605-615. – reference: 21)Griepp RB, Ergin MA, Galla JD, et al. Looking for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of descending thoracic and thoracoabdominal aorta. J Thorac Cardiovasc Surg 1996;112:1202-1213. – reference: 28)Di Eusanio M, Armaro A, Di Marco L, et al. Short- and midterm results after hybrid treatment of chronic aortic dissection with the frozen elephant trunk technique. Eur J Cardiothorac Surg 2011;40:875-880. – reference: 10)Watanuki H, Ogino H, Minatoya K, et al. Is emergency total arch replacement with a modified elephant trunk technique justified for acute type A aortic dissection? Ann Thorac Surg 2007;84:1585-1591. – reference: 25)Etz CD, Halstead JC, Spielvogel D, et al. Thoracic and thoracoabdominal aneurysm repair: is reimplantation of spinal cord arteries a waste of time? Ann Thorac Surg 2006;82:1670-1677. |
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| Snippet | 要 旨：遠位弓部大動脈瘤において遠位側吻合部が深い場合，および急性解離(AAD)に対する全弓部置換手術(TAR)の際には，elephant trunk(ET)を用いてきた．今回，その手術成績と対麻痺の発生，およびET周囲の血栓化からその有用性を検討した．【方法】2004～2012年に行ったTAR... 「要旨」: 遠位弓部大動脈瘤において遠位側吻合部が深い場合, および急性解離 (AAD) に対する全弓部置換手術 (TAR) の際には, elephant trunk (ET) を用いてきた. 今回, その手術成績と対麻痺の発生, およびET周囲の血栓化からその有用性を検討した.... |
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| SubjectTerms | アダムキュービッツ動脈 エレファントトランク ハイブリッド手術 全弓部置換術 |
| Title | 全弓部置換手術におけるエレファントトランクの有用性 |
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| ispartofPNX | 日本血管外科学会雑誌, 2013/04/19, Vol.22(2), pp.77-84 |
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