升主动脉瘤的外科治疗分析

目的总结升主动脉瘤的外科治疗经验。方法23例主动脉根部病变患者(年龄22~55岁,平均31.8岁),其中Mafan’s综合征12例,Stanford A型主动脉夹层8例,主动脉瓣狭窄伴升主动脉扩张3例。手术类型:Bentall手术18例,Wheat手术3例,David手术1例,全弓置换加象鼻手术1例。结果全组手术死亡1例,术后随访12例平均41个月,无并发症。结论Bentall手术是治疗升主动脉瘤的主要术式,主动脉瓣叶正常,瓣膜轻度关闭不全,瓣环无明显扩张,David手术可以减少换瓣后服用抗凝药物所致的出血、血栓等并发症。     

经右腋动脉选择性脑灌注在主动脉夹层手术中的应用

目的总结右腋动脉插管体外循环(ECC)、选择性顺行脑灌注在主动脉夹层手术中应用的初步经验。方法回顾性分析我院2005年1月—2008年7月采用深低温停循环(DHCA)加右腋动脉插管选择性顺行脑灌注(ASCP)手术治疗I型主动脉夹层10例。男8例,女2例。年龄24~63岁,平均(41.7±12.0)岁。升主动脉+全弓置换+降主动脉术中支架置入术5例,升主动脉+全弓置换2例,升主动脉+右半弓置换3例。结果本组主动脉阻断时间83~258min,平均(132.3±52.8)min。深低温停循环时间8~53min,平均(29.10±18.30)min,选择性脑灌注时间8~58min,平均(33.4±18.5)min。手术死亡2例,1例因术中出血、体外循环时间长不能脱机,1例因术后低心排和多脏器功能衰竭。术后暂时性脑损害2例,均治愈出院,无永久性脑损害发生。结论右腋动脉插管灌注和顺行脑灌注在主动脉夹层手术中可提供有效的脑保护,其操作简便、安全。     

88例Stanford A型主动脉夹层外科治疗效果

目的探讨Stanford A型主动脉夹层患者手术治疗效果。方法回顾性分析自2011年1月至2016年3月青岛大学附属医院收治的88例Stanford A型主动脉夹层患者临床资料,分析患者术前、体外循环、围术期输血量、机械通气时间、ICU住院时间、总住院时间及术后并发症等相关资料。结果行非全弓置换术16例为非全弓置换术组,其中,单纯升主动脉置换术7例,单纯Bentall手术9例;行全弓置换术72例为全弓置换术组,其中,升主动脉置换+孙氏手术40例,Bentall手术+孙氏手术31例,David手术+孙氏手术1例。与非全弓置换术组比较,全弓置换术组患者术中鼻咽温及肛温低,体外循环及升主动脉阻断时间长,术中红细胞、血浆及血小板输血量大,术后呼吸机通气时间及ICU住院时间长,引流量多,术后红细胞、血浆、血小板输注量大,神经系统并发症发生率高,差异均有统计学意义(P<0.05)。患者自体输血量,总住院时间,术后急性肾损伤、低氧血症、连续肾替代疗法应用、二次气管插管、气管切开情况及病死率方面,全弓置换术组高于非全弓置换术组,但差异无统计学意义(P>0.05)。术后随访,非全弓置换术组2例(12.5%)患者因主动脉弓部夹层行全弓置换术+降主动脉支架植入术,全弓置换术组无行二次手术者,差异有统计学意义(P<0.05)。结论 Stanford A型主动脉夹层患者病变复杂,病情重,手术风险大,病死率高,但手术治疗效果满意;术中脑保护尤为重要,选择手术方式应综合考虑。     

DeBakey Ⅰ型急性主动脉夹层围术期处理策略

目的 总结DeBakey Ⅰ型主动脉夹层围术期处理要点.方法纳入2004年2月-2008年1月解放军总医院完成DeBakey Ⅰ型主动脉夹层急诊手术的19例患者,其中男16例,女3例,年龄43.6±9.4岁.全部替换升主动脉,同期替换主动脉根部(Bentall)5例、主动脉瓣2例、右半弓11例、全弓6例(其中降主动脉内带膜支架4例、传统象鼻手术1例),同期行二尖瓣成形术1例.涉及主动脉弓部的手术均在深低温停循环下完成.16例经右腋动脉插管.围术期处理策略:入院后立即应用大剂量β受体阻断剂和硝普钠等将收缩压控制在90mmHg左右,2h内完成主动脉CT扫描三维重建、超声心动图、心电图、X线胸片和实验室检查等急诊术前准备.术中根据夹层和内膜破口的部位采取简便可行的手术方案,以挽救生命为第一目标.常规使用超滤以减轻水负荷和炎症反应.术毕将收缩压严格控制在90mmHg左右.术后强化镇静和呼吸机治疗,强调使用呼吸机呼气末正压(PEEP),待低氧血症纠正和肺水肿消退后方可脱离呼吸机.结果 19例患者体外循环时间215.9±73.6min,主动脉阻断时间138.2±55.7min,脑部停循环时间29.3±11.5min.呼吸机辅助通气时间156.1±112.8(11～460)h.死亡3例(15.8%);发生须行血液透析的一过性肾功能不全1例,慢性心包填塞行穿刺引流2例;发生低氧血症(氧合指数PaO_2/FiO_2≤300)10例,其中5例术前已存在低氧血症.结论 DeBakey Ⅰ型主动脉夹层手术风险大,完善的围术期处理是降低死亡率的重要保障.     

胸主动脉瘤外科治疗(附4例报告)

本文介绍4例胸主动瘤外科治疗的经验.全组均为男性,年龄23～37岁.病变属DeBakeyⅠ型2例,Ⅱ型1例,主动脉窦动脉瘤1例,其中2例伴夹层动脉瘤.采用Bentall手术(即升主动脉瘤切除,带瓣血管作主动脉替换和左右冠脉开口移植)和Wheat手术各1例,升主动脉和部分弓切除替换加主动脉瓣置换1例,另1例为单纯主动脉瓣膜置换.手术均获成功,经6～36月随访,临床症状消失,能从事正常生活和轻工作.作者强调早期诊断和早期手术的重要性,并对预防吻合出血进行了讨论.     

主动脉夹层术后截瘫继发骨关节病和软组织钙化一例

患者 男,42岁.1年前因Debakey I型主动脉夹层（扩展至肾动脉开口下方）并冠状动脉受累及主动脉瓣关闭不全,在外院接受升主动脉及主动脉全弓置换、降主动脉支架象鼻术等复合手术.     

Stanford B型主动脉夹层多型支架介入治疗的临床体会

目的 应用多种类型支架行Stanford B型主动脉夹层介入治疗,探讨扩大介入治疗适应证的可行性.方法 回颐性分析2004年5月-2009年12月,18例Stanford B型主动脉夹层患者行介入性腔内修复术治疗的临床资料.根据CTA和DSA结果,个体化选择合适覆膜支架,透视下将覆膜支架经股动脉导入封闭夹层破口.术后CTA随访观察内漏、支架移位、假腔变化等.结果 18例中2例放置分体式主动脉覆膜支架、1例放置分支型覆膜支架、2例放置预留孔型主动脉覆膜支架,13例放置普通主动脉覆膜支架.1例封堵左锁骨下动脉、2例不全封堵左锁骨下动脉均未出现左上肢和椎基底动脉缺血症状;1例因解剖变异右锁骨下动脉起自主动脉弓而行旁路手术.术后发生8例(44.4%)即刻I型内漏,其中1例腔内修复术后持续I型内漏再次放置支架后进展为Standford A型主动脉夹层瘤而行升主动脉人工血管置换术,其余CTA随访内漏逐渐消失;所有患者均无支架移位、断裂、塌陷以及术后截瘫及脑血管意外发生.结论 采取不同方法延长近端锚定区的距离、应用分体式主动脉支架可扩大介入治疗Standflord B 型主动脉夹层的适应证,且近期疗效好,中、远期疗效有待进一步观察.     

胸主动脉瘤腔内隔绝术与传统手术的护理特点比较

胸主动脉夹层动脉瘤腔内隔绝术是近年来血管外科治疗的重大进展 ,我院 1999年 9月～ 2 0 0 1年12月共完成胸主动脉夹层动脉瘤腔内隔绝术 80例 ,完成传统的开胸行人工血管置换术 2 6例。本研究以同期进行的两种手术方式进行对比 ,借此探讨腔内隔绝术的护理特点。资料和方法一、临床资料1999年 9月～ 2 0 0 1年 12月共行胸主动脉瘤手术 10 6例 ,其中传统人工血管置换术 2 6例 ,男 16例 ,女 10例 ,年龄 (37± 10 )岁 ;腔内隔绝术 80例 ,男5 4例 ,女 2 6例 ,年龄 (45± 9)岁。二、术后护理传统手术组患者采用气管插管全麻 ,术后均进入ＩＣＵ病房…     

冠状动脉旁路移植术188例报告

行冠状动脉旁路移植术 (CABG)的患者 188例。年龄(6 0 3± 9 6 )岁 ,有急性或陈旧性心梗者 5 6例 ,合并有糖尿病 4 6例 ,肾功能不全 14例 ,脑卒中或后遗症 2 6例。合并有心脏瓣膜病 2 1例、左室室壁瘤 7例、升主动脉Ⅰ型夹层 1例。体外循环心脏停搏下行CABG 10 4例 ,浅低温间断阻断主动脉行CABG 5 9例 ;非体外循环心脏跳动下CABG 2 5例。平均每例搭桥 2 7支。同期行MVR或MVP8例 ,AVR4例 ,DVR 9例 ,Bentall1例。术后早期死亡 11例 (5 9% ) ,2 0 0 0年后 12 4例术后早期死亡率为 3 2 %。术后晚期死亡 2例 ,4例在术后 2～5年有心绞痛复发。作者认为 :手术技术和围术期处理水平的提高是手术死亡率明显降低的主要原因 ;应正确掌握好手术时机 ,加强术后呼吸道管理和防治消化道出血 ,以及加强术后康复治疗。     

升主动脉瘤51例的外科治疗

升主动脉瘤主要包括马凡综合征和主动脉夹层剥离.升主动脉瘤病情危重,自然预后差,近年来,随着对升主动脉瘤认识,以及手术技术和术后监护水平的提高,升主动脉瘤通过外科治疗获得了良好疗效.1997-12～2009-12,我科对51例升主动脉瘤实施了外科手术治疗,取得了较满意的临床效果.现报道如下.     

RETRACTED ARTICLE: Combined Interventional and Surgical Treatment for Acute Aortic Type A Dissection

Surgical repair and endovascular stent-graft placement are both therapies for thoracic aortic dissection. A combination of these two approaches may be effective in patients with type A dissection. In this study, we evaluated the prognosis of this combined technique. From December 2003 to December 2006, 15 patients with type A dissection were admitted to our institute; clinical data were retrospectively reviewed. Follow-up was performed at discharge and approximately 12 months after operation. Endovascular stent-graft placement by interventional radiology and surgical repair for reconstruction of aortic arch was performed in all patients. Total arch replacement for distal arch aneurysm was carried out under deep hypothermia with circulatory arrest; antegrade-selected cerebral perfusion was used for brain protection. Four patients concomitantly received a coronary artery bypass graft. Hospital mortality rate was 6.7%; the patient died of cerebral infarction. Neurological complications developed in two patients. Multi-detector-row computed tomography scans performed before discharge revealed complete thrombosis of the false lumen in six patients and partial thrombosis in eight patients. At the follow-up examination, complete thrombosis was found in another three patients, aortic rupture, endoleaks, or migration of the stent-graft was not observed and injuries of peripheral organs or anastomotic endoleaks did not occur. For patients with aortic type A dissection, combining intervention and surgical procedures is feasible, and complete or at least partial thrombosis of the false lumen in the descending aorta can be achieved. This combined approach simplified the surgical procedures and shortened the circulatory arrest time, minimizing the necessity for further aortic operation. Jin-Cheng Liu and Jin-Zhou Zhang contributed equally to this work.     

Hybrid endograft for one-step treatment of multisegment disease of the thoracic aorta

PURPOSE: At present, a two-step surgical approach is necessary to treat patients with coexistent pathologic conditions involving the proximal and descending thoracic aorta. A hybrid endograft is described here that enables such treatment during a single operation. MATERIALS AND METHODS: The Chavan-Haverich endograft consists of a Dacron vascular prosthesis with stainless-steel stents affixed at its distal end. After approval by the institutional review board, the endograft was prospectively implanted in 22 patients with multisegment thoracic aortic disease (13 men, nine women; median age, 64 years). Eleven patients had type A dissections (one acute, 10 chronic), four had a chronic type B dissection, and seven had atherosclerotic aneurysms of the ascending aorta or aortic arch as well as of the descending aorta. Of these patients, 11 additionally required aortic valve replacement or coronary artery bypass grafting. Via median sternotomy, the aortic arch was opened in circulatory arrest. After antegrade deployment of the stent-containing portion in the descending aorta, the proximal non-stent-containing endograft was used to reconstruct the aortic arch. Median follow-up was 14 months. RESULTS: Endograft implantation was successful in all but one patient. Complications included neurologic deficits that were transient in one case and lasting in two, two cases of vocal cord paralysis, and one death. In all patients with atherosclerotic aneurysms who received the endograft (six of seven), aneurysm thrombosis was noted at follow-up. In aortic dissections, partial or complete false-lumen thrombosis to the level of the stents occurred in all patients. None of the patients showed a progressive widening of the descending aorta. CONCLUSION: The Chavan-Haverich endograft enables one-step treatment of multisegment pathologic conditions affecting the thoracic aorta that otherwise would require two or more operations.     

JAG Tearing Technique with Radiofrequency Guide Wire for Aortic Fenestration in Thoracic Endovascular Aneurysm Repair

An innovative approach, the JAG tearing technique, was performed during thoracic endovascular aneurysm repair in a patient with previous surgical replacement of the ascending aorta with a residual uncomplicated type B aortic dissection who developed an aneurysm of the descending thoracic aorta with its lumen divided in two parts by an intimal flap. The proximal landing zone was suitable to place a thoracic stent graft. The distal landing zone was created by cutting the intimal flap in the distal third of the descending thoracic aorta with a radiofrequency guide wire and intravascular ultrasound catheter.     

Ruptured intracranial aneurysm associated with isolated aortic arch interruption

Interruption of the aortic arch is a very rare congenital defect consisting of discontinuity between the ascending and descending aorta. Few patients survive to adulthood, due to effective collateral arterial flow to the descending aorta. An intracranial aneurysm is reported in only one patient with aortic arch interruption. We report a 16-year-old boy with an isolated aortic arch interruption and a ruptured anterior communicating artery aneurysm. Received: 30 November 1999 Accepted: 31 January 2000     

特殊类型主动脉夹层的电子束CT表现及诊断

目的探讨表现特殊的主动脉夹层的电子束CT(EBCT)影像特征及诊断.材料和方法20例表现特殊的主动脉夹层,其中不典型夹层13例,三腔以上夹层动脉瘤3例,合并升主动脉壁内血肿的Stanford B型夹层2例,动脉瘤样夹层1例,外伤性主动脉夹层1例.结果主动脉不典型夹层为主动脉壁新月形或环形的低密度血肿包绕,常可见穿透性溃疡或钙化内移等征象;三腔以上夹层动脉瘤有2～3个内膜片,3～4个腔,瘤体管径较大;合并升主动脉壁内血肿的B型夹层见升主动脉管壁低密度新月形或环形增厚,降主动脉则见内膜片及真假两腔形成;动脉瘤样主动脉夹层见降主动脉局限性瘤样扩张,破口大,内膜片不易发现.1例外伤性夹层于主动脉弓峡部及降部起始见破裂内膜片.结论特殊类型的主动脉夹层表现各具特征,EBCT可清晰显示,是极适用于胸部急症的快速、无创的检查方法.     

Coil embolization of an anastomotic leak after ascending aorta replacement

Surgical treatment of diseases of the thoracic aorta (aneurysms, dissections, and ruptures) may be associated with serious postoperative complications. Endovascular repair of thoracic aorta pathology is less invasive and offers a therapeutic alternative in high-surgical-risk patients, particularly in the presence of previous surgical repair of the thoracic aorta. The endovascular procedure, however, is almost only possible in the descending thoracic aorta, although advances have also been made in the aortic arch as well as in the ascending aorta with branched stent grafts. We report a case of a surgically treated aneurysm in the ascending thoracic aorta complicated with an anastomotic leak. If a short prosthesis (6 cm) had been available, the anastomotic leak would have been treated with endovascular repair. In lack of this prosthesis, we were forced to treat the patient with a method not generally accepted--embolization with endovascular coils--successfully resulting in occlusion of the leakage.     

Synthetic interposition grafts of the thoracic aorta: postoperative appearance on serial CT studies

PURPOSE: To determine the normal postoperative appearance of thoracic aortic interposition grafts on serial CT studies and to document CT detectable complications. MATERIALS AND METHODS: The 235 CT studies in 114 patients with one or more thoracic aortic interposition grafts were analyzed for the presence or absence of felt rings, felt pledgets, low-attenuation material surrounding the graft, pseudoaneurysm, and dissection flap. A graft was present in the ascending aorta in 93 patients, in the descending aorta in 25, and in the arch in 11. RESULTS: Low-attenuation material was seen adjacent to the ascending graft in 55%-82% of patients and adjacent to the descending graft in 60%-79% of patients, showing diminishing frequency and thickness over time. CT scans in 30 of 53 patients showed residual low-attenuation material adjacent to the graft more than 1 year after surgery. CT scans in four of 93 patients with ascending grafts and one of 25 patients with descending grafts showed a pseudoaneurysm. CONCLUSION: CT studies obtained after aortic interposition grafting show characteristic findings. Knowledge of the type of operative procedure and typical location and CT appearance of surgical materials used is important to correctly diagnose or exclude postoperative complications following thoracic aortic interposition grafting.     

The use of high-field magnetic resonance in the follow-up of patients with mechanic aortic valve prosthesis and composite aortic tubular prosthesis

Eleven patients who had undergone cardiac surgery were studied by means of high-field MR imaging (1.5 T). Six patients had had aortic root and valve replaced with a Bj?rk-Shiley (BS) composite tubular aortic graft prosthesis for acute dissection of ascending aorta. In the other 5 patients with rheumatic calcific aortic disease, the valve had been replaced with a BS prosthesis. As a whole, MRI studies were 14. Previous evaluations of magnetic field effects had seem carried out ex vivo on both BS valves and BS composite prostheses, on surgical ligation clips (Tantalium and Stainless) and on stainless wires for sternal closure. In 4 patients (2 BS composite grafts and 2 BS valves) MRI diagnosed chronic dissection of both arch and descending aorta. In 1 of them, with a BS valve, associated localized acute dissection of ascending aorta was observed. In 3 patients with BS composite grafts, MRI revealed pseudo-aneurysms (including a thrombosed one) at the graft level. In one case MRI was repeated 4 times and was very helpful in monitoring the pseudo-aneurysm. MRI showed pericardial hematoma in 2 patients with BS grafts and paravalvular abscess in a case with BS valve. In one patient with BS valve fast-imaging MR revealed severe aortic regurgitation. No adverse reactions were demonstrated on MR images of prosthetic implants. MRI artifacts were insignificant with the spin-echo technique, while the fast-imaging technique showed clear image distortion at the valve level.