主动脉弓置换加"象鼻"支架手术治疗Stanford A型主动脉夹层

目的 探讨采用升主动脉及全弓置换加“象鼻”支架手术治疗StanfordA型主动脉夹层的临床意义。方法2010年5月至2011年10月,应用升主动脉及全弓置换加“象鼻”支架手术治疗StanfordA型主动脉夹层患者16例,男性12例,女性4例,平均年龄47（30-67）岁;其中急性主动脉夹层12例、慢性夹层4例,均在深低温停循环、低流量选择性脑灌注下手术。结果急诊手术12例,择期手术4例。行主动脉弓置换及“象鼻”支架术2例,升主动脉及全主动脉弓置换1例,升主动脉及全主动脉弓置换加“象鼻”支架手术13例,其中同期行Bentall术2例、主动脉根部成形术8例。心肌阻断时间59-137（104-31）min,选择性脑灌注时间17-57（29-11）min。术后肾功能衰竭2例,1例经血液透析治疗后肾功能恢复,另1例因多器官功能衰竭死亡。15例患者出院,随访1个月至1．5年,1例患者于术后约1个月双下肢肌肉坏死,在外院施行了截肢手术,8例患者不同程度恢复工作,无晚期死亡或再次手术病例。结论升主动脉及全弓置换加“象鼻”支架手术是治疗StanfordA型主动脉夹层安全、有效的方法。     

传统及改良孙氏手术在急性Stanford A型主动脉夹层的应用

目的 探讨急性Stanford A型主动脉夹层外科治疗应用孙氏手术（主动脉全弓置换+象鼻支架手术）的效果,总结手术经验。方法 回顾性分析2017年09月至2018年06月间收治的急性Stanford A型主动脉夹层17例行孙氏手术治疗的临床资料（均为男性; 年龄为54.5±8.8岁）,统计分析患者手术、术后及随访资料。结果 患者行传统孙氏手术13例,改良孙氏手术（保留头臂动脉的孙氏手术）4例。全组体外循环时间(176.7±25.6)min,主动脉阻断时间(96.6±30.1)min,停循环时间(19.4±3.9)min, 辅助时间(74.2±20.7)min。治愈患者12例,术后30天内患者死亡5例,治愈患者随访2-10个月,均无再次手术,心功能Ⅰ级11例,1例为心功能Ⅱ级。结论 传统以及改良的孙氏手术治疗急性Stanford A型主动脉夹层近中期效果确切,远期疗效有待于进一步监测与随访。     

支架象鼻开窗简化手术在治疗急性Stanford A型主动脉夹层中的临床分析

摘要：目的：研究支架象鼻开窗简化手术在治疗急性Stanford A型主动脉夹层中的临床效果。方法：选取2010年1月-2017年1月于我院就诊的急性Stanford A型主动脉夹层患者78例,按照治疗方法的不同,分为观察组与对照组,各组均为39例。观察组患者采用简化全弓置换加支架象鼻手术进行治疗,对照组患者采用全弓置换术加支架象鼻手术进行治疗,对比两组患者的临床疗效。结果：两组患者的手术均顺利完成,手术过程中均无患者死亡。观察组患者的体外循环时间、阻断时间、机械通气时间、ICU停留时间、住院时间均显著短于对照组患者（P<0.05）;观察组患者术后并发症发生率显著低于对照组（P<0.05）。结论：采用支架象鼻开窗简化手术治疗急性Stanford A型主动脉夹层,能够缩短患者的体外循环时间、阻断时间、机械通气时间、ICU停留时间,降低术后并发症发生率,近期临床治疗效果较好。     

Outcome of stented elephant trunk technique for extensive thoracic aortic aneurysms

Extensive aneurysms involving the ascending aorta,aortic arch,and the descending aorta stand as a therapeutic dilemma in simultaneous management of multiple sites of pathology of the aortic arch and the descending thoracic aorta.We systematically reviewed about literatures of stented elephant trunk operation(SET) identified through searches of the electronic databasesEMBASE and Medline,and aimed to summarize studies of patients undergoing SET for extensive aneurysms.Since 1996,Kato Mintroduced a hybrid technique by using stented graft implantation to the descending aorta for treatment of thoracic aortic aneurysm or dissection.It has been describe a good option for extensive thoracic aortic aneurysms and in a fashion similar to the elephant trunk technique.     

左颈总动脉至左锁骨下动脉转流加支架象鼻术治疗复杂Stanford B型主动脉夹层

目的:总结左颈总动脉至左锁骨下动脉转流,加支架象鼻术治疗复杂Stanford B型主动脉夹层的临床经验及效果。方法:回顾性分析2009年1月至2011年12月,北京安贞医院5例男性复杂型Stanford B型主动脉夹层患者,行左颈总动脉至左锁骨下动脉转流加直视下支架象鼻手术。平均年龄(48.4±10.5)岁,合并高血压5例,急性夹层2例,慢性夹层3例,胸降主动脉覆膜支架置入术后Ⅰ型内漏2例。合并风湿性心脏病1例,合并糖尿病1例。结果:5例Stanford B型主动脉夹层患者均于全麻下行左颈总动脉至左锁骨下动脉转流加直视下支架象鼻术。同期手术包括1例主动脉瓣及二尖瓣机械瓣置换术。平均体外循环时间(151.8±29.2)min,心肌阻断时间平均(76.0±34.39)min,选择性脑灌注时间平均(21.2±8.0)min。住院时间平均(19.8±6.2)d,术后住院时间平均(9.0±2.7)d,ICU时间平均(1.4±0.5)d。5例患者均无截瘫、脑梗死,无围手术期死亡。术后复查夹层破口均封闭良好,未见残余漏。结论:左颈总动脉至左锁骨下动脉转流加直视下支架象鼻手术对复杂型Stanford B型夹层,是有效的外科治疗手段。近期效果满意,远期效果有待进一步观察。     

主动脉夹层/瘤患者全弓置换象鼻支架置入术中的脑保护方法

目的探讨全弓置换象鼻支架置入术治疗DebakeyⅠ型主动脉夹层/瘤合并颈内动脉及基底动脉环狭窄患者的脑保护方法。方法 46例DebakeyⅠ型主动脉夹层/瘤合并颈内动脉及基底动脉环狭窄患者,均行全弓置换象鼻支架置入术治疗。根据颈内动脉和基底动脉环的狭窄程度、灌注量和方法将分为A、B1、B2、C1、C2组。A组（颈内动脉狭窄度〈50%）行单纯深低温停循环（DHCA）、右腋动脉选择性脑灌注,灌注量为5～10 ml/（kg.min）;B1组（颈内动脉狭窄度50%～70%）行DHCA、右腋动脉选择性脑灌注,灌注量为5～10 ml/（kg.min）;B2组（颈内动脉狭窄度50%～70%）行DHCA、右腋动脉选择性脑灌注,灌注量为10～15 ml/（kg.min）;C1组（颈内动脉狭窄度〉70%且合并脑基底动脉环狭窄）行DHCA、右腋动脉选择性脑灌注,灌注量为10～15 ml/（kg.min）,C2组（颈内动脉狭窄度〉70%且合并脑基底动脉环狭窄）行DHCA、经右腋及左颈总动脉选择性脑灌注,灌注量为10～15 ml/（kg.min）。结果A组0例、B1组3例、B2组0例、C1组3例、C2组0例出现神经系统并发症。B2、C2组患者脑干听神经诱发电位明显低于B1、C1组（P均〈0.05）。结论采用全弓置换象鼻支架置入术治疗DebakeyⅠ型主动脉夹层/瘤合并颈内动脉及基底动脉环狭窄时,适当增加DHCA灌注量和行双侧脑灌注,可保护脑功能。     

支架“象鼻”手术治疗复杂性Stanford B型主动脉夹层

目的:总结我中心应用支架"象鼻"手术治疗复杂性Stanford B型主动脉夹层的临床经验及近期疗效。方法:回顾我中心2009年1月至2014年6月收治的28例行支架"象鼻"手术的复杂型Stanford B型主动脉夹层患者,其中18例为直接行支架"象鼻"手术,10例为胸主动脉腔内修复术(TEVAR)术后I型内漏二次手术改行支架"象鼻"手术修补漏口。结果:所有患者均在全麻、体外循环下行支架"象鼻"手术,其中20例患者同时行左锁骨下动脉至左颈总动脉转流术。平均体外循环时间(150±28)分钟,平均心肌阻断时(75±32)分钟,平均选择性脑灌注时间(20±6)分钟。所有患者术后无截瘫发生,无脑出血及脑梗死等中枢神经系统并发症,无围术期死亡。出院时及术后3月复查CT均无内漏发生。结论:应用支架"象鼻"手术治疗复杂性Stanford B型主动脉夹层确实可靠,近期疗效满意,远期结果还有待随访观察。     

The elephant trunk operation in complex aortic disease.

Extensive aneurysmal disease of the aorta presents considerable challenges to the cardiovascular surgeon and is generally treated with a staged approach. The elephant trunk principle, in which the downstream end of the primarily inserted graft is allowed to float freely in the downstream aorta, serves this approach. This principle greatly facilitates subsequent operation(s) and shortens the period of distal aortic occlusion. This review describes the state of the art of this technique, its various uses, and the results obtained.     

Stenting of a left main coronary artery dissection and stent-graft implantation for acute type a aortic dissection.

PURPOSE: To report successful endovascular repair of Stanford type A acute aortic dissection associated with a proximally extended dissection of the left main coronary artery. CASE REPORT: A 71-year-old man presented with acute type A aortic dissection. One day after admission, dissection of the left main coronary artery accompanied by severe myocardial ischemia prompted Palmaz stent placement. Three days later, a customized stent-graft was placed across the entry site of the dissection in the descending aorta. The false lumen in the ascending aorta, transverse arch, and the descending thoracic aorta thrombosed, and the left coronary artery remained patent. At 14 months after the procedures, the patient is doing well and has had no cardiac event. CONCLUSIONS: This staged procedure may be one option for the management of acute type A aortic dissection complicated by coronary artery dissection.     

Transapical valve-in-valve implantation for regurgitant stented aortic bioprostheses

Transcatheter aortic valve implantation (TAVI) is rapidly evolving as an alternative treatment option for elderly patients with severe symptomatic aortic stenosis and excessive risk for surgical intervention. Transcatheter valve-in-valve implantation is an alternative approach to redo-surgery for patients with degeneration of a bioprosthetic valve. Herein are reported three cases of successful transcatheter aortic valve-in-valve implantation for severely regurgitant bioprosthetic valves with a clinical follow up of more than 12 months.     

The elephant trunk procedure: uses in complex aortic diseases

PURPOSE OF REVIEW: The elephant trunk procedure is used for extensive aneurysms involving both the ascending aorta/aortic arch and the descending thoracic or thoracoabdominal aorta. RECENT FINDINGS: This is a high-risk staged procedure; however, with current techniques in our most recent series the survival rate was 98% for the first operation and 92% for the second. SUMMARY: With the more liberal use of hybrid procedures and endovascular stenting for the second stage of the elephant trunk procedure, the operation can be used more often in patients with severe comorbid disease, particularly respiratory problems.     

Simplified elephant trunk graft technique for aortic arch replacement

We refined the elephant trunk graft to facilitate and reinforce the distal anastomosis in aortic replacement operations. A cuff is created in a single four-branch graft, which is used for the distal anastomosis; the trunk below the cuff is inserted into the distal aortic stump. This method is feasible for repairing extensive aortic aneurysm with a fragile wall and for treating acute aortic dissection where thromboocclusion of the remaining false lumen is desired.     

Renal artery stenting following acute aortic dissection: implantation and follow-up

Two patients with renal artery involvement in type B dissection of the aorta were treated by percutaneous stent implantation. Both of them were hypertensive and showed increasing serum creatinine levels. After stent implantation in the renal arteries blood pressure and renal function improved, and the renal arteries were patent in duplex ultrasound 15 and 30 months after treatment respectively.     

Modified “in situ” arch replacement with an integrative frozen elephant trunk device for acute type A aortic dissection

BackgroundTotal arch replacement (TAR) and frozen elephant trunk (FET) has been proposed as the primary arch repair method for acute type A aortic dissection (aTAAD). We introduce a modified “in situ” arch replacement with an integrative FET device for aTAAD.MethodsFrom January 2018 to December 2019, 507 aTAAD patients from Nanjing Drum Tower Hospital received surgical therapy; among them, 57 patients with modified island total arch replacement (MiTAR) and 138 patients with TAR were enrolled. Marfan syndrome, primary intimal tears located in the large curve of aortic arch +/− or supra-arch vessels and dilated aortic arch (≥45 mm) were contraindications for MiTAR. MiTAR involves two steps: first, insert a FET device into the descending aorta during the hypothermic circulation arrest period; second, anastomose the remaining “island” arch with the prosthetic vessel and the proximal part of the FET.ResultsMiTAR patients were older than those receiving TAR (52.1 vs. 48.9 years; P=0.078), but their baseline demographics and manifestations of organ ischaemia were nearly the same. The times of cardiopulmonary bypass (CPB), aortic clamp and hypothermic circulation arrest were significantly shorter with MiTAR (209.3 vs. 267.1 minutes, P=0.000; 147.9 vs. 190.0 minutes, P=0.000; 34.0 vs. 39.4 minutes, P=0.003, respectively). The volumes of intraoperative transfusions of red blood cells (RBCs), fresh frozen plasma (FFP), platelets and cryoprecipitates were significantly lower in MiTAR (5.9 vs. 8.5 units, P=0.000; 758.3 vs. 930.4, P=0.000; 12.5 vs. 17.5 mL, P=0.000; 9.4 vs. 16.6 units, P=0.000). The 30-day mortality was 7.0% (4/57) for MiTAR and 11.6% (16/138) for TAR. One patient died and no patient received reintervention during the follow-up period, while the size of several levels of aorta showed a decreasing trend.ConclusionsMiTAR is a simplified approach to TAR that reduces the surgical trauma while achieving aortic reshaping effects.     

Transapical approach for aortic stented valve implantation: experimental results

OBJECTIVE: Percutaneous aortic valve replacement has been performed in humans mainly for non-surgical candidates. We evaluated on animals a transapical approach to deliver an aortic stented valve without cardiopulmonary bypass. METHODS: A tubular pericardial valve fixed within a cobalt-nickel stent (Medtronic, Inc.) was implanted using a transapical approach in five adult sheep. A left thoracotomy was used to access the apex of the heart. The crimped valve was deployed in orthotopic position with a valvuloplasty balloon catheter on the beating heart after decreasing the left ventricular pressure by using either drugs or inferior vena cava occlusion. Deployments were performed under fluoroscopy and epicardial 2D Doppler echocardiography. Exact positioning of the valve into the target area was confirmed by autopsy at the end of the procedures. RESULTS: Valves were unsuccessfully deployed at the target site in all cases but one. Three valves were implanted in a supra-annular position with two of them in supracoronary position. One valve was implanted below the native annulus in the outflow tract. Valvular leak was noted in all but one implants. Coronary obstruction occurred twice and early valve retrograde migration once. Ventricular fibrillation or diastolic cardiac arrest occurred less than 20 minutes after stent deployment in all cases. CONCLUSION: In our experience the transapical approach does not facilitate delivery of a stented valve. Despite its technically feasibility, advanced stent design and improvements in delivery system are required before to continue experimental studies in transapical approach for aortic stented valve.     

D-dimer in acute aortic dissection

STUDY OBJECTIVE: Laboratory testing plays a minor role in the assessment of aortic dissection. Its main value is in the exclusion of other diseases. Following an incidental observation, we systematically investigated the relationship between elevated d-dimer levels and acute aortic dissection. DESIGN: We prospectively tested d-dimer levels in patients with suspected acute aortic dissection (10 patients). In addition, we investigated 14 patients who had received a confirmed diagnosis of thoracic aortic dissection during the previous 5 years, in whom d-dimer testing had been performed for differential diagnosis. Thirty-five patients with acute chest pain of other origin served as a control group. SETTING: Tertiary referral hospital. PATIENTS: Twelve patients had type A dissection (Stanford classification), and 12 patients had type B. MEASUREMENTS AND RESULTS: A d-dimer analysis was performed (Tina-quant assay; Roche Diagnostics; Mannheim, Germany) [normal limit of the assay, 0.5 micro g/mL]. The result of the d-dimer test was positive (ie, > 0.5 micro g/mL) in all patients (sensitivity of the test, 100%) with a mean value of 9.4 micro g/mL and a range of 0.63 to 54.7 micro g/mL. The degree of the elevation was correlated to the delay from the onset of symptoms to laboratory testing (mean, 12.6 h; range, 1 to 120 h) and showed a trend to the extent of the dissection, but not to the outcome (14 patients could be discharged; 10 patients died). CONCLUSIONS: Based on our observation, we suggest that testing for d-dimer should be part of the initial assessment of patients with chest pain, especially if aortic dissection is suspected. A negative test result makes the presence of the disease unlikely.     

Thrombolytic therapy and acute aortic dissection.

Thrombolytic (tissue plasminogen activator) and antithrombotic treatment (heparin and aspirin) were given to a 47-year-old man with an acute type II aortic dissection presenting as an acute anterior myocardial infarction. During treatment he developed cardiac tamponade and an ischaemic stroke. Transoesophageal echocardiography (but not computed tomographies of the chest) revealed the correct diagnosis. After surgical repair (Bentall procedure) there was a complete recovery.