新生儿及婴儿期主动脉弓中断合并室间隔缺损的手术疗效分析

目的:总结新生儿及婴儿期主动脉弓中断合并室间隔缺损(interrupted aortic arch with ventricular septal defect,IAA/VSD)的外科治疗策略和随访结果。方法:回顾性分析我院2009年1月至2019年1月于新生儿及婴儿期手术的123例IAA/VSD患儿的临床资料。中位手...     

维持性血液透析患者主动脉弓钙化的相关风险因素及其对远期预后的影响

目的:探讨维持性血液透析患者发生主动脉弓钙化（aortic arch calcification,AoAC）的相关风险因素及AoAC对患者远期预后的影响。方法:选取2015年3~6月首都医科大学附属北京世纪坛医院血液净化中心维持性血液透析患者,以胸部X线评估AoAC,将患者分为主动脉弓钙化（AoAC）组与主动脉弓无钙化...     

新生儿完全性大动脉错位合并主动脉弓发育不良的外科治疗

完全性大动脉错位（TCA）是新生儿期最常见的紫绀型心脏病，可合并主动脉弓部畸形，如主动脉缩窄（CoA）、主动脉弓发育不良（HAA）和主动脉弓离断（LAA）等。现将我们2005年收治的2例新生儿TGA合并HAA和室间隔缺损（VSD）的外科治疗及早期随访结果报道如下。     

自体肺动脉补片主动脉弓成形治疗婴儿主动脉缩窄合并弓发育不良

目的 探讨缩窄段切除加自体肺动脉补片主动脉弓成形治疗婴儿主动脉缩窄合并主动脉弓发育不良的方法和效果.方法 2007年5月至2009年12月,14例主动脉缩窄合并主动脉弓发育不良病婴行主动脉缩窄段切除加自体肺动脉补片主动脉弓成形手术,其中男9例,女5例;年龄23天至17个月,中位值4.33月龄;平均体重(6.14±2.36)kg.所有病婴均诊断为合并室间隔缺损的主动脉缩窄,同时存在主动脉弓发育不良.手术在深低温体外循环下完成,其中8例采用选择性脑灌注技术,6例停循环.主动脉成形采用新鲜的自体肺动脉补片.同期修补合并的室间隔缺损.结果 围术期死于循环衰竭1例.13例生存,其中1例合并低心排血量综合征,经相应治疗恢复.术后超声心动图检查主动脉弓无残余梗阻.随访4个月至3年.超声心动图示主动脉弓压力阶差均<16 mm Hg(1 mm Hg=0.133 kPa),随访期间主动脉弓降部血流速度与出院时无明显变化.CT扫描显示主动脉弓几何构形正常;术后半年原左主支气管受压者症状明显改善或完全消失.无主动脉夹层动脉瘤发生.结论 缩窄段切除加自体肺动脉补片主动脉弓成形是治疗婴儿主动脉缩窄合并主动脉弓发育不良理想的手术方法.

Abstract：

Objective To discuss the operative techniques and results of coarctation resection plus aortoplasty with pulmonary autograft patch for coarctation of the aorta combined with hypoplastic aortic arch in infant.Methods Between May 2007 and Dec 2009,14 cases including 9 males and 5 females with caorctation of the aorta and hypoplastic aortic arch underwent coarctation resection plus aortoplasty with pulmonary autograft patch in our hospital.The age ranged from 23 days to 17 months,with a median of 4.33 months.The mean body weight was (6.14 ±2.36) kg.All patients were diagnosed as aortic coarctation combined with VSD and hypoplastic aortic arch.The surgery was performed under deep hypothermia cardiopulmonary bypass with selective cerebral perfusion in 8 cases and circulation arrest in 6 cases.Fresh pulmonary autograft patch harvested from the main pulmonary artery was used for aortoplasty.The associated VSD was repaired in the same stage.Results All patients survived except one died from circulatory failure during the perioperative period.Low cardiac output syndrome occurred in another case who was cured afterwards by correspondent treatments.No residual obstruction was detected by echocar-diography after the operation.Follow-up was carried out in 13 cases from 4 months to 3 years.Echocardiographic examination showed that the pressure gradient across the aortic arch was less than 16 mm Hg in all cases.The blood velocity at the descending aortic arch was not significantly changed during the follow-up period as compared with that of the immediate after operation.Computed tomography showed that the morphology of aortic arch was normal.The left bronchus compression was relieved obviously or totally disappeared in patients who suffered from left bronchus stenosis before operation,and no aortic aneurysm were detected in these patients.Conclusion Conclusion Coarctation resection plus aortoplasty with pulmonary autograft patch is the optimal surgical method for treating coarctation of the aorta combined with hypoplastic aortic arch in infant.     

主动脉弓缩窄合并主动脉弓发育不良的外科治疗

目的探讨主动脉弓补片加宽成形术和主动脉弓扩大端侧吻合术治疗主动脉弓缩窄合并主动脉弓发育不良的优缺点,为临床选择更合理的手术方法。方法回顾性分析2008年6月至2013年6月北京安贞医院45例主动脉弓缩窄合并主动脉弓发育不良患者的临床资料,根据手术中处理主动脉弓发育不良的方法不同,将45例患儿分为两组,I组：26例,其中男15例,女11例;年龄0．5～6．8（0．9±2．5）岁;体重5．0～20.3（9．5±7-3）kg;采用主动脉弓补片加宽技术;术前右侧上下肢压差（38-3±15．6）mmHg。Ⅱ组：19例,其中男14例,女5例;年龄0．6～7．5（1．0±2．7）岁;体重5．5～21．5（10．2±6．6）kg;采用扩大端侧吻合技术;术前右侧上下肢压差（40．7±16．1）mmHg。检测两组患儿手术后上下肢压力差的变化,并与手术前进行比较。结果全组共死亡2例（4．4％）,其中l例死于低心排血量综合征,1例死于呼吸道感染。两组患儿均无肾功能衰竭及神经系统并发症。术后下肢收缩压高于上肢10～20mmHg28例,收缩压上、下肢相差小于10mmHg13例,上肢高于下肢20mmHg4例。右侧上下肢压差（3．2±13．5）mmHg,显著低于术前上下肢压差（P〈0．05）。组内比较：两组手术后上下肢压差明显低于术前（P〈0．05）。组间比较：两组之间上下肢压差术前、术后差异无统计学意义（P〉0．05）。随访38例,随访率88．4％,随访时间3个月至5年。随访期间1例患者出现主动脉弓降部血流速度进行性增快,主动脉弓压力阶差〉40mmHg,电子计算机断层扫描显示：主动脉弓再狭窄,于术后8个月再次行手术治疗;3例患者主动脉弓压力阶差〉20mmHg,仍在继续随访中;其余患者主动脉弓压力阶差均〈20mmHg。结论两种手术方式都是治疗主动脉弓缩窄合并主动脉弓发育不良的理想手术方法,应根据患儿具体病情选择合适的手术方法。     

维持血液透析患者主动脉弓钙化发生情况及相关因素分析

目的观察维持性血液透析（MHD）患者主动脉弓钙化发生的情况并分析其相关因素。方法观察220例MHD患者胸部正位片主动脉弓钙化的发生情况；将其年龄、性别、原发病、血压、心胸比、血常规及血生化结果与主动脉弓钙化进行相关性分析，比较有钙化组和无钙化组的上述指标。结果82例发生主动脉弓钙化，其中48例透析前已存在主动脉弓钙化,34例透析后（21.15±12.12）月出现。钙化组的年龄、MHD时间、心胸比、钙磷乘积、脉压、球蛋白（G）明显高于非钙化组，全段甲状旁腺激素（iPTH）、白蛋白（A）明显低于非钙化组。结论MHD患者发生主动脉弓钙化的几率很高；影响主动脉弓钙化的因素主要为年龄、脉压、钙磷乘积。     

主动脉弓部疾病腔内治疗的新进展

<正>胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)的出现彻底打破了降主动脉疾病以开放手术为主的治疗格局^[1],但受限于主动脉弓特殊的解剖形态、复杂的血流动力学环境及分支重建难度大等不利因素,弓部疾病一度被视为腔内治疗的“禁区”和“最后争夺的阵地”^[2]。尽管目前开放手术仍然是年轻、能耐受手术风险患者的治疗首选,但近年来随着腔内技术及器材不断改良及成熟,主动脉弓腔内修复术(endovascular aortic arch repair,EAAR)已被推向了全新的高度,逐渐成为外科手术风险较高患者的一种可行性选择。     

导管前主动脉弓缩窄及主动脉弓管状发育不良

主动脉缩窄 (ｃｏａｒｃｔａｔｉｏｎｏｆｔｈｅａｏｒｔａ)是较常见的心血管畸形之一 ,国内报道〔1〕在先天性心脏病尸检材料中占 7% ,主动脉弓管状发育不良 (ｔｕｂｕｌａｒｈｙｐｏｐｌａｓｉａｏｆｔｈｅａｏｒｔａ)是指主动脉弓某一部分狭窄的长度较长。婴幼儿中主动脉缩窄和主动脉弓管状发育不良常同时出现。我们收集的 2 0 0例先天性心脏病尸检材料中共检出主动脉弓缩窄 15例 ,占 7 5 % ,均位于动脉导管前主动脉弓段 ,我们称之为导管前型主动脉弓缩窄 ,其中 5例伴有主动脉弓管状发育不良。现报告如下。全部资料来自尸检标本 ,每例均…     

右侧肱动脉入路左颈动脉支架成形术治疗颈内动脉狭窄合并牛型主动脉弓1例报告

2013年10月我科收治1例63岁女性左颈动脉狭窄,有左侧脑梗死病史并频繁出现一过性脑缺血发作（transient ischemic attack,TIA）。术前CTA检查为牛型主动脉弓,左侧颈内动脉起始部重度狭窄,但位于C2水平不适合行颈动脉内膜切除术。采用全麻下经右侧肱动脉人路穿刺,造影导管选人左颈外动脉,加硬导丝引导F6长鞘选人左颈总动脉建立手术通路,然后常规进行保护伞下的颈动脉球囊扩张和支架成形术。手术成功,未发生任何并发症。术后1个月随访,TIA症状完全消失,颈动脉超声提示左颈内动脉支架术后血流通畅。我们认为经右侧肱动脉人路行支架成形术治疗牛型主动脉弓变异的左侧颈内动脉狭窄是安全、可行的。     

非体外循环下全主动脉弓替换术治疗主动脉弓降部动脉瘤的早、中期结果

目的 评价采用常温、非体外循环下全主动脉弓替换手术治疗主动脉弓、降部动脉瘤的术后早、中期结果.方法 2004年4月至11月,对连续7例主动脉弓降部动脉瘤病人实施常温、非体外循环下全主动脉弓替换手术.术后对所有病人进行长期随访,随访截止日期为2011年3月.7例均为男性,年龄23～75岁,中位年龄57岁.真性动脉瘤3例,假性动脉瘤4例,其中1例为弓降部巨大假性动脉瘤覆膜支架置入术失败者.采用胸部正中与左胸前外侧联合切口,全身肝素化后,依次在升主动脉前外侧壁安放主动脉侧壁钳,降主动脉与头臂动脉分别放置主动脉阻断钳,将带四分支人工血管依次与升主动脉行端-侧吻合、与降主动脉及3支头臂动脉行端-端吻合,最后闭合升主动脉残端,切除弓降部主动脉瘤壁.结果 平均胸降主动脉阻断(13.6±5.6)min,左颈总动脉阻断(5.7±0.8)min,无名动脉阻断(7.8±2.5)min,左锁骨下动脉阻断(11.2±1.5)min.术后使用呼吸机平均(12.3±4.1)h.病人全部生存.与同期常温体外循环下主动脉弓替换手术组相比,本组机械通气时间显著减少.无神经系统并发症.术后CT扫描结果显示,主动脉弓降部人工血管形态佳,吻合口周围无渗漏或假性动脉瘤形成.全组平均随访(79.7±2.1)个月,病人生活质量良好,复查CT结果均未见异常.无远期死亡.结论 在常温、非体外循环状态下实施全主动脉弓替换手术,是一种治疗主动脉弓、降部真性或假性动脉瘤的安全、有效的方法,严格把握手术适应证是手术成功的关键.

Abstract：

Objective Study the early and midterm results of a technique-total aortic arch replacement without using extracorporeal circulation or aortic bypass for the treatment of aortic aneurismal disease involving the transverse aortic arch and proximal descending aorta. Methods Between April and November 2004, 7 consecutive patients with true (n = 3) or false (n =4) aortic aneurysm underwent this procedure. The mean follow-up was 6. 6 years. The median age at operation was 57years ( range 23 to 75 years). Normothermia general anesthesia and median sternotomy combined with left anterior thoracotomy were administered. A partially occluding clamp was placed on ascending aorta and a longitude aortic incision was made. Anastomosis of a branched graft to ascending aorta in an end-to-side fashion was commenced. The descending aorta distal to the aneurysm was occluded and transected, and anastomosed to the distal end of the branched graft in an end-to-end fashion. Finally,the arch vessels were divided and anastomosed to the branches of the graft and the aneurysm excised. Results The average cross-clamp time of descending aorta, left common carotid artery, and innominate artery was (13.6 ±5.6)min, (5.7 ±0.8)min, and (7.8±2.5) min respectively. The mean intubation time was (12.3 ±4.1) hours. There were no adverse outcomes or neurologic complications in this series. All patients survived and recovered completely. The mean follow-up time was (79.7 ±2.1) months. All patients lead a normal life. There was no late death. CT follow-up study 6 years after surgery reveals no abnormal image. Conclusion Total aortic arch replacement without cardiopulmonary and aortic bypass is a feasible and effective method for the aortic aneurismal disease involving the transverse aortic arch and proximal descending aorta in selected patients.     

主动脉瓣上狭窄合并主动脉弓及分支发育不良的外科治疗

2003年11月我们成功为1例主动脉瓣上狭窄合并主动脉弓及分子支血管发育不良病儿进行手术治疗，现报道如下。     

一期手术矫治先天性主动脉弓中断

目的　探讨先天性主动脉弓中断 (IAA)一期手术矫治的手术方法、疗效 ,总结其临床经验。　方法　对10例少见的先天性 IAA进行一期手术矫治 ,平均手术年龄 2 .7± 2 .4岁 ,其中 5例为 A型 IAA,3例为 B型 ,另 2例IAA合并残存第 5弓狭窄 ;8例患者均合并其它心血管畸形和重度肺动脉高压。一期矫治术中有 7例进行了主动脉弓直接端侧或端端吻合连接术 ,2例行 Gore- Tex管道连接重建主动脉弓 ,1例 IAA合并残存第 5弓狭窄用自身心包补片作狭窄处扩大成形术 ;8例患者于矫治 IAA的同时矫治心血管其他畸形。　结果　术后早期发生心功能不全、心律失常、肺动脉高压危象等并发症 5例 ,其中近 10年仅发生 1例。住院死亡 3例 ,近 10年连续 6例无住院死亡。术后早期 5例肺动脉收缩压 /体循环动脉收缩压 (Pp/ Ps)由术前的 0 .84± 0 .0 4显著下降至正常范围 (0 .2 8± 0 .0 3) ,1例主动脉弓部压力阶差为 30 mm Hg(1k Pa=7.5 mm Hg)。随访 7例 ,平均随访 2 .6± 4 .0年 ,均存活 ,其中有 3例主动脉弓部压力阶差≥ 30 mm Hg。心功能均正常。　结论　先天性 IAA一旦诊断明确 ,应尽早进行一期矫治术 ;主动脉弓直接吻合连接术效果较佳。     

一期杂交手术治疗主动脉弓部疾病的远期结果

目的:回顾分析我院接受杂交手术(Hybrid arch repair,HAR)治疗主动脉弓部疾病的远期预后结果。方法:2009年1月至2018年1月,共87例患者因主动脉弓部疾病于北京安贞医院接受HAR治疗,男76例,女11例;年龄(62.2±9.6)岁。2例为0区,46例为1区,39例为2区。结果:5例(5.7%)手...     

主动脉弓动脉瘤治疗进展

主动脉弓动脉瘤是指累及主动脉弓的动脉瘤，可分为主动脉弓近端动脉瘤、主动脉弓远端动脉瘤和横跨主动脉弓的动脉瘤。主动脉弓动脉瘤约占胸主动脉瘤的10％。主动脉弓动脉瘤因其特殊的解剖部位，涉及弓上三大血管（无名动脉、左颈总动脉和左锁骨下动脉），手术操作复杂，难度大，术中、术后病死率和神经系统并发症的发生率高。近年来，虽然手术技巧、手术器材和术中脑保护措施不断改进，但主动脉弓动脉瘤仍是当今心血管外科领域最具挑战的疾病之一。现将近年来国内外主动脉弓动脉瘤的外科治疗进展综述如下。     

深低温分侧脑供血行主动脉弓置换术

深低温分侧脑供血行主动脉弓置换术张卫邱兆李寿叶伟丁之向徐新根主动脉弓置换手术难度高，开展较少。我们成功地完成１例，效果满意，现报告如下：病人男，３２岁。经磁共振成像，ＣＴ和彩超诊断为主动脉夹层动脉瘤Ａ型（Ｍｉｌｅｒ法）。１９９５年１２月行主动脉弓...     

急性Stanford A型主动脉夹层弓部病变处理决策

目的 总结急性Stanford A型主动脉夹层弓部处理的临床经验,探讨选择手术时机、确定治疗方案和手术方式的重要性.方法 2005年8月至2010年8月对210例急性Stanford A型主动脉夹层行弓部替换手术治疗.手术方式采用深低温停循环及顺行性脑灌注,半弓替换+支架象鼻手术92例;次全弓替换+支架象鼻手术50例;全弓替换+支架象鼻手术68例.术后随访,胸腹主动脉CT观察降主动脉假腔闭合情况.结果 全组体外循环(146±52)min,主动脉阻断(93±25)min,深低温停循环(35±14)min.主动脉弓部手术围手术期死亡10例(4.8%).术后18例(8.6%)发生并发症,主要包括急性肾功能不全、神经系统并发症、纵隔感染及急性呼吸功能衰竭.术后随访2～60个月,平均(27±18)个月.随访过程中无死亡,再次入院行降主动脉替换术1例.增强CT检查结果显示支架远端胸降主动脉假腔闭合率为74%.结论 主动脉弓部处理是急性Stanford A型主动脉夹层治疗的重要手段.正确的决策对于提高手术的疗效有重要意义.

Abstract：

Objective Stanford type A acute aortic dissection is a life-threatening medical condition with high rates of morbidity and mortality that requires surgical repair, on an emergency basis. The extent of aortic arch repair that should be carried out during emergency surgery of this type is controversial. This study was conducted to report clinical experience on aortic arch repair and determine surgical indication, optimal operative procedures and strategy for Stanford type A acute aortic dissection. Methods 210 consecutive patients with acute Stanford A aortic dissection who underwent aortic arch replacement combined with implantation of stented elephant trunk into the descending aorta between August 2005 and August 2010. Surgical procedures included hemi-aortic arch replacement in 92 patients, subtotal aortic arch replacement in 50 patients and total aortic arch replacement in 68 patients. All operations were performed with the aid of deep hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP). Enhanced computed tomography scanning was performed to evaluate the postoperative outcomes, particularly the fate of the false lumen remaining in the descending thoracic aorta by aortic arch replacement combined with implantation of stented elephant trunk during follow up. Results Average cardiopulmonary bypass time was (146 ±52) min. The average cross clamp time was(93 ±25)min and average selective cerebral perfusion and circulatory arrest time was(35 ±14)min. The overall in-hospital mortality was 4. 8% (10/210) and morbidity was 8. 6% ( 18/210). Postoperative complications included acute renal failure, stroke, mediastinitis and respiratory insufficiency. During the follow-up period [mean (27 ± 18) months, ranged 2 to 60 months], 1 patient underwent reoperation due to the descending thoracic and abdominal aortic aneurysm. There was no late death. Follow-up enhanced CT scanning showed about 74% false lumens obliterated at the level of the distal border of the stent graft post operation. Conclusion Open aortic arch replacement is an effective approach and provides acceptable outcomes for type A acute aortic dissection. Optimal treatment strategy is the key factor to success in emergency surgical intervention.     

一期手术矫治主动脉弓缩窄合并心内畸形

目的：探讨主动脉弓缩窄合并心内畸形病人的一期手术矫治方法及治疗效果。方法：自１９８９年１２月至１９９８年２月,运用一期手术方法为１０例主动脉弓缩窄合并心内畸形病人进行外科矫治。合并的心内畸形有室间隔缺损７例,二尖瓣关闭不全２例,主动脉瓣狭窄１例;６例同时合并动脉导管未闭。采用左后外侧切口矫治主动脉弓缩窄,正中切口行心内畸形矫治６例、正中切口采用主肺动脉内隧道同时矫治主动脉弓缩窄及合并心内畸形３例;     

婴儿主动脉弓中断矫治术中体外循环方法的探讨

2001年2月至2003年11月，我们对7例主动脉弓中断（IAA）病婴进行手术治疗，现总结探讨婴儿术中体外循环方法。     

应用肺动脉管道矫治主动脉弓离断后管道重度扩张一例

临床资料患者,男,18岁,体重59.5 kg。主动脉弓离断合并室间隔缺损（VSD）矫治术后2年。患者于2年前发现心脏杂音16年,劳力后心悸、气促1年,入院行手术治疗。经胸骨正中切口径路手术,深低温停循环下用自体肺动脉片制作管道（Neville管,直径20 mm）行A型主动脉弓离断矫治术（图1）、VSD修补和动脉导管结扎术。     

主动脉弓部手术中脑保护的进展

主动脉弓部手术中脑保护的进展郎希龙综述郝家骅审校作者单位：２００４３３第二军医大学长海医院心胸外科早期主动脉弓部手术死亡率达５０％〔１〕，死因主要为心肌损害、中枢神经系统（ｃｅｎｔｒａｌｎｅｒｖｏｕｓｓｙｓｔｅｍ，ＣＮＳ）损伤及手术区域出血〔２〕。随...