杂交技术治疗B型主动脉夹层的258例预后分析

目的 报道杂交技术治疗B型主动脉夹层(type B aortic dissection, TBAD)的单中心早远期预后。 方法 回顾性分析2006年1月至2018年8月应用杂交技术治疗TBAD的258例患者资料,男性238例(92.2%),平均(52.4±10.3)岁。主要不良事件定义为全因死亡、再次主动脉手术、卒中、脊髓缺血、主动脉破裂、逆撕A型夹层及血管移植物感染;早期结局定义为术后30天或院内事件。通过Kaplan-Meier分析评估远期生存率及桥血管通畅率。结果 手术成功率98.8%(255/258),早期主要不良事件发生率13.6%(35/258),其中全因死亡18例(7.0%)、再手术3例(1.2%)、卒中13例(5.0%)、脊髓缺血5例(1.9%)、主动脉破裂12例(4.7%)、逆撕A型夹层4例(1.6%)。平均随访(46.1±35.8)个月,随访期间新增主要不良事件37例(15.4%),其中全因死亡22例(9.2%)、再手术13例(5.4%)、卒中6例(2.5%)、主动脉破裂9例(3.8%)、逆撕A型夹层2例(0.8%)、血管移植物感染3例(1.3%)。术后1年、5年和10年生存率为(90.1±1.9)%、(83.9±2.6)% 和(77.1±3.8)%,桥血管通畅率为(98.3±0.8)%、(96.2±1.3)%和(87.9±4.5)%。结论 杂交技术是治疗TBAD的有效方法,但早远期并发症发生率较高,需要密切随访。     

Aortic arch replacement without circulatory arrest: a simplified technique with two grafts

Aortic arch reconstruction remains a challenge for the cardiothoracic surgeon. We present our simplified technique in which we used two grafts for arch reconstruction without circulatory arrest. It is a relatively easy and quick technique consisting of a unique modification of the selective antegrade cerebral circulation system without the need for circulatory arrest in selected cases.     

DeBakeyI型主动脉夹层患者行杂合技术治疗的护理体会

主动脉夹层（aorticdissection,AD）是心血管疾病的灾难性危重急症,其中以DeBakeyI型最为凶险。其起病急,病情进展迅速,患者大多需要急诊手术以避免发生主动脉破裂,如治疗不及时,     

Complication of hybrid treatment in type B aortic dissection diagnosed by echocardiography

This case illustrates an unusual and fatal complication after endovascular treatment of type B aortic dissection and highlights the role of echocardiography in the early diagnosis of complications. In this case, a patient with previous diagnosis of chronic type B aortic dissection and moderate aortic regurgitation underwent endovascular repair of the proximal descending aorta and conservative surgical correction of the aortic valve. On early postoperative, a transesophageal echocardiogram and aortic angiotomography demonstrated proximal endoleak by contrast extravasation around the proximal graft attachment site, causing compression of the stent in its middle portion, resulting in narrowing with reduced cross‐sectional area.     

Repair of acute type A aortic dissection without the use of blood products

Ascending aorta replacement for acute aortic dissection repair was carried out in a 29-year-old man without the use of blood or blood products. Intraoperative blood loss was minimized with the use of biological glues and red cell salvage. Erythropoietic agents were started before surgery and continued during and after operative repair. Postoperatively, oxygen balance was maintained despite very low hemoglobin levels by increasing the cardiac output to compensate for the low oxygen-carrying capacity, thus maximizing oxygen delivery. Only essential laboratory determinations were carried out, which reduced additional blood loss. Repair was successful, and the patient was discharged from the hospital despite a delay in diagnosis and definitive surgical repair.     

分站式杂交手术治疗老年StanfordA型主动脉夹层

目的总结分站式一期杂交手术治疗老年StanfordA型急性主动脉夹层的临床经验及教训,探讨其可行性及适应证。方法2010年4月至2012年1月,广东省人民医院共8例老年（60岁以上）StanfordA型急性主动脉夹层患者接受分站式一期杂交手术治疗。8例患者均正中开胸,在中低温体外循环下以四分支人工血管行“升主动脉置换加主动脉弓去分支技术”。外科手术完成后送介入手术室逆行置入主动脉腔内覆膜支架。观察住院期间康复指标．定期复查全主动脉计算机断层扫描。观察人工血管通畅情况和夹层真假腔情况。结果本组患者无围术期死亡。体外循环时间（70．8_＋13．2）rain;主动脉阻断时间（37．8±6．5）min。患者术后呼吸机使用时间为2~16h,中位时间5h,住重症监护病房时间2—20d,中位时间2d。所有患者全部接受随访,随访时间3～27个月,中位时间13个月,所有患者均生存。术后3个月复查全主动脉增强计算机断层扫描,结果满意。结论分站式一期杂交手术处理老年StanfordA型急性主动脉夹层安全、有效,能明显缩短手术时间、术后呼吸机辅助时间和住院时间．减轻患者的创伤和痛苦,避免深低温停循环的风险,取得满意的近期效果。     

Surgical treatment for acute type A aortic dissection in pregnancy: a case of aortic root replacement just after Cesarean section

A 25-year-old woman with Marfan syndrome in the 37th week of pregnancy was referred for acute chest pain and dyspnea. An emergency Cesarean section was performed because of fetal distress. Intraoperative echocardiography at the end of the Cesarean section showed dilatation of the aortic root and dissection of the ascending aorta. The patient underwent replacement of the aortic root and the ascending aorta on the following day because of uterine bleeding. The postoperative course was uneventful for the mother and her baby.     

Current treatment of acute type A aortic dissection. Surgical treatment and treatment of malperfusion syndrome

Acute type A aortic dissection is a surgical emergency. Treatment is based on dissected ascending aortic replacement and correction of an associated aortic insufficiency. Catheterization of the axillary artery, open distal anastomosis and systematic resection of the intimal tear are the main surgical evolutions of the last years. They allowed to significantly reduce intraoperative mortality rate particularly due to bleeding. Thirty days mortality rate of operated aortic dissection is about 20 to 30%. Visceral malperfusion syndromes induced by aortic dissection represent an important cause of postoperative death. An early diagnosis and treatment appears necessary. Thoracoabdominal CT scan allows understanding mechanisms inducing malperfusion. Aortography and an emergency endovascular procedure allow restoring arterial blood flow before renal or mesenteric irreversible ischemia. Collaboration between radiologist, anesthesiologist and surgeon is necessary to optimize survival of acute type A aortic dissection.     

Dynamic aortic obstruction in a patient with acute type B dissection

There are at least 7000 aortic dissections diagnosed in the United States each year. Type B dissections accounted for 38% of cases enrolled in the prospective International Registry of Aortic Dissection. We report a case of a 48-year-old hypertensive woman with an acute type B aortic dissection causing significant dynamic obstruction of the aorta. Intravascular ultrasound of her aorta revealed a mobile intimal flap nearly obliterating the true lumen with each systolic contraction. Simultaneous pressure tracings obtained from her ascending aorta and femoral artery demonstrated a systolic pressure gradient in excess of 100 mm Hg. The patient developed progressive renal failure and ultimately underwent successful operative replacement of the proximal descending thoracic aorta with a Dacron graft. In this case presentation, we highlight the unusual physiology exemplified by this case and explore contemporary management strategies for complicated type B aortic dissection, including surgery and catheter-based techniques.     

Diagnosis and management of acute type A aortic dissection

Acute aortic dissection (AAD) is the most common aortic catastrophe. The mortality rate of type A dissection approaches 40% to 50% in 48 hours. Causes of death include rupture, aortic insufficiency, or malperfusion involving the coronary arteries, head vessels, visceral arteries, and lower extremities. Other acute aortic conditions can be confused with AAD. Emergent surgery is usually recommended, although there are some situations in which initial management of malperfusion or conservative therapy can be considered prior to proximal aortic repair. Various surgical techniques are employed to manage AAD. This article reviews the etiology, clinical presentations, and management of patients with type A AAD.     

Stanford A型主动脉夹层的外科治疗

目的 总结A型主动脉夹层外科治疗经验,探讨治疗A型主动脉夹层安全有效的术式和方法.方法 我院2008年1月至2013年11月对40例A型主动脉夹层患者予以外科治疗.Bentall（带瓣人造血管替代升主动脉根部和主动脉瓣膜,并移植左右冠状动脉）手术17例,其中10例同期行主动脉弓部替换＋降主动脉象鼻支架置入术;单纯升主动脉人工血管置换术8例;窦部成形＋主动脉瓣交界悬吊术6例,窦部替换＋主动脉瓣成形＋升主动脉半弓替换5例;升主动脉人工血管置换术＋主动脉全弓替换4例.采用深低温停循环技术（DHCA）12例,其余为浅中低温体外循环.采用冷血心脏停搏液灌注12例,组氨酸-色氨酸-酮戊二酸（HTK）停搏液灌注7例,冷晶体心脏停搏液21例.采用改良超滤技术19例.结果 手术死亡1例,围术期死亡4例,死亡率12.5％（5/40）,余均痊愈出院.结论 细化A型主动脉夹层的分型有利于制订个体化手术方案.术中止血彻底及心肌、脑保护确切可提高手术成功率.     

80岁以上高龄A型急性主动脉夹层患者行微创快速置换术的中期结果及生活质量评估

Objective： We presented initial results of less invasive quick replacement （LIQR） with moderate hypothermic arrest without cerebral perfusion followed by aggressive rapid re-warming to shorten the duration of brain ischemia, eardiopulmonary bypass （CPB）, and overall surgery （J-TCVS 2008）. We then assessed the mid-term outcomes and quality of life for octogenarian patients who undergo the LIQR for type A acute aortic dissection （AAD）.     

Endovascular repair of acute type B aortic dissection: midterm results.

PURPOSE: To evaluate midterm results of endovascular stent-graft placement for acute Stanford type B dissection (TBD). METHODS: A retrospective review was conducted of 35 consecutive patients who were treated with stent-graft implantation for acute TBD between July 1996 and July 2007. Computed tomographic (CT) volumetric analysis of the true lumen (TL) and false lumen (FL) changes in 23 patients was performed, as well as evaluation of the influence of re-entry points and length of stent-graft coverage on volume changes. In addition, complications were evaluated. Follow-up was performed at 6 and 12 months and yearly thereafter. RESULTS: The technical success rate was 82.7%, and the 30-day mortality rate was 8.5%. Mean follow-up was 34 months. The overall survival rate at 5 years was 78.4%. Complications included retrograde type A dissections in 3 patients during the perioperative period and in 1 patient during midterm follow-up. In addition, 5 early and 3 late endoleaks were observed. Three patients were converted to open surgery and 2 needed secondary interventions. In the stented segment, stabilization of the aorta was achieved even during midterm follow-up, with a TL volume increase of 59% at 5 years and nearly stable FL volume. The segment from the distal end of the stent-graft to the celiac artery, however, showed unstable TL and FL volumes, with high standard deviations after the first postinterventional year and circumferential aneurysmal dilatation of the aorta immediately adjacent to the stent-graft in 5 patients. The abdominal aorta showed no substantial volume changes over time. The length of stent-graft coverage and the occurrence of re-entries greatly influenced FL volume changes distal to the stent-graft. CONCLUSION: Serious complications can occur during and after endovascular repair of TBD. Therefore, it should be reserved for high-risk patients.