再次及多次主动脉瘤手术的临床分析

目的：总结13例共27次主动脉瘤手术的经验。方法：全组13例中男8例,女5例,2次手术者12例,3次手术1例,再次手术距前次手术平均50个月（22d-233个月）,首次手术分别是：主动脉根部置换7例,慢性B型夹层行胸降主动脉人工血管置换3例,肾动脉下方腹主动脉瘤切除人工血管置换1例,急性A型夹层行主动脉瓣及升主动脉成形,川崎病行升主动脉人工血管置换和左冠状动脉前降支成形各1例,再次手术分别是因残余夹层扩大行全弓置换加ElephantTrunk1例,胸降主动脉置换2例,2例再发弓部夹层,1例行根部置换＋部分弓部置换,1例行升弓部置换;2例胸降主动脉瘤,1例胸腹主动脉瘤,1例B型夹层,常温阻断下行人工血管置换术,1例根部瘤在中低温体外循环下行根部置换术,川崎病再发无名动脉和弓部动脉瘤行无名动脉及部分弓置换1例,1例A型夹层升主动脉及主动脉瓣成形术后感染性假性动脉瘤形成,1例再发升主动脉瘤行升主动脉置换;1例根部置换再行弓降部置换术后,再发弓部动脉瘤,第3次手术行全弓置换,再手术时采用深低温停循环8例,常温阻断4例,中低温体外循环2例。结果：术后4例出现脑部并发症,1例肝功能异常,均治愈,无住院死亡。随访远期死亡3例,另有2例随访6个月和70个月,现待手术。结论：再次手术以再发或多发动脉瘤（包括主动脉夹层）为最常见原因,其次是残余夹层进一步发展,再次手术一定要积极,以免延误手术时机导致死亡。应根据再次手术的部位选择基本方法,累及弓部需深低温停循环并选择性脑灌注,远弓部和胸,腹主动脉可用常温阻断或股一股转流,如无法游离阻断则需要深低温停循环,累及根部则只需要一般体外循环,大出血和昏迷是再次手术最危险的并发症,尽早建立体外循环,低温和停循环期间的脑灌注可有效预防这类并发症。     

主动脉夹层的外科治疗

目的总结84例主动脉夹层患者的外科治疗经验,探讨手术技巧和围术期处理,以提高手术疗效。方法50例Stanford A型主动脉夹层患者在体外循环下（11例采用深低温停循环技术）行Bentall手术或Cabrol手术24例,升主动脉人工血管置换术8例,Trusler手术5例,Wheat手术5例,升主动脉＋主动脉全弓或半弓人工血管置换术8例;34例Stanford B型主动脉夹层采用带膜支架主动脉腔内修复术治疗。结果住院死亡11例,死亡率13．1％。术中死亡3例,其中1例升主动脉＋次全弓人工血管置换患者因术中主动脉开放后主动脉根部大出血无法止血;1例升主动脉部分切除＋人工血管置换患者心脏无法复跳;1例升主动脉＋半弓血管置换患者因降主动脉夹层破裂死亡。术后早期死亡8例,其中死于低心排血量综合征2例,肺部感染2例,肾功能衰竭2例,呼吸衰竭1例,永久性神经系统损害1例。术后发生并发症16例。随访62例（84．9％,62／73）,随访时间3个月～10年。随访期间死亡2例,其中1例死于心内膜炎,1例猝死（原因不明）。结论快速准确地诊断、个体化的手术方案和精确的手术技术是主动脉夹层手术成功的关键。     

胸主动脉瘤外科综合治疗

目的 总结2001年5月～2005年5月我院对223例各类胸主动脉瘤行介入腔内隔绝、“杂交手术”等综合外科治疗的经验,探讨手术方法的选择和手术新技术的应用。方法 单纯Bentall手术83例,单纯升主动脉置换17例,David手术3例,Wheat手术7例,Bentall及右半弓人工血管置换术12例,全弓人工血管置换联合象鼻或改良象鼻手术10例,“杂交手术”（Bentall手术＋全弓置换＋介入腔内隔绝）8例,降主动脉人工血管置换术4例,降主动脉及左半弓人工血管置换术3例,腔内覆膜支架介入治疗降主动脉夹层动脉瘤76例。急诊手术98例,同期行冠状动脉旁路移植术6例（包括“杂交手术”＋冠状动脉旁路移植术1例）。结果 手术死亡9例：1例Ⅰ型夹层动脉瘤术后死于大面积脑出血;2例Bentall手术后呼吸功能衰竭合并肺部感染,分别在术后7、12 d死亡;1例急性肝功能衰竭,经人工肝,血浆置换治疗未好转术后3 d死亡;2例分别于术后8、14 d死于多脏器功能衰竭;2例分别于术后4、6 d死于心脏功能衰竭;1例术后3 d脑梗塞家属放弃治疗。76例腔内隔绝术即时操作成功率100%,即夹层裂口完全封闭,恢复真腔血流,动脉假腔不再显影。214例随访4～52个月,（27±18）个月,3个月内无死亡。1例Bentall术后8个月因突发心律紊乱死亡;1例Bentall及右半弓人工血管置换术后12个月因脑栓塞死亡;1例马凡综合征行Bentall术后6个月出现降主动脉夹层动脉瘤,再次行胸降主动脉置换和肋间血管移植痊愈。结论 早期根据病变部位、程度采用包括经导管植入支架、杂交手术等综合外科治疗可以简化手术操作、提高手术安全性、降低胸主动脉瘤手术病死率。深低温停循环联合右锁骨下动脉插管选择性脑灌注是一种简便易行有效的脑保护方法。     

主动脉瘤40例治疗体会

目的介绍外科与腔内隔绝术治疗主动脉瘤的体会。方法手术与腔内隔绝术治疗主动脉瘤40例,手术治疗30例,Bentall术9例,Bentall 部分弓置换3例,主动脉瘤切除人工血管置换6例,主动脉瘤切除补片修补4例,升主动脉 部分弓置换、主动脉瓣二尖瓣置换 升主动脉折叠缝合术各2例,主动脉瓣置换 升主动脉置换、主动脉瓣置换升主动脉折叠缝合术、主动脉瘤切除直接缝合、主动脉瘤切除人工血管置换 左全肺切除术各1例。腔内隔绝术治疗假性胸降主动脉瘤1例、假性腹主动脉瘤1例、夹层主动脉瘤ⅢA型1例、ⅢB型7例,经股动脉切口植入32~38mm覆膜支架。结果手术后因低心排出量综合征和出血各死亡1例,死亡率6.7%,无截瘫、偏瘫和感染。覆膜支架腔内隔绝术后1~2周内低热8例,无大出血、内漏和死亡。生存38例,随访1个月~5年,无死亡和远期并发症。结论升弓部主动脉瘤的手术治疗效果满意,覆膜支架腔内隔绝治疗DeBakeyⅢ型夹层主动脉瘤创伤小、并发症少、恢复快。     

部分主动脉根部重建术在急性Stanford A型主动脉夹层的应用

目的分析部分主动脉根部重建术在急性Stanford A型主动脉夹层的临床效果。方法 2010年1月至2015年12月,南京医科大学附属南京医院共30例急性A型主动脉夹层累及根部患者行手术治疗,其中男25例、女5例,年龄27~72(51.2±8.0)岁。夹层近心端施行了部分主动脉根部重建术:部分根部成形+升主动脉置换术9例,部分根部成形+升主动脉置换+半弓置换术6例,部分根部成形+升主动脉置换+孙氏手术15例。术后随访10~60(37.9±3.2)个月。比较术前、术后主动脉瓣反流程度等指标。结果全组中无手术死亡发生,1例患者术后15 d死于肺炎,生存率96.7%(29/30)。1例患者随访期间死亡,2例患者因主动脉瓣严重反流分别于术后1年和15个月再次入院行主动脉瓣置换术。截至最后一次随访,24例无主动脉瓣膜反流,2例少量反流。结论 Stanford A型主动脉夹层导致主动脉根部病变,部分主动脉根部重建术能够保留主动脉瓣瓣膜的持久性和功能性,可获得较满意的早、中期疗效。     

一期次全或全主动脉替换术的中期随访结果

目的 总结一期全主动脉替换术治疗全程主动脉瘤的中期随访结果.方法 2004年2月至2008年7月22例全程主动脉瘤的患者接受一期次全(7例)或全主动脉替换术(15例).男性17例,女性5例,年龄19～47岁.慢性A型夹层动脉瘤15例,主动脉根部瘤合并慢性B型夹层动脉瘤5例,主动脉根部瘤合并弓部和胸腹主动脉瘤1例,慢性B型合并急性A型夹层动脉瘤1例.手术均在全身麻醉深低温停循环顺行性脑灌注下进行.采用胸骨正中切口+左后外胸腹联合切口.采用分段阻断法用人工血管置换全部病变主动脉.结果 无手术死亡病例.术后早期死亡1例,死于多器官功能衰竭.术后发生脑梗死2例,二次开胸止血7例.存活21例,随访3～56个月,平均(35.0±16.9)个月,情况良好,无晚期死亡.1例David+全主动脉替换术患者术后1年因主动脉瓣反流行主动脉瓣置换术.此外无再手术病例.结论 一期次全或全主动脉替换术是治疗全程主动脉瘤的有效方法.手术结果满意,术后中期随访效果良好.     

32例Wheat手术临床分析

目的　探讨主动脉瓣置换合并升主动脉扩张的外科处理方法。方法　 1996年至 2 0 0 2年间32例Wheat手术病人中男 2 5例 ,女 7例。平均年龄 ( 4 8 6± 8 9)岁。主动脉瓣病变主要是先天性二瓣化畸形 ( 19例 ,5 9% )。升主动脉内径 4 5～ 6 0mm ,平均 ( 5 2 2± 4 5 )mm。均在体外循环下行主动脉瓣和升主动脉置换。结果　无手术和住院死亡。心功能均恢复至I～II级。平均随访 2 2个月 ,无死亡 ,无远期假性动脉瘤发生。结论　Wheat手术对需要主动脉瓣置换同时合并单纯升主动脉扩张的治疗是一种简单有效的术式     

血管腔内治疗主动脉夹层和夹层动脉瘤

目的 探讨血管腔内治疗主动脉夹层和夹层动脉瘤的技术方法和疗效。方法 对20例主动脉夹层和夹层动脉瘤患者的临床资料进行分析。Stanford A型2例,其中1例内膜撕裂口位于升主动脉。Stanford B型18例。5例在不同部位有2个以上撕裂口。全组均以带膜支架型人工血管腔内植入行隔绝术。其中1例加作腹主动脉开窗和人工血管置换术,1例先行升主动脉．左锁骨下动脉和左颈总动脉Y形人工血管旁路术,再行腔内隔绝术。结果 无一例患者术中死亡,术后3d 1例Stanford B型患者死于心肌梗死,其余19例健康存活,生存率95％。术后随访1—20个月,各例主动脉夹层和动脉瘤均消失,无内漏,各器官灌注良好。结论 血管腔内植入带膜支架型人工血管是治疗主动脉夹层和夹层动脉瘤的简便、安全而有效的方法。手术死亡率低,手术成功率和生存率高。     

114例升主动脉瘤的外科治疗

目的　总结升主动脉瘤手术治疗的经验 ,并分析探讨其相关的问题。　方法　对 114例升主动脉瘤患者(其中 6 2例伴升主动脉夹层分离 )施行了手术治疗。 10 5例升主动脉瘤伴主动脉瓣关闭不全患者行 Bentall手术 (升主动脉和主动脉瓣置换术以及冠状动脉开口移植术 ) ,其余 9例患者仅行升主动脉置换术。　结果　手术死亡 7例(6 .14 % ) ,其中 6例为术前心功能 (NYHA) 级患者。随访 10 7例 ,随访时间 7天～ 12 .4年 (40± 30月 ) ,死亡 8例 ,死于颅内出血 3例 ,腹内动脉瘤破裂出血 3例 ,急症冠状动脉旁路移植术 1例 ,原因不明猝死 1例。存活的 99例(86 .8% )情况良好 ,心功能为 、 级。　结论　主动脉置换术治疗升主动脉瘤、Bentall手术治疗升主动脉瘤合并主动脉瓣关闭不全 ,术后可使大多数存活患者获得良好的功能恢复和生活质量 ,手术效果满意。     

Stanford A型主动脉夹层的外科治疗

目的总结A型主动脉夹层的外科治疗经验。方法回顾分析手术治疗68例StanfordA型主动脉夹层患者的临床资料。其中急性主动脉夹层45例,慢性主动脉夹层23例。采用中低温体外循环53例,深低温停循环(DHCA)和上腔静脉逆行灌注脑保护11例,DHCA加选择性脑灌注4例。急诊手术39例(其中紧急手术19例),择期手术29例。术式为升主动脉置换术7例,升主动脉加右半弓置换术6例,升主动脉加全弓置换术3例,升主动脉加全弓置换加术中支架置入术4例,Bentall手术34例,改良的Wheat术12例,同时行主动脉瓣成形术2例、二尖瓣成形1例。结果全组死亡5例(7%),其中急诊手术3例,急诊手术病死率8%(3/39);择期手术2例,择期手术病死率7%(2/29)。共随访58例,随访率92%(58/63),随访时间(37±22)个月(5~77个月),死亡4例,累积1,3和5年的生存率分别是100%,95%和86%。结论StanfordA型夹层的手术方式应根据内膜破口位置决定,正确的手术指征、技巧和脑保护是手术成功的关键。     

Surgical treatment and their long-term results of the ascending aortic lesions involving coronary arteries

Seventeen patients underwent surgical treatment of the ascending aorta, aortic valve, and coronary artery as well. Diagnosis of 13 patients were annulo-aortic ectasia, 3 had dissecting aneurysm (type I: 2, type II: 1), and one had supra-valvular aortic stenosis. In annulo-aortic ectasia, Bentall's method was carried out in 11 cases, and Cabrol's operation was performed in 3, one of the latter group had received Bentall's procedure 4 years prior to the second operation. One patient died of acute myocardial infarction 3 days following operation, who had severe stenosis of the left anterior descending artery not detected by preoperative angiography. During long-term follow up, 2 patients died of cardiac failure. Three patients had dissection of the ascending aorta and coronary artery (right coronary artery: 2, left coronary artery: 1). The aorta was reconstructed, aortic valve was replaced, and coronary artery was revascularized with saphenous vein graft. They have been alive and well up to post operative 6 years. Right coronary ostioplasty as well as aortic valve replacement and extended aortoplasty were attempted in one patient with Williams' syndrome. This patient had been well until sudden death which occured 11 months after the operation.     

一期次全或全主动脉替换术的临床应用

目的 总结全主动脉替换术治疗全程主动脉瘤及慢性Stanford A型主动脉夹层的临床经验。方法 2004年2月至11月对8例全程主动脉瘤或慢性Stanford A型主动脉夹层的患者施行一期次全（2例）或全主动脉替换术（6例）。其中7例男性,1例女性,年龄23～47岁。病因均为马凡综合征。手术均在全身麻醉深低温停循环顺行性脑灌注下进行。采用左后外胸腹联合切口及胸骨正中切口。手术采用四分支人工血管,先行升主动脉替换或Bentall手术,然后行主动脉弓替换,最后完成胸腹主动脉替换。结果 无手术及住院死亡。1例脑梗死。随访2～12个月,无晚期死亡及再手术病例。结论 一期次全或全主动脉替换术可减少分期手术的痛苦,节约医疗费用,并消除分期手术残余动脉瘤破裂的风险,是治疗全程主动脉瘤及慢性Stanford A型主动脉夹层的有效方法。     

Surgical treatment of acute ascending aortic dissection.

Since adopting a policy of immediate operation on patients with acute dissection of the ascending aorta, 42 men and 6 women (ages 18-67 years) have been managed surgically. Thirty-two patients had graft replacement of the ascending aorta and resuspension of the incompetent aortic valve. One of these had a coronary graft. There were five deaths in this group. Eight patients required aortic valve replacement because of a diseased aortic valve as well as grafting of the ascending aorta, with one death. Three patients had resuspension of the aortic valve and primary repair of their dissection without mortality. Two patients were managed successfully with an intraluminal prosthesis and resuspension of the aortic valve. Another patient had successful repair with a valved conduit and reimplantation of the coronaries. Two patients dissected 4 and 6 years after aortic valve replacement and neither survived operative repair. Of the surviving patients, one required dialysis, one a femoral-femoral bypass graft, and one an axillo-femoral bypass graft. One patient required a pacemaker for heart block, and two underwent successful repair of suture line aneurysms, both occurring three years after operation. On the basis of this experience, prompt surgical intervention for acute ascending aortic dissection is the treatment of choice. A variety of techniques are available to repair the dissected aorta. Long-term results for resuspension of the aortic valve in acute ascending aortic dissection have been excellent and emphasize that valve replacement should be reserved for those patients found at operation to have a primary abnormality of the aortic valve.     

Reoperative cryopreserved root and ascending aorta replacement for acute aortic prosthetic valve endocarditis

BACKGROUND: Prosthetic aortic valve endocarditis (PVE) is an important complication of aortic valve replacement (AVR) and is a particularly difficult situation after an operation combining AVR with ascending aortic replacement. METHODS: From 1988 through 2000, 27 patients with aortic valve PVE after previous ascending aortic replacement (aortic root replacement in 13, aortic valve replacement with a supracoronary graft in 14) underwent reoperation for aortic root replacement with a cryopreserved aortic allograft and prolonged intravenous antibiotic therapy. All patients were considered to have active PVE (25 with positive cultures); root abscess formation was present in 89% and aortoventricular discontinuity in 41%. RESULTS: One patient (3.7%) died in-hospital, and permanent pacemakers were required in 10 patients (37%). Mean postoperative follow-up interval was 3.9 +/- 3.0 years, and survival at 1, 2, 5, and 7.5 years was 92%, 88%, 70%, and 56%, respectively. One patient underwent reoperation for recurrent PVE 8 months after operation. CONCLUSIONS: Radical debridement of infected prosthetic material and tissue, and allograft aortic root and ascending aorta replacement, combined with intravenous antibiotic therapy, appears to achieve a low hospital mortality and a high degree of freedom from recurrent infection for patients with PVE after AVR and ascending aortic replacement.     

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.     

Replacement of the ascending aorta. Early and late results

From 1978 through 1987, 225 patients underwent operations that included replacement of the ascending aorta. One hundred twenty-three patients underwent composite aortic valve and ascending aortic replacement, 30 had aortic valve replacement with separate graft replacement of the ascending aorta, and 72 underwent replacement of the ascending aorta without aortic valve replacement. Thirty-one (13.8%) in-hospital deaths occurred. Univariate testing of preoperative and operative variables followed by logistic regression analyses identified miscellaneous aortic disease, coronary artery bypass grafting, aortic arch replacement, emergency operation, surgical date (1978 to 1983), and age (all p less than 0.05) as factors having independent association with in-hospital mortality. Follow-up of in-hospital survivors (mean interval 46 months, range 8 to 123 months) documented an overall 5-year survival rate of 76%, 83% after primary operation and 37% after reoperation. Univariate analyses followed by multivariate testing indicated that previous operation (p less than 0.0001) and a history of preoperative neurologic symptoms (p = 0.021) were associated with decreased late survival. At follow-up 88% of late survivors were free of symptoms. Seven patients have undergone reoperation 1 day to 69 months postoperatively. Although the in-hospital mortality for operations that include ascending aortic replacement exceeds that for isolated aortic valve replacement, the late death rate and rate of reoperation are low.     

Aortic root replacement after operation for the ascending aorta and/or aortic valve

We reviewed ten cases who underwent aortic root replacement after operation for the ascending aorta and/or aortic valve. As initial operation, aortic valve replacement (AVR) was performed in five patients, replacement of the ascending aorta in two, original Bentall operation in two, and entry closure and suspension of the aortic valve in one. At reoperation, three patients were diagnosed as aneurysm of the ascending aorta, two were annulo-aortic ectasia, and one was acute aortic dissection, chronic dissecting aneusym, pseudoaneurysm of the ascending aorta, prosthetic valve endocarditis, and massive aortic regurgitation. Aortic root replacement was performed using mechanical valved composite graft in all cases. One patient who underwent repeat aortic root replacement for prosthetic valve endocarditis was died of septemia and ventricular fibrillation. Five patients had nine complications (two low output syndrome, respiratory failure and cerebral infarction, one gastrointestinal bleeding, septemia and ventricular fibrillation). In conclusion, aortic root replacement after operation for the ascending aorta and/or aortic valve was performed with acceptable morbidity and mortality.