Stanford A型主动脉夹层的血管腔内治疗前景

Stanford A型主动脉夹层（Stanford type Aaortic dissection,TAAD）累及升主动脉,其内膜撕裂口可位于升主动脉、主动脉弓或降主动脉,夹层可同时累及主动脉弓、降主动脉和（或）腹主动脉。TAAD发病两周内的死亡率可高达80%[1],死因主要有夹层破裂、心包填塞、主动脉瓣关闭不全和心律失常等。TAAD一经确诊即有手术指征,传统的手术方式是升主动脉置换术．其中包括单纯人工血管置换术、Wheat术、Bentall术、Cabrol术和David术等。     

急性复杂型Stanford A型主动脉夹层的外科治疗

目的：评价急性复杂型Stanford A 型主动脉夹层手术中改良双侧选择性顺行脑保护的效果及升主动脉插管、左锁骨下动脉（LSA）“开窗”技术对手术风险的影响。方法122例急性复杂型Stanford A 型主动脉夹层患者行改良全主动脉弓置换加降主动脉内支架象鼻植入术,按照脑保护及动脉供血管插管方式分为单侧脑保护组与改良双侧脑保护组及右锁骨下动脉（RSA）插管组与主动脉插管组,比较各组的手术方式、死亡率及并发症率。部分患者采用左锁骨下动脉“开窗”技术重建血运。结果单侧脑保护组与改良双侧脑保护组总的院内死亡率分别为5．77％、2．86％,差异无统计学意义（P值为0．650）;神经系统总并发症率分别为26．92％、10．00％,差异有统计学意义（P值为0．014）。右锁骨下动脉插管组与升主动脉插管组总的院内死亡率均为4．55％,总并发症率分别为15．9％、15．2％,差异均无统计学意义（P值分别为1、0．914）。左锁骨下动脉“开窗”者术后多次复查CTA左锁骨下动脉均通畅,无左锁骨下盗血综合征发生,1例出现无需处理的少量内漏。结论改良双侧选择性顺行脑保护安全、可行、可靠;选择升主动脉插管符合生理、操作简捷,不增加手术风险;左锁骨下动脉“开窗术”简化了手术,缩短了深低温停循环时间,增加了手术安全性。     

Repeat surgical intervention after aortic repair for acute Stanford type A dissection

Objective

This study aimed to evaluate the outcomes of repeat interventions on the aorta and aortic valve after surgery for acute Stanford type A aortic dissection.

Methods

The hospital records of patients who underwent repeat surgical intervention between April 2011 and March 2017 for late complications after acute type A aortic dissection repair were retrospectively reviewed.

Results

We identified 17 patients with mean age of 62?±?8 years; 13 were men. The mean interval from the initial emergency aortic repair to the repeat intervention was 5.8?±?5.4 years (range 133 days–16.6 years). Ten patients had dilatation or rupture of the residual type B aortic dissection; six of them had retrograde type A aortic dissection at the onset and did not undergo resection of the primary entry. Five patients had a pseudoaneurysm at the anastomosis; four of them were receiving anticoagulation medication. Three patients had aortic regurgitation; two of them were associated with the gelatin-resorcinol-formaldehyde glue that was used during the initial surgery. There was no early mortality after repeat intervention and no late death after a mean follow-up period of 3.3?±?2.0 years.

Conclusions

Repeat surgical intervention on the aorta and aortic valve after repair of acute type A aortic dissection had favorable early and mid-term outcomes and was not associated with early or late death. Long-term follow-up with imaging and echocardiography was considered to be essential for early detection of residual type B dilatation, anastomotic pseudoaneurysm, and aortic regurgitation after initial aortic repair.

     

A treatment strategy for early thrombosed Stanford type A acute aortic dissection

Objective

Early thrombosed aortic dissection is a form of aortic dissection and includes the condition called aortic intramural hematoma. It was generally considered as surgical emergency. However, the optimal treatment strategy for acute type A intramural hematoma is becoming controversial after recent studies indicated more benign clinical course for this disease. We evaluated our strategy that integrated medical therapy, serial imaging, and timed surgery.

Methods

We reviewed 34 consecutive patients who were admitted to our hospital for early thrombosed Stanford type A acute aortic dissection from 2006 to 2011. Medical therapy or timed surgery was offered on the basis of radiological findings. Emergency or urgent surgery was not considered for a hemodynamically stable patient unless the ascending aortic diameter was ≧50 mm or the thickness of the thrombosed false lumen was ≧10 mm. Follow-up computed tomography was performed to detect a potential progression to aortic dissection.

Results

During the average follow-up period of 24.3 months, there was no aortic dissection-related mortality. And aortic dissection-related event was not recorded in patients who had surgical repair; however, in patients who did not have surgery, 3 (8.8 %) surgical conversions were recorded due to aortic dissection progression during the follow-up period. Twenty-one patients (61.8 %) ultimately had surgical repair, and 13 patients (38.2 %) had complete medical therapy. The overall survival rate at 3 years was 86.5 %.

Conclusions

Our strategy for the treatment of early thrombosed Stanford type A acute aortic dissection is reasonable, and the mid-term results were acceptable.     

Recent advance in treatment of Stanford type A aortic dissection

During the period between November 1986 and November 1988, 13 consecutive patients with Stanford type A aortic dissection (8 acute and 5 chronic) were treated as follows: (1) urgent operation for cases with pericardial tamponade or severe heart failure, (2) initial medical treatment followed by elective operation for acute but stable cases or chronic cases, and (3) routine use of open distal anastomosis or selective cerebral perfusion. One patient died during medical treatment: 5 patients were operated on emergently. The remaining 2 acute and 5 chronic cases were operated on electively. There were no operative deaths, neurological disturbances, or late deaths. It is suggested that acute dissection of the ascending aorta requires immediate surgical intervention, especially when the entry is in the ascending aorta. On the other hand, it is also suggested that one could avoid emergency operations in selected cases with retrograde extension of the aortic dissection.     

主动脉弓三分支覆膜支架在Stanford A型急性主动脉夹层外科治疗中的应用

目的 总结外科处理升主动脉加主动脉弓三分支覆膜支架置入治疗Stanford A型急性主动脉夹层的临床经验.方法 对2010年1月至12月收治的14例Stanford A型主动脉夹层患者行升主动脉手术处理加主动脉弓三分支覆膜支架置入,其中男性12例,女性2例,年龄20～70岁,平均49岁.手术包括升主动脉置换术加支架置入4例,主动脉根部置换术(Bentall术)加支架置入5例,主动脉瓣置换加升主动脉置换术(Wheat术)加支架置入4例,主动脉瓣成形加升主动脉置换术加支架置入1例;其中6例为急诊手术.结果 平均心肺转流时间(186±38)min,心肌阻断时间(101±27)min,选择性脑灌注时间(39±11)min.无住院死亡病例;术后出现短暂性神志障碍1例,肢体活动障碍1例,急性肾功能衰竭1例,二次开胸手术1例,消化道出血1例,乳糜胸1例,治疗后均痊愈.出院前及出院后3个月内行大血管CT血管造影检查:升主动脉及弓部覆膜支架内血流通畅,主动脉弓段及降主动脉假腔缩小,主动脉管壁结构恢复.随访1～12个月,无晚期死亡及需要再次手术纠治血管病变者.结论 主动脉弓三分支覆膜支架置入的主要适应证为内膜破口位于升主动脉但需重建弓部形态的Stanford A型急性主动脉夹层.其同期结合手术处理升主动脉是治疗急性Stanford A型主动脉夹层安全、有效的一种新手段.

Abstract：

Objective To sum up the experience of performing ascending aorta replacement combined triple-branched stent graft implantation for acute Standford type A aortic dissection. Methods From January 2010 to December 2010, 14 patients with acute Standford type A aortic dissection underwent the procedure of performing ascending aorta replacement combined triple-branched stent graft implantation.Right axiuary artery cannulation was used for cardiopulmonary bypass and selected cerebral perfusion.When the body temperature drops below 18 ℃, the ascending aorta was transected near the base of the innominate artery.From the incision, the triple-branched stent graft was implantated into the true lumen of the arch,descending aorta and the aorta bifurcation vessel. The transected stump of the ascending aorta was anastomosis to the proximal of the branched blood vessel prosthesis.Results Cardiopulmonary bypass time was (186 ±38) min,cross clamp time was (101 ±27) min,and average selective cerebral perfusion and lower body arrest time was ( 39 ± 11 ) min.The in-hospital mortality was zero.One patient of transient postoperative neurologic dysfunction, one of acute renal failure, one of transient limbs disturbance, one of secondary thoracotomy operation, one of gastrointestinal hemorrhage and one of postoperative chylothorax were observed.CT angiography rechecked showed the position of the vascular stent were satisfactory and the blood flow of arterial branches stents were lucid .The false lumen of the aortic arch and descending aorta closed with thrombus or shrinked.Conclusions The patients required aortic arch to be reconstructed which had no main tearing of intima in the arch may be best candidates for this technique.Open triple-branched stent graft placement combined ascending aorta replacement is an effective means for aortic arch reconstruction in acute Stanford type A aortic dissection.     

腔内隔绝术治疗StanfordB型夹层主动脉瘤

目的探讨腔内隔绝术治疗StanfordB型主动脉夹层的适应证和并发症的防治。方法分析21例StanfordB型主动脉夹层的微创腔内隔绝术病例与治疗效果。结果死亡3例，痊愈18例。4例发生术后内漏，3个月后CT检查自行封闭。18例随访10～60个月，无并发症发生。结论腔内隔绝术治疗StanfordB型主动脉夹层安全、有效，可作为治疗本病的首选方法。     

急性A型主动脉夹层的急诊外科治疗体会(附八例报告)

目的提高急性A型主动脉夹层（acute type A aortic dissection．AAAD）的急诊外科治疗水平。方法2002年4月至2005年3月对8例AAAD行急诊手术,其中Bentall手术7例,Cabrol手术1例。结果手术死亡1例,死亡率12．5％。7例痊愈出院。随访3～40个月,术后远期因霉菌感染致冠状动脉吻合口破裂死亡1例。其余6例患者生活质量良好。心功能Ⅰ级3例、Ⅱ级3例。结论对AAAD采用积极急诊手术治疗,可提高患者生活质量。     

Endoluminal and surgical treatment for the management of Stanford Type A aortic dissection.

Stanford Type A aortic dissection is a life-threatening disease. A 46-year-old female patient with Stanford Type A aortic dissection was successfully treated by placing a stent-graft into the ascending aorta via femoral artery. No complication was found immediately after the operation. Bentall operation was performed to treat the development of severe aortic insufficiency 21 months after the stent-grafting procedure. Literature review was done to discuss the possibility of using endoluminal stent placement to treat Stanford Type A aortic dissection.     

Stanford type A aortic dissection with intimal intussusception

A 51-year-old man presented with acute chest pain and loss of consciousness. Computed tomography showed no intimal flap in the ascending aorta and clear dissection involving the aortic root and arch, as well as the descending aorta. At surgery, the intimal tear was found to be circumferential and dissection extended to the proximal aortic arch with intussusception of the intimal layer. Emergency graft replacement of the ascending aorta was performed successfully and his postoperative course was uneventful.     

Postoperative respiratory dysfunction in patients with Stanford type A aortic dissection]

Between 1986 and 1990, 24 patients with Stanford type A dissection (acute; 14, chronic; 10) underwent surgery through median sternotomy. The patients were divided into two groups by a duration of postoperative ICU stay for respiratory care. Six patients in the long-period group stayed in ICU for more than 15 days and 18 patients in the short-period group stayed for less than 15 days after surgery. Acuity of disease, age, sex, operation time, pump time, aortic clamp time, lowest esophageal temperature, amount of blood transfusion, arch manipulation for cerebral perfusion with or without arch reconstruction, occurrence of phrenic nerve palsy and other postoperative complications, postoperative cardiac, hepatic and renal functions were compared between two groups. Conclusions are as follows: 1) Arch manipulation for cerebral perfusion with or without arch reconstruction, phrenic nerve palsy, other complications (pericardial and pleural fluid accumulation, recurrent nerve palsy, postoperative bleeding and coronary spasm) and high serum creatinine level were main factors for prolonged postoperative ICU stay for respiratory care and 2) arch manipulation in the patients with chronic type A aortic dissection induced high incidence of phrenic nerve palsy.     

Standford A型主动脉夹层的外科治疗分析

目的 总结Standford A型主动脉夹层的外科治疗经验.方法 2001年1月至2006年12月共收治Standford A型夹层动脉瘤患者54例,急性夹层(发病＜2周)36例,慢性夹层18例.46例接受手术治疗,其中急诊手术(入院后24 h内)35例,择期或限期手术11例;未行手术治疗8例.按主动脉根部术式分为单纯升主动脉置换术9例,Bentall术11例,Wheat+升主动脉置换术12例,David+升主动脉置换术14例.主动脉弓降部术式包括右半主动脉弓置换术6例,四分支人造血管全弓置换术25例,支架象鼻术24例.合并冠状动脉粥样硬化性心脏病及右冠状动脉断裂各1例,行冠状动脉旁路移植术.涉及主动脉弓部手术患者采用深低温停循环+双侧顺行选择性脑灌注,非急诊病例辅以体表降温.结果 手术组死亡率8.7%(4/46),未手术组死亡率75.0%(6/8).围手术期并发精神症状1例,胸腔积液或心包积液3例,声音嘶哑1例,切口愈合不良1例,经过积极处理后所有患者均痊愈出院.出院患者随访2～70个月,平均(13.0±14.2)个月,生活质量良好.结论 Standford A型主动脉夹层应积极手术治疗,术中根据不同情况采取最佳术式及合适的脑保护方案,术后及时处理并发症,可以取得良好的效果.     

Stanford A型主动脉夹层外科手术方法和疗效

目的探讨Stanfond A型主动脉夹层的手术方法，评价其疗效。方法回顾分析手术治疗108例Stanford A型主动脉夹层的临床资料，其中急诊手术53例，择期手术55例；深低温停循环（DHCA）下手术85例。手术包括升主动脉和半弓部置换或全弓置换（附加降主动脉支架人工血管置入术）以及“象鼻”手术；同期行弓部或降主动脉近端破口修补术、Bentall手术、主动脉瓣置换手术、Cabrol或改良Cabrol手术、主动脉瓣悬吊成形术、二尖瓣成形或二尖瓣置换术、三尖瓣环缩成形术和冠状动脉旁路移植术。结果住院死亡7例（6．5％），其中急诊手术死亡4例（7．5％），择期手术死亡3例（5．4％）。101例出院，96例随访1个月-13．3年，平均（3．2±1．3）年，晚期死亡2例，再次手术3例。结论Stanford A型的手术方法依病变部位不同而不同，准确掌握手术适应证，完善手术技术，加强术后处理，可以取得更好的手术效果。     

胸腹主动脉夹层动脉瘤(Stanford B型)的腔内血管外科治疗

目的 探讨Stanford B型胸腹主动脉夹层动脉瘤腔内治疗的方法。方法 对l2例StanfordB型胸腹主动脉夹层动脉瘤患者的临床资料进行回顾性研究。结果 l2例患者全为男性，年龄40～68岁，平均52．1岁。其中10例患者进行了腔内血管外科治疗，均取得了技术上的成功，术后内漏1例，3d后漏血停止。其余病例术后即时造影示瘘口已被完整覆盖，假腔无血漏入，内脏动脉等恢复真腔供血。2例未行腔内治疗的患者，l例因并发呼衰死亡，l例死于夹层动脉瘤破裂。结论对Stanford B型胸腹主动脉夹层动脉瘤的治疗，如适应证掌握合适，腔内治疗与传统的开胸手术相比，具有操作简单，损伤小，安全度大，并发症少等优点，且可大大缩短患者的住院时间。保守治疗难以控制病情的发展，易导致死亡等严重后果。     

手术治疗老年Stanford A型急性主动脉夹层的近期和远期疗效分析

目的:探讨外科手术治疗老年Stanford A型急性主动脉夹层(AAD)的近远期疗效。方法:回顾性分析2008年6月—2017年3月郑州大学第二附属医院心血管外科应用手术治疗的196例Stanford A型AAD患者资料,患者均采用全麻、深低温停循环加单侧选择性脑灌注技术进行外科手术治疗,其中33例患者年龄≥60岁(老年组),163例患者年龄60岁(年轻组),比较两组患者的临床资料和预后情况。结果:与年轻组比较,老年组男性患者比例低(45.5%vs.73.0%,P=0.000),De Bakey II型主动脉夹层发病率高(21.2%vs.6.7%,P=0.009);升主动脉置换+全弓置换+象鼻支架术应用比例低于年轻组(9.1%vs.28.2%,P=0.021)升主动脉置换+全弓置换+象鼻支架术应用比例减少(9.1%vs.28.2%,P=0.021),但单纯升主动脉置换比例增加(21.2%vs.2.5%,P=0.000),平均体外循环时间、主动脉阻断时间、手术时间均缩短(215.70 min vs.252.98 min,P=0.000;121.12 min vs.134.00 min,P=0.008;489.15 min vs.533.52 min,P=0.004);术后ICU停留时间延长(235.27 h vs.163.55 h,P=0.011),术后肾功能不全(21.2%vs.6.7%,P=0.009)、感染发生率(30.3%vs.9.8%,P=0.002)升高;术后生存率差异无统计学意义(P=0.1466)。全组病例分析显示,体外循环时间是AAD患者手术后院内死亡的危险因素(OR=0.987,95%CI=0.977~0.997,P=0.011),而年龄(OR=1.790,95%CI=0.651~4.921,P=0.259)与其他因素并非手术后院内死亡的危险因素。结论:对于老年AAD患者,根据夹层累及范围选择恰当的手术方式可以取得较满意的预后,术中尽可能缩短体外循环时间有助于提高手术疗效。     

腔内治疗破口位于升主动脉的Stanford A型主动脉夹层

目的:总结腔内方法治疗破口位于升主动脉的Stanford A型主动脉夹层的经验。方法:回顾性分析6例破口位于升主动脉的Stanford A型主动脉夹层行升主动脉覆膜支架植入术或联合弓部分支重建术的患者临床资料。结果:所有患者全部成功施行手术,4例行升主动脉覆膜支架植入术,2例先行颈-颈动脉人工血管转流后再行升主动脉覆膜支架植入术。术后并发急性脑梗塞1例,急性心功能衰竭1例,呼吸功能不全2例。1例因夹层破裂出血术后1 d死亡,其余患者均安全出院。随访时间3~48个月,随访期间2例出现I型内漏,均未再接受手术继续随访。结论:对于一些不能耐受传统手术的高危患者,腔内治疗A型夹层以其微创的优势,可作为传统手术的替代方法挽救患者生命。     

Operative management of Stanford type A aortic dissection using selective cerebral perfusion]

Ten patients underwent surgical treatment for type A aortic dissection from October 1986 to April 1989 using hypothermic cardiopulmonary bypass (CPB) with selective cerebral perfusion (SCP). CPB was begun with femoral artery cannulation. The right axillary artery (RAA) and the left common carotid artery (LCCA) were separately cannulated and perfused with CPB blood by individual pump heads. The average flow to the RAA was 5.4 +/- 1.2 ml/min/kg body weight (mean +/- SD) and 5.6 +/- 2.6 ml/min/kg body weight to the LCCA. The average blood pressure of the superficial temporal artery was 53.1 +/- 15.1 mmHg in the right side and 52.5 +/- 24.7 mmHg in the left. The nasopharyngeal temperature during SCP was maintained at 19.3-24.7 degrees C (mean, 21.1 degrees C). The SCP time ranged from 112 to 197 minutes (mean, 168 +/- 20.8 minutes). There was one operative death. She died of myocardial infarction 3 days after operation. There were two late deaths. One patient died of infection 3 months after operation and another died of cholecystitis 4 months after operation. Cerebral infarction developed in the last patient. Among the 10 patients it was only one neurological sequela, which was surmised to be caused by technical problem in carotid artery cannulation. The good cerebral protection was obtained in our experience by SCP as mentioned above.     

Stanford A型主动脉夹层的血管腔内治疗

主动脉夹层是主动脉最常见的疾患．是由于主动脉腔内血液从主动脉内膜撕裂口进入主动脉壁层．形成主动脉壁两层分离状态而成。夹层可沿主动脉长轴方向扩展．如其假腔不断扩大，在主动脉壁间形成动脉瘤．称为主动脉夹层动脉瘤。主动脉夹层可发生于主动脉任何部位．按Stanford分型，凡病变累及升主动脉者为A型．内膜撕裂口可位于升主动脉、主动脉弓或近端降主动脉．病变扩展可累及升主动脉．也可延至弓部、降主动脉或腹主动脉。根据DeBakey分型，如撕裂口位于升主动脉，病变扩展累及主动脉弓、降主动脉、胸主动脉甚至腹主动脉者，称为DeBakeyⅠ型：而内膜撕裂口位于升主动脉．病变扩展仅限于升主动脉者．称为DeBakeyⅡ型。