不同手术方式治疗急性StanfordA型主动脉夹层——单中心5年临床经验

目的 总结不同手术方式治疗急性Stanford A型主动脉夹层的临床经验。 方法 回顾性分析2008年1月至2012年11月于中国医科大学附属第一医院因急性Stanford A型主动脉夹层而实施外科治疗的197例患者的临床资料。男131例、女66例,年龄 （51.2±13.9） 岁。所有患者经磁共振成像 （MRI） 或主动脉CT血管造影（CTA）确诊。根据主动脉根部病变情况,进行单纯升主动脉置换、Bentall、Wheat、Cabrol或David手术。主动脉弓部进行全主动脉弓置换、半弓置换或简化全主动脉弓置换＋降主动脉支架象鼻手术。 结果 近端单纯升主动脉置换113例（57.4%）,Bentall手术67例（34.0%）,Wheat手术13例（6.6%）,Cabrol手术1例（0.5%）,David手术3例（1.5%）。全主动脉弓置换＋降主动脉支架象鼻手术82例（41.6%）,半弓置换＋降主动脉支架象鼻手术77例（39.1%）,简化全主动脉弓置换＋降主动脉支架象鼻手术41例（20.8%）。二次开胸止血1例（0.5%）,无永久性神经系统并发症发生,手术30 d死亡率为4.1%（8/197）;随访时间3～52（15.9±11.4）个月,随访率65.0%;1例马方综合征患者术后8个月死于腹主动脉瘤破裂。 结论 根据病变情况,选择适当的外科治疗策略,急性Stanford A型主动脉夹层外科治疗效果满意。     

孙氏手术治疗升主动脉替换术后残余主动脉夹层

目的 探讨Stanford A型主动脉夹层近端主动脉替换术后残余主动脉夹层的手术时机和手术方式.方法 2009年3月至2011年11月,连续收治16例Stanford A型主动脉夹层术后残余夹层的患者,男13例,女3例;年龄23 ～ 61岁,平均44岁.其中8例为马方综合征.中低温停循环、低流量顺行脑灌注下行孙氏手术(主动脉弓替换+支架象鼻术).其中单纯行孙氏手术12例;同期行主动脉根部替换术(Bentall手术)3例,主动脉根部替换术+冠状动脉旁路移植术(Bentall+ CABG)1例,冠状动脉吻合口漏修补术1例,二尖瓣置换术(MVR)1例.结果 再次手术距离首次手术时间(66±40)个月.体外循环(193±49)min,心肌阻断(90±28) min,选择性脑灌注(22±10) min.术后气管插管(17±10)h.无住院死亡.术后并发症4例,其中左下肢轻瘫1例随访期间好转;开胸止血、乳糜胸和胸骨后感染各1例,均于治疗后痊愈出院.患者出院前均行主动脉CT血管造影检查,示人工血管血流通畅,降主动脉真腔较术前明显扩大,支架段假腔血栓形成.随访3～42个月,平均17个月.1例术后3个月因远端夹层破裂死亡,1例术后6个月行全胸腹主动脉替换术,1例因胸降主动脉扩张合并内膜残余破口行胸主动脉腔内修复术.结论 Stanford A型主动脉夹层升主动脉替换术后残余夹层的患者,当主动脉弓扩张速度超过0.5 cm/年,或直径扩张至5 cm以上(或扩张至4.5 cm但合并弓部破口或马方综合征)时,应再次接受手术治疗,孙氏手术治疗安全有效,手术死亡及相关并发症发生率较低,近期结果良好.     

Stanford B型主动脉夹层的外科治疗

目的 总结外科治疗Stanford B型主动脉夹层的初步效果和临床经验,分析影响再次手术的危险因素.方法 2009年2月至2011年12月,81例Stanford B型主动脉夹层患者接受外科手术治疗,其中男54例,女27例;年龄19～77岁,平均(41.6±11.7)岁.合并高血压48例,马方综合征15例,主动脉根部瘤7例,主动脉窦部扩张、升主动脉扩张、主动脉缩窄各1例.其中二次手术18例,三次手术4例.对再次手术的相关危险因素进行logistic回归分析.结果 主动脉弓部替换加支架象鼻手术(孙氏手术)16例,同期Bentall手术7例,升主动脉替换2例,David手术1例,冠状动脉旁路移植手术1例;胸腹主动脉替换31例;支架象鼻术24例,同期左锁骨下动脉左颈总动脉转流5例,主动脉瓣置换+升主动脉成形3例,左锁骨下动脉重建2例,双瓣置换1例,升主动脉降主动脉人工血管转流1例;胸降主动脉替换9例;内漏修补1例.术后2例死于出血致多脏器功能衰竭,均为全胸腹主动脉替换患者,住院病死率2.5％(2/81例).术后并发症发生率7.4％(6/81例),其中二次开胸止血3例,呼吸功能不全气管切开1例,术后食管瘘开胸探查+空肠造瘘1例,声音嘶哑1例.全组无截瘫及卒中.Logistic回归分析表明,马方综合征是再次手术的危险因素.结论 外科治疗StanfordB型主动脉夹层早期效果满意,中、远期结果需进一步随访.马方综合征是需要再次手术干预的危险因素.     

主动脉瓣置换术后患者再次主动脉外科干预47例

目的 回顾性分析47例主动脉瓣术后再次主动脉外科治疗病例,提高对主动脉瓣术后主动脉疾病再治疗的认识.方法 2003年1月至2012年6月,47例患者因主动脉瓣术后接受再次主动脉手术治疗.男38例,女9例,再次手术间隔时间(6.0±3.8)年.行主动脉根部替换14例,升主动脉替换10例,主动脉根部/升主动脉+全弓替换+象鼻支架置入术21例,全胸腹主动脉替换2例.所有出院患者均行门诊复查和电话随访.结果 47例患者中主动脉夹层25例(53％),升主动脉瘤12例(26％),主动脉根部瘤10例(21％).风湿性心脏病患者升主动脉直径年增长值高于马方综合征患者(P＜0.05).47例均接受外科手术治疗,术中死亡1例;余患者均出院并随访,随访时间(53.49±33.79)个月,3年生存率83％.结论 对马方综合征、风湿性心脏病等主动脉瓣疾病合并主动脉病变要积极干预、严格随访,减少术后主动脉不良事件.     

风湿性主动脉瓣疾病术后再发主动脉病变的外科治疗

目的探讨风湿性主动脉瓣疾病术后再发主动脉疾病的外科治疗,提高对主动脉瓣术后继发主动脉病变防治的认识。方法回顾性分析2003年8月至2012年5月阜外心血管病医院收治的风湿性主动脉瓣疾病术后再发主动脉病变患者27例的临床资料,男20例、女7例,年龄28~69(50±10)岁。继发主动脉病变包括Standford A型主动脉夹层13例(急性夹层4例,慢性夹层9例),升主动脉瘤6例,主动脉根部瘤8例。所有患者均行手术治疗,主动脉根部置换7例,升主动脉+全主动脉弓置换+象鼻支架植入术6例,主动脉根部置换+全主动脉弓置换+支架象鼻手术6例,升主动脉置换8例。对所有出院患者进行门诊复查和电话随访。结果再次手术间隔时间6~110(57±32)个月,术后早期无死亡,再次手术体外循环时间50~274(143±65)min,住院时间13~27(19±11)d。术后早期并发症包括肾功能不全4例,神经功能障碍3例(无轻瘫或截瘫发生),肺部并发症4例,肠道并发症2例。术后随访率81.5%,随访时间4~118(43.5±32.2)个月,随访期间4例死亡,3年生存率为85.1%。结论对因风湿性主动脉瓣疾病行主动脉瓣手术的患者,若同期合并主动脉病变,需积极处理;即使未合并主动脉病变,也应严格随访,定期复查,减少术后主动脉不良事件的发生。     

保留主动脉瓣的根部重建术治疗马方综合征主动脉根部瘤

目的 总结保留主动脉瓣的根部重建术治疗马方综合征主动脉根部瘤的经验.方法 2003年7月至2007年12月22例马方综合征患者接受保留主动脉瓣的根部重建术.其中男性12例,女性10例;年龄10～57岁;平均(28±10)岁.手术方法包括再植技术9例、成形技术8例、单片法2例,再植手术+全主动脉置换1例,成形手术+全弓置换+支架象鼻手术1例,单片法+全弓置换+支架象鼻手术1例.术后随访17～64个月,平均随访(46±16)个月.结果 无住院及随访期死亡,1例患者再次开胸止血,随访期无瓣膜相关并发症发生.截至最后一次随访,16例无主动脉瓣反流,4例少量反流,中度及重度反流各1例.中度及重度反流的患者于术后1年进行了再次瓣膜置换手术.结论 保留主动脉瓣的根部重建术早、中期效果满意,可用于治疗马方综合征患者的主动脉根部瘤.     

分期全主动脉置换治疗急性A型主动脉夹层合并胸腹主动脉瘤

目的总结采用分期全主动脉置换治疗急性A型主动脉夹层合并胸腹主动脉瘤的手术方式和早期治疗效果。方法自2013年2月至2014年2月,2例急性A型主动脉夹层合并CrawfordⅡ型胸腹主动脉瘤的马方综合征患者进行了分期全主动脉置换手术。患者均为男性,年龄分别为41岁和26岁。一期在部分深低温停循环下行主动脉根部、全弓置换及支架象鼻植入术,二期在常温非体外循环下应用四分叉人工血管行全胸腹主动脉置换术。结果手术结果满意,2例患者均康复出院,无任何并发症。结论分期全主动脉置换术治疗急性A型主动脉夹层合并全胸腹主动脉瘤是一种安全、有效的方法。     

改良全主动脉弓置换治疗老年Stanford A型主动脉夹层

目的总结改良全主动脉弓置换治疗老年Stanford A型主动脉夹层的临床经验,并探讨其疗效。方法 39例老年Stanford A型主动脉夹层患者在深低温停循环、双侧顺行脑灌注下行外科手术。根部处理根据不同病变情况,选择不同术式,包括单纯升主动脉置换、Bentall、Wheat手术。主动脉弓部采用四分支血管行全主动脉弓置换,降主动脉内置入硬象鼻支架,并行支架开窗,完成左锁骨下动脉重建。结果全组平均体外循环时间为(180.49±30.46)min,平均停循环时间(27.22±10.58)min,平均脑灌注时间(32.42±12.36)min,平均心肌阻断时间(94.84±24.83)min。升主动脉置换17例,Wheat手术10例,Bentall手术12例。全组无术中死亡,术后住院死亡2例,脑梗塞1例,短暂性神经功能障碍3例,行肾脏透析治疗3例。全组无出血再次开胸、声音嘶哑、左上肢感觉运动功能障碍等情况。术后复查主动脉CTA弓部分支血管血流通畅,象鼻支架无内漏。无术后死亡及二次手术者。结论选择合适的手术时机及手术方式,老年Stanford A型主动脉夹层患者仍能获得满意的外科手术效果。     

全主动脉弓置换加支架象鼻手术治疗A型主动脉夹层

目的介绍全主动脉弓置换加支架象鼻手术治疗A型主动脉夹层的方法,总结其治疗经验。方法2007年1月至2008年11月,采用四分支人工血管行全主动脉弓置换加覆膜支架象鼻手术治疗A型主动脉夹层10例,其中急性夹层8例,慢性2例。10例均在深低温停循环及选择性脑灌注下完成手术,对5例合并主动脉瓣中至重度关闭不全的患者同期行Bentall手术,余5例行升主动脉置换术。结果1例于术后26d因多器官功能衰竭死亡;余9例均顺利康复出院,无严重神经系统并发症。术后随访2～25个月,均生存,心功能Ⅰ～Ⅱ级。结论采用四分支人工血管行全主动脉弓置换加覆膜支架象鼻手术是治疗A型夹层的有效手术方式,手术操作技术和脑保护措施是决定手术效果的关键。     

Cabrol手术治疗Stanford A型主动脉夹层的疗效分析

目的总结并分析Cabrol手术用于Stanford A型主动脉夹层患者进行主动脉根部处理的疗效及效果。方法回顾性分析2009年1月至2014年4月广东省心血管病研究所心外科行Cabrol术治疗Stanford A型主动脉夹层37例患者的临床资料,其中男34例、女3例,年龄21~66岁,发病至手术时间为(15.2±28.5)d。全组均行Cabrol手术处理主动脉根部,根据主动脉弓受累情况,行右半弓置换或全主动脉弓置换加降主动脉腔内支架隔绝术。结果全组手术均成功,行单纯Cabrol术4例,其中1例行Bentall术中转行Cabrol术,右半弓置换术10例,全主动脉弓置换加降主动脉腔内支架隔绝术23例。二次开胸止血1例(2.7%),术后死亡4例(10.8%);随访1~24个月,随访期间死亡2例。结论 Cabrol手术治疗Stanford A型主动脉夹层效果良好,远期人造血管通畅,冠状动脉无压迫,效果满意。     

Late reoperation for proximal aortic and arch complications after previous composite graft replacement in Marfan patients

BACKGROUND: Marfan patients who received composite graft replacement for proximal aortic disease frequently require late reoperation. The initial surgical technique for this lesion remains controversial. METHODS: Fourteen Marfan patients who received composite graft replacement for annuloaortic ectasia with or without aortic dissection required late reoperation thorough re-median sternotomy. The techniques used for an initial composite graft replacement were the original Bentall procedure in 11 patients, the Cabrol procedure in 2, and coronary button technique in 1. Reoperation was indicated for prosthesis-related complications in 10 patients, distal aortic lesion in 13, or for both lesions in 8. Reoperations were performed, on average, 8.4 years after an initial operation. Reoperative procedures included re-composite graft replacement in 1 patient, total arch replacement in 5, and re-composite graft replacement with total arch replacement in 8. RESULTS: There were two in-hospital deaths (14.3%). Although pseudoaneurysms of the coronary artery or distal aorta occurred in the original Bentall or Cabrol procedures, true aneurysms of the coronary artery were noted even in the coronary button technique. Six patients required a total of eight subsequent descending or thoracoabdominal aortic replacements for an aneurysmal formation of a distal false lumen. CONCLUSIONS: The coronary button technique, with a small side hole for coronary anastomosis, is the procedure of choice for annuloaortic ectasia because it reduces the risk of coronary artery-related complications. Concomitant total arch replacement may be recommended for annuloaortic ectasia with DeBakey type I aortic dissection in selected patients to avoid the risk of reoperation on the aortic arch.     

Midline exposure of the thoracoabdominal aorta

Extended aortic replacement from the aortic arch to the descending thoracic or thoracoabdominal aorta has been performed through a left thoracotomy or a thoracoabdominal incision combined with or without a median sternotomy. However, a left thoracotomy incision may be unfavorable when dense adhesion of the lung is anticipated. We report a redo patient who underwent simultaneous replacements of the aortic arch and the thoracoabdominal aorta through a midline incision without entering the left pleural cavity.     

Combined valve-sparing root replacement and total arch replacement with frozen elephant trunk

We report a case of simultaneous repair of an extensive thoracic aortic aneurysm from the aortic root to the distal aortic arch. A 54-year-old male had annuloaortic ectasia and a transverse aortic and distal arch aneurysm. Aneurysms of the descending aorta and the abdominal aorta were also demonstrated. The patient underwent aortic valve-sparing root reconstruction, replacement of the aortic arch and placement of a frozen elephant trunk stent-graft concomitantly through a median sternotomy incision. Because a complicated procedure was necessary, root reconstruction was performed first and coronary perfusion was resumed. This case suggests that the surgical procedure should be determined on the bases of the situation of thoracic aortic aneurysm and the general condition of the patient. Treatment for extensive diseased aorta from the aortic root to the distal aortic arch is a surgical challenge. Although single-stage repair is one of the options for this condition, it is very invasive. Total arch replacement with the frozen elephant trunk technique is efficacious to exclude distal arch aneurysm or descending aortic aneurysm through median sternotomy. An aortic valve-sparing operation was developed to preserve the native aortic valve function in order to improve the patient's quality of life. We herein report a case of concomitant total arch replacement using a frozen elephant trunk and aortic valve-sparing operation for extensive thoracic aortic aneurysm.     

“改良”次全弓置换加支架象鼻手术治疗Stanford A型主动脉夹层

目的总结和评价"改良"次全弓置换加支架象鼻手术治疗Stanford A型主动脉夹层患者的临床疗效。方法 2009年12月至2011年1月,中国医科大学附属第一医院接收47例Stanford A型主动脉夹层患者行"改良"次全弓置换加支架象鼻手术,其中男35例,女12例;年龄29～86(57.9±16.0)岁。患者均依据术前主动脉计算机断层扫描动脉成像诊断分型,在深低温停循环选择性脑灌注下施行手术;近心端采用升主动脉置换术29例,Bentall手术11例,Wheat手术4例,David手术3例;同期行冠状动脉旁路移植术(CABG)5例。结果体外循环时间(136±32)min,主动脉阻断时间(97±28)min,深低温停循环选择性脑灌注时间(27±11)min。47例患者中住院期间死亡2例(4.25%,2/47),术后一过性精神障碍2例(4.25%,2/47),术后出现截瘫1例(2.12%,1/47),二次开胸止血4例。生存的45例患者均于出院前及术后6个月行主动脉3维CT血管造影(3D CTA)检查显示,降主动脉内支架血管膨胀良好,气管隆突及腹腔干平面真腔较术前明显扩大(P0.05);术后随访1～13个月,无因夹层进展需二次手术及动脉瘤破裂患者。结论 "改良"次全弓置换术加支架象鼻手术是治疗弓部三分支血管无破口的Stanford A型主动脉夹层安全、有效的方法,改良之处在于简化手术,缩短了手术时间、体外循环和深低温停循环时间,减少了手术相关并发症的发生;近期效果良好。     

Late Reoperations in Patients with Aortic Dissection

Aortic dissection is an evolving process that may require one or several reoperations after the initial emergency repair. From January 1977 to September 1993, 148 patients undement emergency surgery for type A acute aortic dissection. The replacement of the ascending aorta was extended to include the transverse arch in 43 patients (29%). One hundred fifteen patients (78%) survived surgery. During the same period, 37 patients required reoperation once (28), twice (7), or three times (2), for a total of 48 reoperations. Wenty-one patients had undergone initial repair in our instltution; 16 patients had been operated on elsewhere. Reoperation was indicated for: aortic valve disease (4); a new dissecting process (7); threatening aneurysmal evolution of a persisting dissection (34); or false aneurysm (3). The redo procedure involved: the aortic root and/or ascending aorta in 12 cases (group I); the ascending aorta and the transverse arch in 6 cases (group 11); the transverse arch alone in 8 cases (group III); the transverse arch and descending aorta, or the descending aorta alone in 11 cams (group IV); and the thoracoabdominal aorta in 11 cases (group V). Risk factors for reoperation were analyzed in the 115 survivors initially operated on at our institution. Seven of 20 Marfan patients (35%) versus 12 of 95 non-Marfan patients (12.6%) required reoperation (p < 0.02). None of the 31 patients surviving arch replacement at initial repair required a reoperation, versus 21 of 84 (25%) patients surviving replacement limited to the ascending aorta (p < 0.01). The overall mortality rate of reoperation was 18.9% (7/37), with a risk of 14.5% (7/48) at each procedure (group I 8.3%, group II 0%, group III 20%, group IV 18%, group V 27%). Hospital mortality was influenced by whether the operation was done as an emergency (5/10) (p < 0.005), and whether thoracoabdominal replacement was required (3/11) (p < 0.03). The late survival rate after reoperation is 67.1%± 17.6% at 1 year, and 57%± 19.6% at 5 years (Kaplan-Meier CI 95%). The late survival rate, after initial repair, of reoperated patients is 89.6%± 11.0% at 1 year, 79.3%± 14.7% at 5 years, 53.9%± 18.1% at 10 years, and 35.9%± 21.8% at 12 years. In conclusion, elective reoperation should be considered before the occurrence of complications, especially in patients with Marfan syndrome. It entails a relatively low risk, except in the case of thoracoabdominai replacement, and allows satisfactory long-term survival. In our experience, resection of the entry site at initial emergency operation, when it is located on or extends to the transverse arch, reduces the incidence of reoperation. (J Card Surg 1994;9:740–747)     

Concomitant replacement of the aortic root and aortic arch with or without secondary thoracoabdominal aorta replacement.

OBJECTIVES: Extensive aortic replacement, such as concomitant aortic root and arch replacement, thoracoabdominal aortic repair, and complete thoracic aorta replacement, remains controversial. We studied surgical morbidity and mortality in patients undergoing concomitant aortic root and arch replacement, and those undergoing secondary replacement of the thoracoabdominal aorta after this preceding procedure. SUBJECTS AND METHODS: Between January, 1987 and March 1999, 21 patients (mean age: 52 years) underwent concomitant aortic root and arch replacement involving 3 surgical procedures--aortic root replacement with composite graft and arch (n = 12), aortic root replacement with valve sparing and arch (n = 4), or aortic root replacement with composite graft and arch and elephant trunk (n = 5). RESULTS: Overall hospital mortality was 4.8%. Six patients (mean age: 42 years) underwent secondary thoracoabdominal aorta replacement after the concomitant root and arch procedure. The mean time until secondary surgery was 9.5 months. There was 1 hospital death. CONCLUSION: Concomitant replacement of the aortic root and arch, or secondary replacement of the thoracoabdominal aorta after concomitant root and arch replacement can be conducted with low surgical morbidity and mortality.     

Results of staged repair of aortic disease in patients with Marfan syndrome

ObjectiveWe present our open surgical strategies for staged replacement of the thoracic and thoracoabdominal aorta in patients with Marfan syndrome.MethodsBetween October 1999 and December 2017, 82 patients with Marfan syndrome underwent 118 aortic repairs. We divided the aorta into 4 segments for categorization: (1) the aortic root, (2) aortic arch, (3) descending thoracic, and (4) abdominal aorta. Procedures were categorized according to the types of surgery. Staged repair was defined as a subsequent operation on a different segment of the aorta after initial repair (n = 111, 94.1%), and reoperation was defined as an operation on the same segment (n = 7, 5.9%).ResultsThe mean age at initial operation was 41.7 ± 14.9 years. Staged repairs included aortic root replacement (n = 42, 36%), total arch replacement (n = 11, 9.3%), combined aortic root and total arch replacement (n = 13, 11%), descending aorta replacement (n = 4, 3.4%), thoracoabdominal aortic repair (n = 36, 31%), and extensive arch-descending or thoracoabdominal repair (n = 5, 4.2%). Four patients received 3 staged repairs. Operative mortality was 0.8% (1/118). Stroke occurred in 1.7% (2/118), and spinal cord injury occurred in 1.7% (2/117). Overall survival was 95.8 ± 2.4% at 10-years. Twenty-four patients underwent replacement of the whole aorta after 2.5 ± 3.8 years following initial repair.ConclusionsOur strategies for staged replacement of the thoracic and thoracoabdominal aorta in patients with Marfan syndrome resulted in excellent early- and long-term outcomes.     

The reversed and bidirectional elephant trunk technique in the treatment of complex aortic aneurysms

BACKGROUND: The elephant trunk technique with a free-floating vascular prosthesis was originally developed to facilitate a subsequent operation on the downstream aorta. We present here our experience with further developments of this technique, which we call the reversed elephant trunk and bidirectional elephant trunk. METHODS: Between January 1, 1995, and December 31, 2000, 505 adult and adolescent patients underwent operations of the thoracic aorta. A reversed elephant trunk procedure in 13 patients and a bidirectional elephant trunk procedure in 4 patients was performed to facilitate either subsequent proximal or proximal and distal aortic replacement. Nine patients underwent subsequent aortic arch replacement with the reversed prosthetic portion after a mean interval of 8 +/- 5.5 months, and 2 patients received distal extension by use of the distal portion of the free-floating graft. RESULTS: There was no hospital mortality (30 days) in this small group of patients, and no patient had aortic rupture, malperfusion caused by the technique itself, or thromboembolic complications during the waiting interval between the first and the second operations. Five patients are still being observed until the contiguous aortic size is large enough to require an operation, and one 74-year-old patient declined a second-stage operation. CONCLUSION: The reversed and bidirectional elephant trunk techniques are interesting options that may be suitable for patients having complex abnormalities of the thoracic aorta and thoracoabdominal aorta when the proximal portion of the descending aorta has to be replaced before the aortic arch with or without the ascending aorta or the distal descending aorta with or without the thoracoabdominal aorta.     

Concomitant replacement of the aortic root and aortic arch with or without secondary thoracoabdominal aorta replacement

Objectives: Extensive aortic replacement, such as concomitant aortic root and arch replacement, thoracoabdominal aortic repair, and complete thoracic aorta replacement, remains controversial. We studied surgical morbidity and mortality in patients undergoing concomitant aortic root and arch replacement, and those undergoing secondary replacement of the thoracoabdominal aorta after this preceding procedure.Subjects and Methods: Between January, 1987 and March 1999, 21 patients (mean age: 52 years) underwent concomitant aortic root and arch replacement involving 3 surgical procedures—aortic root replacement with composite graft and arch (n=12), aortic root replacement with valve sparing and arch (n=4), or aortic root replacement with composite graft and arch and elephant trunk (n=5).Results: Overall hospital mortality was 4.8%. Six patients (mean age: 42 years) underwent secondary thoracoabdominal aorta replacement after the concomitant root and arch procedure. The mean time until secondary surgery was 9.5 months. There was 1 hospital death.Conclusion: Concomitant replacement of the aortic root and arch, or secondary replacement of the thoracoabdominal aorta after concomitant root and arch replacement can be conducted with low surgical morbidity and mortality.     

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.