Stanford B型主动脉夹层术前心肌酶谱影响因素的多因素分析

目的 探讨Stanford B型主动脉夹层术前心肌酶谱状态并分析影响因素.方法 2004年1月-2013月9月,新疆维吾尔自治区人民医院共收治151例Stanford B型主动脉夹层患者,男性118例,女性33例,年龄31 ～76岁,平均（51.51±10.90）岁.将其作为选取同期年龄和性别匹配的体检健康人群为对照组.入院患者采集空腹12 h以上静脉血,采用罗氏模块式全自动生化分析系统测定血清心肌酶谱,指标包括肌酸激酶（CK）、肌酸激酶同工酶（CKMB）、乳酸脱氢酶（LDH）、α-羟基丁酸脱氢酶（HBDH）.采用东芝Aquilion ONE 320排CT行全主动脉CTA,测定夹层原发破口,剥离范围.飞利浦5500型彩色多普勒心脏超声诊断仪行心彩超检查,评估主动脉瓣反流情况.结果 Stanford B型主动脉夹层组术前心肌酶谱相关指标LDH、HBDH显著高于对照组（P＜0.01）.将Stanford B型主动脉夹层患者进行分期后发现急性期组夹层心肌酶谱各指标与对照组相比除CKMB均存在差异（P＜0.05）.急性期组与亚急性期以及慢性期心肌酶谱相关指标仅CK存在差异（F=18.72,P=0.000）.亚急性期,慢性期两组心肌酶谱各指标未见明显差异,两组心肌酶谱LDH、HBDH与对照组相比存在差异（P＜0.01）.相关分析显示,CK与夹层分期以及患性别呈负相关[（r=-0.446;P =0.000）;（r=-0.303;P=0.000）].CKMB与性别呈负相关[（r=-0.203;P=0.020）].LDH与患者性别负相关[（r=-0.171;P=0.049）],与心脏左室舒张期末径,收缩期末径呈正相关[（r =0.202;P=0.022）;（r=0.271;P =0.002）].HBDH与心脏左室舒张期末径,收缩期末径呈正相关[（r =0.385;P=0.002）;（r=0.515;P=0.000）],与主动脉瓣膜反流程度呈负相关[（r=-0.528;P=0.006）].结论Stanford B型主动脉夹层术前心肌酶谱明显升高,主要表现为骨骼肌损伤.受主动脉夹层分期影响,急性期夹层下肢骨骼肌损伤明显,度过急性期后下肢骨骼肌损伤持续存在.     

Ascending aorta cannulation in stanford type a acute aortic dissection

Establishment of cardiopulmonary bypass for Stanford type A acute aortic dissection( type A AAD) should be quick and safe. The femoral artery, axillary artery, ascending aorta, and left ventricular apex are potential access points for cannulation. The most important reason for establishing cardiopulmonary bypass for type A AAD is to allow antegrade blood flow through the true lumen. Starting in 2007, Jakob et al, and Inoue et al. applied the technique of ascending aortic cannulation for type A AAD. From 2008, we applied this method of ascending aorta cannulation in 8 patients and compared preoperative, operative, and postoperative data with a control group, or the femoral artery cannulation group. Ascending aorta cannulation was done safely and easily with the use of the Seldinger technique under epiaortic color Doppler echography and transesophageal echography. No cerebral events or hypoperfusion-based complications occurred in the group of ascending aorta cannulation. Given that no cases of complication occurred using this method, it could be considered as an effective choice of cannulation for cardiopulmonary bypass.     

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.     

Endovascular therapy for stanford type B aortic dissection in 102 cases

OBJECTIVE: To share our experience of 102 cases of endovascular therapy for Stanford type B aortic dissection. METHODS: Multiple imaging diagnostic modalities were used preoperatively to obtain the anatomical parameters of the aortic dissection. Stent grafts were implanted using digital subtraction angiography and intravascular ultrasound guidance. Follow-up computed tomography angiography 1 week and 1 year postoperatively was used to evaluate treatment efficacy and reveal complications such as endoleak, migration and fracture of the stent graft. RESULTS: Clinical success was achieved in 101 cases (99.0%); one patient (1.0%) died within the perioperative period. Neither postoperative paraplegia nor conversion occurred. Endoleak occurred in 18 cases (17.6%). CONCLUSION: Endovascular therapy for Stanford type B aortic dissection is less invasive and leads to less severe complications and shorter hospital stay compared with traditional surgery. The short- and mid-term efficacy are persuasive, but further follow-up is required to determine long-term efficacy.     

New type A dissection after acute type B aortic dissection

Objective

Aortic dissection is a dynamic process that can progress both proximal and distal to the initial entry tear. We sought to determine associations for development of proximal progression or new type A aortic dissection (NTAD) after acute type B dissection (ATBD) and its effect on survival of the patient.

The distal perfusion first technique for complicated stanford type B aortic dissection.

We present a new technique, which is the distal perfusion first technique, for chronic dissection with dilatation of the aorta. Using a "side-ways-tau shaped" incision, this technique allows single-staged repair, full-time antegrade perfusion, less possibility of mesenteric malperfusion and cerebral embolism.     

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.     

Total aortic arch grafting for acute type A dissection: analysis of residual false lumen

BACKGROUND: In surgery for acute type A dissection, an unresected dissection and residual false lumina are causes of the progression of aneurysms and ruptures. We grafted the ascending aorta and total arch, the maximum grafting possible through a median sternotomy alone, in all patients with type A dissection extending to the descending aorta, wherever initial tears existed in the arch. METHODS: A total of 37 consecutive patients with acute type A dissection underwent ascending and total arch grafting between August 1994 and December 2000. Cerebral protection was achieved by selective cerebral perfusion. The distal anastomosis was conducted using the "Elephant Trunk" technique. Patent false lumina were evaluated using computed tomography 3 months after the operation. RESULTS: The hospital mortality was 8.1%. No major cerebral complications were observed. The incidence of residual thoracic patent false lumina was 26.5%. Univariate analyses showed Marfan syndrome and preoperative extension of false lumina to be statistically significant determinants of residual thoracic false lumina. On multivariate analysis, no other significant independent predictor of residual false lumina in the thoracic aorta was found. CONCLUSIONS: Outcomes of our strategy were satisfactory. However, residual thoracic false lumina could not be prevented in 26.5% of the patients. Thus, this extended operation is indicated in patients with initial tears in the aortic arch or distal arch, those with Marfan syndrome, and young patients with preoperative patent false lumina extending to the abdominal aorta.     

Acute type B aortic dissection complicated with a mycotic aortic arch aneurysm

A successfully-treated case of acute type B aortic dissection associated with a mycotic aneurysm is reported. A 69-year-old man had a history of febrile illness and a high CRP level with increased enzyme activity of the hepatobiliary system before the onset. The culture of the abscess in the distal arch aneurysm revealed Bacteroides fragilis. A Dacron graft replacement between the distal arch and the proximal descending aorta was successfully performed with Teflon felt reinforcement, and the graft was covered with omental flap. The patient was discharged without recurrence of infection 2 months after the graft replacement.     

Endovascular treatment of acute type B aortic dissection

Intervention is currently reserved in acute aortic dissection for Stanford Type A and for complications of Type B. Endovascular techniques such as fenestration of the intimal flap and stenting of vessel origins have been used to alleviate end-organ ischaemia due to compromised branches. The introduction of stent grafts has offered a realistic alternative to surgery for Type B dissections. Closure of the primary entry tear encourages thrombosis of the false lumen, which is associated with good long-term outcome. Many questions remain unanswered and randomised controlled trials need to be performed to establish the role of stent grafts in uncomplicated Type B dissections, and the use of bare stents to encourage thrombosis of the more distal false lumen. Improvements in the design and engineering of stent grafts may help to establish endoluminal repair as the first line treatment of aortic dissection.     

急性B型主动脉夹层的腔内治疗

目的 讨论腔内修复术(endovascular repair,EVR)对治疗急性B型主动脉夹层(acuteaortic dissection,AAD)的安全性及有效性.方法 回顾性分析2002年2月至2008年3月收治的39例急性B型主动脉夹层患者的临床资料.EVR按常规方法进行,2例需覆盖左颈总动脉而行旁路术,其中1例同时无名动脉支架型血管(stent graft,SG)开窗术;1例因肢体严重缺血同期行左下肢截肢术.13例完全覆盖左锁骨下动脉,1例覆盖迷走右锁骨下动脉,5例部分覆盖左锁骨下动脉(leftsubclavian artery,LSA).术后全部病例均经CTA(computer tomography angiography)随访,并监测支架覆盖段(Ll)及支架远端(L2)主动脉段的假腔变化.结果 所有支架释放到预定位置;30 d死亡率10.3%.术后1个月L段假腔血栓率100%,完全血栓率77.8%(21/27例),部分血栓率22.2%(6/27例),其中18.5%(5/27例)达到血栓完全吸收、主动脉重塑;L2段假腔血栓率28%,完全血栓率8%(2/25例),部分血栓率20%(5/25例).结论 急性B型主动脉夹层腔内修复术治疗效果肯定,30 d内死亡主要与术前伴随的并发症有关.     

Extended total arch replacement for type B aortic dissection with ascending aneurysm following healed aortic dissection

We describe a case of type B aortic dissection with large ascending aortic aneurysm occurring 12.8 years after aortic root replacement (Cabrol procedure) in a non-Marfan patient with cystic medial necrosis of the aorta. We have successfully performed an extended total aortic arch replacement using a four-branched graft through the “L-indsion” approach (a combination of a left anterior thoracotomy and upper half median sternotomy). Of note, a histological specimen from the aneurysmal ascending aortic wall revealed “healed aortic dissection” with fibrous tissue replacing the media and intima in addition to multiple foci of cystic medial necrosis.     

Aortic arch type,a novel morphological indicator and the risk for acute type B aortic dissection

 Open in a separate windowOBJECTIVESAortic arch type is a readily recognizable and obtainable morphological feature of the aorta that does not require complex measurements. The goal of this study was to evaluate whether aortic arch type is a comparable and alternative morphological parameter for predicting acute type B aortic dissection (aTBAD) by comparing the prognostic value of the aortic arch type with that of other morphological parameters such as aortic length, angulation and tortuosity index. METHODSThe patients with aTBAD (n = 216) were matched 1:1 with a control group (n = 263) by propensity score matching. The morphological data of the ascending aorta and the aortic arch, which included diameter, length, angulation and tortuosity index, were collected on a three-dimensional aortic model using 3mensio Vascular software. The aortic arch type was identified by the vertical distance from the origin of the brachiocephalic trunk to the top of the arch. The binary logistic regression models were analysed to determine the independent geometric variables related to the aTBAD. The nonparametric approach was performed to assess whether there were statistical differences between the area under the receiver operating characteristic curves (AUC) of the models.RESULTSAfter propensity score matching, 151 matched pairs of patients were selected. The diameters at the sinotubular junction and the mid-ascending aorta, the ascending aorta length and the ascending aorta angulation in the aTBAD group were significantly greater than those of the controls. Compared with the control group, the diameters at the proximal aortic arch, mid-aortic arch and distal aortic arch, the angulation and the tortuosity index of the aortic arch were significantly greater in the aTBAD group. The proportion of the type III arch in the patients with aTBAD is higher than that of the type I arch and the type II arch (χ² = 70.187; P < 0.001). Binary logistic regression analysis showed that the diameter at the mid-aortic arch, the ascending aorta length, the aortic arch angulation and the tortuosity index were independently related to the aTBAD with an AUC value of 0.887. Another binary logistic regression analysis indicated that the diameter at the mid-aortic arch and the aortic arch type were independent correlative variables associated with the aTBAD with an AUC of 0.874. No significant difference was observed in the prognostic value of receiver operating characteristic curves between the 2 models (P = 0.716).CONCLUSIONSThe type III arch, which has the characteristics of aortic elongation, incremental angulation and tortuosity index, is a comparable and alternative identifier for patients at high risk for aTBAD.