支架象鼻手术治疗急性Stanford B型主动脉夹层

目的 总结深低温停循环下支架象鼻手术治疗急性Stanford B型主动脉夹层的临床经验.方法 对146例急性Stanford B 型主动脉夹层患者行支架象鼻手术.结果 平均体外循环时间(155±30)min,平均心肌阻断时间(32±3)min,停循环时间(20±3)min.住院死亡3例(2.05 %,3/146),术后脑栓塞及脑出血各1例.随访138例,随访时间4～98个月,平均57.3个月,1年生存率为97.16%(137/141),1例11个月后死于广泛性肠坏死.无截瘫及再次手术者.结论 支架象鼻植入术治疗急性Stanford B 型主动脉夹层简单、安全、有效.     

支架"象鼻"术治疗DeBakey Ⅰ型主动脉夹层动脉瘤

目的 探讨支架"象鼻"手术治疗DeBakey Ⅰ型主动脉夹层动脉瘤(AD)的方法和效果.方法 12例DeBakey Ⅰ型AD患者,平均年龄48.1岁.采用深低温停循环(DHCA),右腋动脉顺行灌注(SCP)脑保护,实施支架"象鼻"手术(即升主动脉和全弓置换及降主动脉腔内支架植入).结果 术后死亡1例,手术死亡率8.3%.术中体外循环时间(163.2±17.7)min,停循环时间(41.6±12.3)min.随访3～6个月,无死亡病例.结论 支架"象鼻"手术简单,停循环时间短,治疗DeBakey I型夹层主动脉瘤安全、有效.     

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.     

主动脉弓替换加支架“象鼻”术治疗Stanford A型主动脉夹层患者的护理

对8例Stanford A型主动脉夹层累及主动脉弓部的患者采取主动脉弓替换加支架“象鼻”术治疗，术前注意心理疏导，控制血压和疼痛；术后加强血流动力学、肾功能和体温监测，严密观察引流量，预防感染，加强脑部并发症的观察。结果8例均痊愈出院。提示充足的术前准备和术后细致周到的护理是亍术获得满意效果的重要保证。     

孙氏手术治疗急性Stanford A型主动脉夹层

目的 总结急性Stanford A型主动脉夹层采用孙氏手术(主动脉弓部替换加支架象鼻手术)的临床经验与随访结果.方法 2004年8月至2012年3月,73例急性A型夹层患者施行了孙氏手术,其中男60例、女13例,平均年龄49.6(26 ～79)岁.手术均采用深低温停循环、低流量选择性脑灌注技术.单纯行升主动脉替换加孙氏手术30例;主动脉根部替换(Bentall术)加孙氏手术10例,主动脉瓣及升主动脉替换加孙氏手术12例,主动脉瓣成形加孙氏手术21例(同时行主动脉窦重建16例),同期行冠状动脉旁路移植术( CABG)9例,术后通过CTA评价胸腹主动脉塑形及假腔愈合情况.结果 体外循环平均(248.1±69.8)min,选择性脑灌注(38.2±10.5)min.手术死亡5例(6.85％,5/73例).术后60例随访2个月～7.6年,术后3个月CTA复查显示,91.7％的患者主动脉夹层的假腔在膈肌水平形成血栓,患者术后1、5和7年的生存率分别是97％、87％和81％.结论 孙氏手术治疗急性A型主动脉夹层安全有效且远期效果令人满意.     

1例Stanford B型主动脉夹层胸主动脉腔内修复术中封闭左锁骨下动脉的安全性观察

Dake等 [1]报道使用支架型移植物腔内治疗Stanford B型主动脉夹层患者并获得良好的临床疗效,随着经验积累和技术进步,目前胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)凭借其微创、安全、有效的特点已成为Stanford B型主动脉夹层的首选治疗方案 [...     

Stanford B型主动脉夹层杂交和开窗胸主动脉腔内修复术重建左锁骨下动脉技术的有效性和安全性比较

目的观察胸主动脉腔内修复术(TEVAR)联合开窗治疗Stanford B型主动脉夹层有效性和安全性。方法前瞻性队列研究分析,2012年4月～2017年1月于我院收治的Stanford B型主动脉夹层病人81例,根据重建左锁骨下动脉方法不同分为开窗TEVAR组(47例)和杂交TEVAR组(34例)。比较两组病人临床特点、手术情况、并发症及生存结局。结果两组病人均无死亡及截瘫,开窗TEVAR组平均手术时间为(128±27)分钟,平均住院时间为(7.5±2.1)天,术后疼痛发生率为17%;杂交TEVAR组分别为(237±47)分钟、(13.3±3.6)天和41.2%,两组比较差异有统计学意义(P0.05)。开窗TEVAR组脑梗发生率为4.3%、Ia型内漏发生率6.4%、瞻妄发生率10.6%、肾功能不全发生率14.9%,杂交TEVAR组分别为8.8%、11.8%、23.5%、20.6%。两组比较差异无统计学意义(P0.05)。开窗TEVAR组植入支架的数目、长度、近远端直径与杂交TEVAR组比较,差异无统计学意义(P0.05)。随访时间36个月,随访率为90.1%。随访期间开窗TEVAR组全因死亡率为8.5%,夹层近端逆撕裂发生率为4.3%,胸主动脉远端扩张14.9%,二次手术行腔内修复发生率为4.3%,主动脉重塑发生率为74.5%。杂交TEVAR组分别为8.8%,5.9%,17.6%,2.9%,82.4%,两组比较差异无统计学意义(P0.05)。结论与杂交TEVAR组相比,开窗TEVAR组改善远期预后,未增加术后并发症发生率,缩短手术时间、住院时间,减轻术后疼痛。Stanford B型主动脉夹层保留左锁骨下动脉可优先考虑开窗TEVAR。     

主动脉弓替换加支架"象鼻"术治疗Stanford A型主动脉夹层患者的护理

时8例Stanford A型主动脉夹层累及主动脉弓部的患者采取主动脉弓替换加支架"象鼻"术治疗,术前注意心理疏导,控制血压和疼痛;术后加强血流动力学、肾功能和体温监测,严密观察引流量,预防感染,加强脑部并发症的观察.结果8例均痊愈出院.提示充足的术前准备和术后细致周到的护理是手术获得满意效果的重要保证.     

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。     

Stanford B型夹层动脉瘤腔内修复术中支架重建肾动脉一例

患者男,59岁,因突发胸背部持续撕裂样剧痛,伴左腰胁部、右下肢压榨样疼痛于2005年12月入我院,入院时血压控制在120／70 mm Hg左右,右侧下肢皮温降低,右侧股动脉搏动减弱。主动脉CTA检查提示：Stanford B型夹层,第一裂口位于左锁骨下动脉远端30 mm,主动脉真腔被假腔挤压变细。     

Aortic remodelling effect of the frozen elephant trunk technique on Stanford type A acute aortic dissection

Total arch replacement using the frozen elephant trunk procedure is performed for true lumen expansion of the descending aorta in patients with type A acute aortic dissection. However, the remodelling effect of the frozen elephant trunk on the dissected descending aorta is unclear. We aimed to evaluate the effect of the frozen elephant trunk on postoperative descending aortic remodelling after surgery. Between December 2012 and January 2020, we retrospectively investigated 24 patients who underwent total arch replacement using the frozen elephant trunk for type A acute aortic dissection. Remodelling of the descending aorta was evaluated using computed tomography. The aortic remodelling effect, based on aortic true lumen ratio, was determined for (i) DeBakey type (type I versus type III retrograde); (ii) thoracic endovascular aneurysm repair reintervention status (reintervention versus no reintervention); and (iii) stent length of the frozen elephant trunk (60 vs 90 mm). Postoperative true lumen ratio significantly increased in the type I dissection group. The true lumen ratio in the no-reintervention group, which had many patients with the type I dissection, significantly increased after the frozen elephant trunk. Aortic remodelling due to the frozen elephant trunk can be expected after type I acute aortic dissections.     

Frozen elephant trunk technique with different proximal landing zone for aortic dissection

Open in a separate window OBJECTIVESThe objective of the study was to evaluate early and midterm outcomes after the frozen elephant trunk (FET) procedure with different proximal landing zones in patients with aortic dissection.METHODSForty-four patients with type A and type B aortic dissection that extended down to the abdominal aorta were enrolled in the study. All of the patients had the FET procedure. The patients were divided in 2 groups according to the level of the proximal landing zone: the zone 2 (Z2) group and zone 3 (Z3) group. Early and midterm outcomes including the false lumen (FL) thrombosis rate were monitored in both groups.RESULTSThe incidence of stroke, delirium and spinal cord ischaemia was 5.9% vs 3.7% (P = 0.533), 5.9% vs 7.4% (P = 0.903) and 5.9% vs 0 (P = 0.533) in the Z2 and Z3 groups, respectively. The 30-day mortality was 9.1% in both groups. The mean distal landing zone was T7.5 (T7; T9) in the Z2 group vs T9 (T8; T10) in the Z3 group (P = 0.668). The 2-year overall survival was 62.2% with no significant difference in the Z2 and Z3 groups (61.6% vs 64.2%; P = 0.940). There were no aortic-related deaths during the follow-up period. Freedom from reintervention at 24 months was 73% and was comparable between Z2 and Z3 (74.1% vs 91.7%; P = 0.123). The rate of early complete FL thrombosis was comparable in the Z2 and Z3 groups. By 24 months of observation in the Z3 group, the rate of complete FL thrombosis was significantly higher (60% vs 77%; P = 0.046).CONCLUSIONSNo statistically significant differences were observed between landing zones 2 and 3 during the FET procedure with regard to early outcomes. Proximalization of the FET was associated with a shorter FL thrombosis in the midterm follow-up period that affected the distal aortic reintervention rate.     

Thoraflex hybrid as frozen elephant trunk in chronic,residual type A and chronic type B aortic dissection

OBJECTIVESThe frozen elephant trunk technique is an increasingly common treatment for extensive disease of the thoracic aorta. The objective of the study was to evaluate the outcomes of frozen elephant trunk specifically in chronic (residual) aortic dissections, focusing on downstream aortic remodelling.Open in a separate windowMETHODSBetween 2013 and 2019, a total of 28 patients were treated using the Vascutek Thoraflex hybrid graft at our institution for chronic dissections/post-dissection aneurysms. Immediate and follow-up outcomes were studied, as well as the changes in total aortic diameter, true lumen and false lumen diameter and the status of the false lumen at 3 different levels of the thoraco-abdominal aorta.RESULTSNo in-hospital or 30-day mortality was observed, temporary paraparesis rate was 7% and disabling stroke incidence was 14.3%. Freedom from all-cause mortality at 2 years was 91.6 ± 5.7%, while freedom from reintervention on the downstream aorta at 2 years was 59.1 ± 10.8%. Positive aortic remodelling was achieved in 50.0%, with an enlargement in the true lumen and a reduction of the false lumen not only at the level of the proximal descending aorta with 73.1% of complete thrombosis but also at the level of the distal descending thoracic aorta, with 41.7% of complete thrombosis.CONCLUSIONSThe frozen elephant trunk is a good solution in chronic (residual) downstream aortic dissections inducing positive aortic remodelling and preventing from II stage operations or allowing an endovascular approach.     

应用象鼻技术治疗主动脉夹层与主动脉瘤

目的 评价应用象鼻技术治疗病变范围广泛的主动脉夹层及主动脉瘤的临床效果与安全性。方法 自1997年12月至2006年6月，应用象鼻技术治疗主动脉夹层及主动脉瘤199例，男169例，女30例。平均年龄（45．67±10．73）岁。象鼻技术32例，支撑型象鼻技术167例；其中应用于胸降主动脉141例，升主动脉15例，腹主动脉11例。急诊手术38例。结果 全组平均体外循环（171．68±51．64）min。住院死亡6例，住院病死率3．02％。并发脊髓损伤6例，脑卒中3例，肾功能衰竭4例。结论 应用象鼻技术及支撑型象鼻技术治疗病变范围广泛的主动脉夹层及主动脉瘤有良好的临床效果。     

Left subclavian artery management in frozen elephant trunk: A novel technique

Proximilization of frozen elephant trunk (FET) necessitates the ligation and reimplantation of the left subclavian artery (LSA), the origin of which is distal and posterior, make rerouting difficult and cumbersome. We describe a rather simple technique for subclavian artery exposure and effective anatomical reconstruction in the mediastinum coupled with hybrid FET utilization for aortic aneurysm in elective and nonelective settings. The division of the sternocleidomastoid coupled with the sandbag behind the left shoulder brings the LSA superficial enabling anastomosis without any difficulty.     

Frozen elephant trunk technique and partial remodeling for acute type A aortic dissection

Objective: The aimed to describe the frozen elephant trunk (FET) technique and partial remodeling (PR) for acute type A aortic dissection (ATAAD), considering the long-term prognosis on the basis of our 13 years of experience. Methods: There were 80 consecutive patients (mean age: 66.4 years) with an FET and PR technique for ATAAD between September 1997 and February 2010. We indicated a PR for all 80 patients without dilatation of the sinuses and a FET for 20 patients with a distal entry in the descending aorta, 14 patients with a dilatation more than 4 cm on the distal arch and 46 patients with a narrow true lumen younger than 70 years with a narrow true lumen. During moderate hypothermic circulation with selective cerebral perfusion and distal perfusion from the femoral artery, a stent graft (mean diameter: 27.7 mm, mean length: 9.9 mm, mean distal depth: thoracic vertebra (Th) 6.0th) was inserted through the transected proximal aortic arch. The plication of the sinotubular junction (N = 42) or partial remodeling for right and/or non-coronary cusp (N = 38) was performed after total arch replacement with a four-branched prosthesis. Results: Four patients died in hospital. Early morbidity included two (2.5%) strokes but no spinal cord injury. In long-term follow-up (mean 94.6 months), five patients died of non-aortic events and two re-operations (Bentall and stent grafting to the descending aorta) were required. No patients had patent false lumen on the stent graft and residual aortic regurgitation, according to late follow-up computed tomography (CT) and echogram. The 10-year survival was 75% and the overall 10-year re-operation free rate on the thoracic aorta was 95%. Conclusion: FET and modified PR techniques could be effective for improving the long-term outcome on the distal and proximal aorta in an ATAAD.     

65例Stanford A型主动脉夹层患者在不同温度下手术的效果分析

目的 分析不同温度对Stanford A型主动脉夹层手术后效果的影响.方法 回顾2007年4月至2012年3月65例接受主动脉根部成形加升主动脉置换加主动脉弓替换加支架象鼻术的Stanford A型主动脉夹层患者的临床资料.根据术中降温程度不同分为A、B两组,A组温度控制在20℃～24℃;B组温度控制在25℃～28℃.对比分析体外循环时间、术后引流量、呼吸机使用时间、术后脑部并发症的发生率等指标.结果 两组术中体外循环时间、停循环时间、术后引流量、呼吸机使用时间以及术后短暂性神经系统功能障碍的发生率比较差异有统计学意义.术后永久性神经系统功能障碍的发生率、连续性肾脏替代治疗的使用以及术后死亡比例方面比较组间差异无统计学意义.结论 低温停循环手术中,在保证熟练的手术操作的前提下,适当提高降温水平是安全的,也可以在一定程度上减小对患者身体的创伤、缩短手术时间和患者恢复时间,减少用血量,减少并发症.     

Stanford A型主动脉夹层的外科治疗

目的 总结Stanford A型主动脉夹层的治疗经验,评价其外科手术疗效。 方法 回顾性分析2006年10月至2013年3月兰州军区兰州总医院48例Stanford A型主动脉夹层行外科手术治疗的临床资料,其中男41例,女7例;年龄26～72 （47.6±9.2） 岁。急性Stanford A型主动脉夹层（发病至确诊＜14 d） 43例,慢性5例。主动脉瓣中重度关闭不全19例＋主动脉瓣良好、但合并马方综合征6例,行Bentall＋全弓置换＋支架象鼻术;累及主动脉根部、但瓣膜功能良好的8例行改良David＋全弓置换＋支架象鼻术;累及升主动脉10例行升主动脉＋全弓置换＋支架象鼻术;累及部分主动脉弓5例行升主动脉＋次全弓置换术。出院后于术后3、6、12个月随访,以后每年随访1次。随访内容包括：患者的生存情况、血压控制情况、有无疼痛复发、运动、活动情况和复查主动脉计算机断层扫描成像（computerized tomography arteriography,CTA）。 结果 全组体外循环时间121～500 （191.4±50.6） min,主动脉阻断时间58～212 （112.3±31.7） min;停循环＋选择性脑灌注时间26～56 （34.8±8.7） min;术后呼吸机辅助时间32～250 （76.2±35.6） h;住ICU时间3～20 （7.1±3.4） d。术后24 h胸腔引流量680～1 600 （1 092.5±236.3） ml。围术期死亡7例,病死率14.5%,其中死于多器官功能衰竭2例、低心排血量综合征2例、肾功能衰竭1例、迟发性难治性出血1例、昏迷1例。围术期发生其它并发症20例,经治疗均痊愈或好转出院。随访38例,随访率92.7%（38/41）,随访时间3～48 （13.0±8.9） 个月;失访3例。随访期间36例存活,无与主动脉夹层相关的死亡,因其它慢性疾病死亡2例。无因主动脉夹层继续形成、假腔扩张行二次手术患者,术后6个月CTA检查未见吻合口渗漏及人工血管扭曲或血流不畅。 结论 根据主动脉夹层破口的位置、升主动脉直径及夹层累及范围等,选择合适的手术方式、手术时机及脏器保护策略是提高Stanford A型主动脉夹层治疗效果的关键。应用腋、股动脉联合灌注及提高术中最低温度等策略治疗Stanford A型主动脉夹层可获得良好的效果。     

Risk factors for stroke after total aortic arch replacement using the frozen elephant trunk technique

Open in a separate window OBJECTIVESThis study aimed to analyse risk factors for postoperative stroke, evaluate the underlying mechanisms and report on outcomes of patients suffering a postoperative stroke after total aortic arch replacement using the frozen elephant trunk technique.METHODSTwo-hundred and fifty patients underwent total aortic arch replacement via the frozen elephant trunk technique between March 2013 and November 2020 for acute and chronic aortic pathologies. Postoperative strokes were evaluated interdisciplinarily by a cardiac surgeon, neurologist and radiologist, and subclassified to each’s cerebral territory. We conducted a logistic regression analysis to identify any predictors for postoperative stroke.RESULTSOverall in-hospital was mortality 10% (25 patients, 11 with a stroke). A symptomatic postoperative stroke occurred in 42 (16.8%) of our cohort. Eight thereof were non-disabling (3.3%), whereas 34 (13.6%) were disabling strokes. The most frequently affected region was the arteria cerebri media. Embolism was the primary underlying mechanism (n = 31; 73.8%). Mortality in patients with postoperative stroke was 26.2%. Logistic regression analysis revealed age over 75 (odds ratio = 3.25; 95% confidence interval 1.20–8.82; P = 0.021), a bovine arch (odds ratio = 4.96; 95% confidence interval 1.28–19.28; P = 0.021) and an acute preoperative neurological deficit (odds ratio = 19.82; 95% confidence interval 1.09–360.84; P = 0.044) as predictors for postoperative stroke.CONCLUSIONSStroke after total aortic arch replacement using the frozen elephant trunk technique remains problematic, and most lesions are of embolic origin. Refined organ protection strategies, and sophisticated monitoring are mandatory to reduce the incidence of postoperative stroke, particularly in older patients presenting an acute preoperative neurological deficit or bovine arch.