不同部位主动脉插管在A型主动脉夹层手术中的应用体会

目的评价无名动脉插管作为主动脉夹层手术患者体外循环插管的可行性以及安全性。方法选择湖南省人民医院(湖南师范大学附属第一医院)心脏大血管外科2019年1月至2022年12月收治的行急性A型主动脉夹层急诊孙氏手术的259例患者为研究对象,按入选及排除标准选取71例进行回顾性研究。观察组32例,主动脉灌注插管位于无名动脉;对照组39例,主动脉灌注插管位于右侧腋动脉。结果两组比较,观察组手术时间短于对照组,为(338.0±15.2)min vs.(373.1±14.3)min(P=0.001);体外循环时间、主动脉阻断时间、深低温停循环时间、72 h内引流量以及72 h内红细胞输注量无差异(P>0.05)。观察组有2例(6.2%)二次开胸止血,均为近端吻合口少量渗血,与插管位置无关。呼吸机辅助呼吸时间、ICU停留时间、住院时间、肾功能不全发生率两组间比较无统计学差异(P>0.05)。71例患者中,无30 d内死亡;术后脑卒中观察组有2例(6.2%),对照组有3例(7.7%),且两组各有1例患者因此出现术后右侧肢体活动障碍,经2个月左右康复治疗后均能扶拐行走。术后在出院前均复查主动脉电子计算机断层扫描血管造影(computed tomography angiography,CTA),未见插管处腋动脉、头臂干新发夹层或存在狭窄。结论无名动脉插管和腋动脉插管在主动脉夹层手术中都是安全可行的,具体选择哪种方法需要根据患者的具体情况和手术需求来确定。     

股动脉和腋动脉插管策略在急性Stanford A型主动脉夹层中的疗效分析

目的 探讨股动脉和腋动脉插管策略在急性Stanford A型主动脉夹层中的应用疗效.方法 收集2011年1月至2021年1月福建医科大学省立临床医学院/福建省立医院收治的562例急性Stanford A型主动脉夹层患者的临床资料,所有患者均行手术治疗.根据插管策略不同将患者分为腋动脉组[n=328,行腋动脉插管建立体外...     

不同主动脉断端加固方法在急性Stanford A型主动脉夹层手术中的应用

目的总结不同主动脉断端加固方法在主动脉夹层手术中的应用及其效果。方法2012年1月至2013年5月,共有95例主动脉夹层在南京医科大学附属南京医院接受手术治疗。根据主动脉断端的加固方法不同,将其中72例患者（23例Bentall手术患者未纳入本研究）分为3组,A组：23例,男18例、女5例,年龄（48．67±9．23）岁,其中主动脉壁内外均使用毛毡条行“三明治”加固;B组：11例,男8例、女3例,年龄（48．00±9．17）岁,仅主动脉内膜内侧使用心包条加固;C组：38例,男29例、女9例,年龄（49．20±8．57）岁,主动脉断端不进行任何加固,与人工血管直接吻合。分析并比较3组患者的术后转归情况。结果术后住院死亡8例[其中A组1例（4．35％,1／23）,C组7例（18．42％,7／38）],住院死亡率11．11％。1例（A组）死于创面广泛渗血,最后出现弥散性血管内凝血;3例（均为C组）死于术后针眼、吻合口广泛渗血,循环不能维持;4例（均为C组）术后三尖瓣重度反流,继发严重低心排血量综合征,最终导致多脏器功能衰竭而死亡。术后严重并发症包括肾功能衰竭5例,呼吸功能不全7例,严重脑梗死致偏瘫1例,轻瘫3例,延迟苏醒2例,下肢缺血坏死1例。术后胸腔引流量C组最多,A组胸腔引流量与B组比较差异无统计学意义。随访64例,随访时间1～6个月。随访期间无死亡。5例肾功能衰竭患者中只有1例定期行血液透析治疗,其余4例患者肾功能均恢复正常;1例脑梗死患者肢体功能部分恢复,可以拄拐行走;3例轻瘫患者肢体功能均恢复正常。结论主动脉夹层断端的吻合质量异常重要,术中可根据具体情况选择合适的加固方式;使用毛毡条行“三明治”加固可以减少吻合口渗血,预防吻合口撕裂所致急性心肌梗死的发生,降低术后死亡率;若主动脉夹层剥离累及冠状动脉开口,需同期行冠状动脉旁路移植术。     

不同腋动脉插管方法在StanfordA型主动脉夹层手术中的应用

目的比较两种不同右侧腋动脉插管方法对Stanford A型主动脉夹层患者行主动脉弓置换术的安全性和临床效果。方法 2008年7月至2010年7月北京安贞医院对280例Stanford A型主动脉夹层患者采用右侧腋动脉插管建立体外循环(CPB),行全弓置换+降主动脉支架人工血管植入术。根据术中腋动脉插管方式将280例患者分为两组,直接插管组(n=215),年龄(43.1±9.5)岁,行直接腋动脉插管;间接插管组(n=65),年龄(44.7±8.3)岁,腋动脉连接人工血管行间接插管。观察两组患者的安全性,比较相关手术参数、临床结果和术后恢复情况。结果住院死亡10例,其中直接插管组7例(7/215,3.3%),间接插管组3例(3/65,4.6%);所有患者均成功行腋动脉插管;术后25例(25/280,8.9%)出现暂时性神经系统功能障碍,其中直接插管组19例(8.8%),间接插管组6例(9.2%),均经治疗痊愈。间接插管组患者术后腋动脉插管并发症明显少于直接插管组,差异有统计学意义((1例vs.19例,P=0.045)。两组患者体外循环期间最高流量、最高泵压,深低温停循环时间、顺行性脑灌注时间和CPB时间差异均无统计学意义(P0.05)。结论经人工血管右侧腋动脉插管可以降低腋动脉插管相关并发症,安全用于Stanford A型主动脉夹层患者的外科手术治疗。     

急性Stanford A型主动脉夹层主动脉根部重塑与再植技术meta分析北大核心CSCD

目的系统性比较急性Stanford A型主动脉夹层主动脉根部瓣膜保留手术中使用重塑(remodeling)和再植(reimplantation)两种技术的安全性和可靠性。方法检索中国知网(CNKI)、维普、万方、中国生物医学文献数据库(CBM)、Pubmed、EMBASE、Cochrane对照试验中心注册库(CENTRAL)数据库,查找有关急性A型主动脉夹层重塑和再植的临床对照研究文献。相关结局指标通过Review Manager 5.3联合Stata 15.0统计软件进行分析。结果纳入7项研究,共计356例患者。重塑手术与再植手术相比,术后Ⅱ或Ⅲ度主动脉瓣反流发生率高(OR=5.56,95%CI:1.89~16.41,P<0.05)、术后5年再手术率高(OR=7.50,95%CI:2.11~26.65,P<0.05)、体外循环时间较短(MD=-20.81,95%CI:-35.08~6.54,P<0.05)、主动脉阻断时间较长(MD=35.23,95%CI:21.21~49.26,P<0.05)。两组术后30天/住院病死率(OR=1.09,95%CI:0.56~2.13,P>0.05)、术后二次开胸止血(OR=2.91,95%CI:0.34~24.99,P>0.05)、术后1年再手术率(OR=1.22,95%CI:0.20~7.56,P>0.05)、术后5年病死率(OR=7.50,95%CI:2.11~26.65,P>0.05)差异均无统计学意义。结论急性A型主动脉夹层患者重塑手术相较于再植手术,术后Ⅱ或Ⅲ度主动脉瓣关闭不全发生率较大及术后5年再手术率发生率较高、体外循环时间较短、主动脉阻断时间相对较长。使用重塑和再植技术在术后住院/30天病死率、术后二次开胸手术、术后1年再手术率及晚期病死率差异均无统计学意义,可根据主动脉根部的实际情况及术者经验进行选择。     

急性Stanford A型主动脉夹层中低温停循环手术围手术期大量出血的危险因素分析

目的:研究急性Stanford A型主动脉夹层中低温停循环手术围手术期大量出血的危险因素。方法:2016年1月至2017年10月连续486例急性A型主动脉夹层患者纳入研究。所有手术均在中低温停循环下进行。回顾性收集患者的基本临床资料,分别以成人心脏手术出血定义(universal definition of perio...     

妊娠合并急性A型主动脉夹层的外科治疗

目的 总结妊娠合并急性A型主动脉夹层的治疗经验.方法 2007年1月至2012年2月,6例妊娠合并急性A型主动脉夹层的患者接受治疗,年龄24～37岁,平均31岁.妊娠12～38周,平均24.5周.4例马方综合征,2例妊娠期高血压.主动脉夹层病理分型A3S1例,A2C2例,A3C3例.5例手术治疗,1例药物保守治疗.手术在低温体外循环或深低温停循环选择性脑灌注下完成.其中Bentall手术1例,Bentall加孙氏手术2例,升主动脉替换加孙氏手术2例,术后母亲和活体胎儿均接受随访.结果 接受药物治疗患者治疗9天后因为主动脉夹层破裂母体及胎儿死亡.5例接受外科手术患者母体均生存,胎儿成活3例,死亡2例.体外循环75～210min,平均167min;主动脉阻断83～145min,平均98min;停循环19～27min,平均23.5min.随访1.0～3.5年,平均2.2年,5例均生存.CT示手术部位形态、结构、血流无异常,支架远端的自体血管无扩张;3例婴儿生长发育好,智力正常.结论 妊娠合并急性A型主动脉夹层患者应及时手术治疗,药物治疗风险高、夹层破裂可导致母体及胎儿死亡的不良后果.术前应在多学科会诊下综合考虑主动脉病理改变、妊娠周龄来决定灌注部位、体外循环方法,选择恰当的胎儿处理方式及手术方式,从而最有效的保证母婴的安全.     

急性Stanford A型主动脉夹层合并下肢缺血的外科治疗

目的:探讨使用缺血侧下肢股动脉及右腋动脉插管行孙氏手术在急性A型主动脉夹层合并下肢缺血外科治疗中的效果。方法:回顾性分析2017年7月至2019年5月,12例采用缺血侧股动脉人工血管及右腋动脉双插管治疗的合并下肢缺血的急性Stanford A型主动脉夹层患者资料。患者均为男性,年龄(48.4±8.4)岁。合并单侧下肢缺...     

急性A型主动脉夹层根部的个体化治疗与精准外科操作策略

目的 探讨急性A型主动脉夹层(acute type A aortic dissection, ATAAD)根部的个体化处理策略。方法 回顾性分析我院2021年7月～2022年10月77例ATAAD资料,均在急性期(发病时间<14 d)行全主动脉弓替换及降主动脉支架象鼻人工血管置入术(孙氏手术),根部施行个体化治疗与精准外科操作方案,应用“三明治”法31例,改良“三明治”法37例(人工血管片内衬和夹入,外垫毛毡条,其中3例冠脉开口撕裂行“铜钱样”牛心包片修复冠脉开口及窦的根部成形),Bentall术5例,Wheat术1例,改良David术1例,改良Cabrol术2例。其中5例行单支或多支大隐静脉冠状动脉旁路移植术。结果 死亡5例,其中2例心肌灌注不良,1例肾灌注不良,1例下肢灌注不良,1例病房猝死。出院72例,其中2例术后直接应用床旁血液滤过,术后出血二次开胸1例,胸骨愈合不良再次胸骨固定1例。出院前全部复查主动脉CTA及心脏超声,无主动脉瓣大量反流,无近端吻合口漏及残余夹层。术后随访3～12个月,平均6个月,均无临床症状,无死亡。术后随访心脏超声及主动脉CTA,无主动脉瓣大量反流...     

妊娠期急性Stanford A型主动脉夹层的诊断与治疗

目的 总结妊娠期急性Stanford A型主动脉夹层（acute type A aortic dissection,AAAD） 患者的诊治经验。 方法 回顾性分析2008年5月至2010年7月首都医科大学附属北京安贞医院3例妊娠期AAAD患者（年龄分别为：30岁、32岁、35岁） 经手术治疗的临床资料。1例剖宫产后3 d行Sun’s手术 （全主动脉弓置换＋降主动脉支架置入手术）,胎儿宫内死亡;1例行剖宫产、子宫切除术后立即实施Bentall＋Sun’s手术成功;1例先行剖宫产,保留子宫同期行升主动脉置换＋Sun’s手术。 结果 3例孕妇顺利恢复,病例2及病例3 的胎儿亦顺利恢复。术后6个月进行随访,CT （computerized tomographic） 检查提示主动脉夹层假腔血栓机化形成。3例产妇术后恢复佳,2例存活婴儿发育正常。 结论 妊娠期AAAD的治疗原则为：首先及时准确地诊断至关重要;其次保证母体血流动力学平稳;第三应保证止血确切;最后,多种方法联合应用对保证母体及胎儿的良好预后非常重要。     

Ascending aorta cannulation in acute type A aortic dissection

Objective: Antegrade perfusion for type A acute aortic dissection prevents malperfusion and retrograde cerebral embolism during cardiopulmonary bypass. Prompt establishment of antegrade perfusion via ascending aorta may improve the surgical results of type A dissections, especially in the situations of hemodynamic instability. Thus, we evaluated the efficacy of use of the dissected ascending aorta as an alternative arterial inflow. Methods: Between 2002 and 2006, 32 patients underwent prosthetic graft replacement of the ascending aorta or hemiarch for acute type A aortic dissection. The ascending aorta was routinely cannulated, in addition to the femoral artery, with a heparin-coating flexible cannula for arterial inflow, using Seldinger technique, and by epiaortic ultrasonographic guidance (n = 6). Antegrade systemic perfusion via ascending aorta was performed. Results: Ascending aorta cannulation was safely performed in all cases. There was no malperfusion or thromboembolism due to ascending aorta cannulation. Cardiopulmonary bypass was established within 30 min after skin incision. There was one in-hospital death due to duodenal bleeding (1/32 = 3.1%), two cases of cerebral infarction (2/32 = 6.3%), and one case of pulmonary embolism. Twenty-nine patients (29/32 = 90.6%) were discharged in New York Heart Association class I and have been followed up uneventfully for a mean of 17 months. Conclusions: Antegrade perfusion via the ascending aorta was successfully performed with low mortality and morbidity. With ultrasound-guided Seldinger technique, ascending aorta cannulation has a potential to be a simple and safe option that enables rapid establishment of antegrade systemic perfusion in patients with acute type A aortic dissection.     

Changing predictors of postoperative mortality in acute type A aortic dissection

OBJECTIVES: Rapid emergency transport and early diagnosis and surgical treatment for acute type A aortic dissection have improved postoperative survival, which has, however, plateaued at about 80%. End-organ malperfusion is regarded as a strong predictor of postoperative mortality, replacing factors such as cardiac tamponade complications, aortic rupture, and left ventricular dysfunction due to aortic insufficiency. It is thus important to reevaluate risk factors for surgical death to assess current therapeutic strategies. METHODS: We statistically analyzed potential risk factors for perioperative death in 88 patients undergoing surgical repair for type A aortic dissection between January 1990 and December 1999. RESULTS: Univariate analysis showed that cardiopulmonary arrest (adjusted odds ratio: 13.78; p < 0.01) and malperfusion of more than 1 vital organ (adjusted odds ratio 4.97, p < 0.01), especially myocardial ischemia due to coronary artery dissection (adjusted odds ratio 3.21, p < 0.05), significantly increased the likelihood of operative death. Multivariate logistic regression analysis showed only cardiopulmonary arrest (p < 0.01) and concomitant coronary artery bypass grafting necessitated in cases complicated by evolving myocardial infarction (p < 0.05) to be independent predictors of postoperative mortality. CONCLUSION: Preoperative complication from coronary dissection was the most important predictor of early postoperative mortality in this series. In such cases, rapid surgical intervention before myocardial infarction develops is vital to saving lives.     

143例微创冠状动脉旁路移植术有效性和安全性的倾向性评分匹配研究

目的 对比微创冠状动脉旁路移植术(minimally invasive coronary artery bypass grafting,MICABG)和常规开胸搭桥围术期临床效果,分析MICABG的有效性和安全性.方法 收集2017年1月至2020年9月北京安贞医院单医疗组接受不停跳冠状动脉旁路移植术患者共543例,其...     

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.     

The role of ascending aortic size in outcomes of patients with uncomplicated acute type B aortic dissection

Objective

Recent studies demonstrate that uncomplicated acute type B aortic dissection (uATBAD) patients with enlarged descending thoracic aortic diameters are at high risk for development of complications. This study aimed to determine the association of maximum ascending aortic diameter and area and outcomes in patients with uATBAD.

Severe stenosis of the true lumen in the abdominal aorta after an ascending aorta reconstruction for an acute type a dissection: report of a case

We encountered a case of severe symptomatic stenosis of the abdominal aorta after a surgical repair of an ascending aortic dissection. A 75-year-old woman underwent a reconstruction of the ascending aorta to treat a Stanford type A acute aortic dissection and cardiac tamponade. Eight hours postoperatively, the patient was anuric. An abdominal computed tomography scan revealed severe stenosis of the true lumen of the suprarenal abdominal aorta due to a dilatation of the false lumen. The patient's ischemic symptoms progressed to include a weakening femoral pulse and, as a result, an emergency right axillofemoral artery bypass was performed. We hypothesize that the stenosis of the true lumen of the abdominal aorta was secondary to the mechanical obstruction due to a false lumen, which already existed because of the thoracic dissection, and its size increased postoperatively as a consequence of uncontrolled postoperative hypertension. Received: July 23, 2001 / Accepted: January 8, 2002     

Frozen elephant trunk in acute type A aortic dissection: surgical techniques and the extracorporeal circuit management

Acute type A aortic dissection (ATAAD) is a challenging clinical condition with immediate and late complications. Frozen elephant trunk (FET) has been offered as a solution for it promises to address the late complications—false lumen thrombosis and aortic remodelling. Here, we describe the implantation of the FET in ATAAD with the surgical technique and extracorporeal circuit management. A 54-year-old male presented with retrograde type A aortic dissection with an entry point distal to the left subclavian artery. He underwent FET using Thoraflex™ hybrid vascular prosthesis (Vascutek, Inchinnan, Scotland). Three-month follow-up showed a complete obliteration of the false lumen in the descending thoracic aorta. FET in ATAAD is a valid option in the hands of experienced surgeons, while patient selection still remains the key in this surgery.