DeBakey Ⅰ型主动脉夹层的围术期处理

目的 探讨DeBakey Ⅰ型主动脉夹层行三分支型主动脉弓腔内覆膜支架手术治疗的围术期处理要点.方法 我院2009年7月至2010年8月应用三分支型主动脉弓腔内覆膜支架手术治疗DeBakey Ⅰ型主动脉夹层患者56例,观察手术时间和术后并发症发生情况.结果 体外循环时间90.0～248.0 min,中位数180.6 min;主动脉阻断时间69.0～180.0 min,中位数108.2 min;停循环时间17.0～37.0 min,中位数22.6 min;术后呼吸机辅助时间16.0～260.0 h,中位数42.8 h;ICU停留时间3.0～23.0 d,中位数6.6 d.54例痊愈出院.术后急性肾功能不全6例,气管切开5例,延迟性心包填塞1例,二次开胸止血3例;截瘫1例,脑出血1例;发生顽固性心律失常5例.死亡2例,1例为急诊手术的大面积急性心肌梗死患者,无法脱离体外循环机;1例术后8 d出现多脏器功能衰竭死亡.结论 DeBakey Ⅰ型主动脉夹层手术创伤大,术前积极控制血压、镇静止痛,术中维持良好的脏器灌注、尽量缩短体外循环及停循环时间,术后密切观察、处理各种并发症是降低并发症发生率及病死率的重要保障.

Abstract：

Objective To investgate the proper perioperative management of Debakey Ⅰ aortic dissection by new type of three branches aortic arch covered stent graft implantation. Methods A total of 56cases with Debakey Ⅰ aortic dissection were enrolled into the study and operated by new type of three branches aortic arch covered stent graft implantation from July 2009 to August 2010. Results The cardiopulmonary bypass time during the operation was 90. 0 -248.0 min( median time 180. 6 ains) ,aortic cross clamp time was 69. 0 - 180. 0 min(median time 108. 2 mins) ,circulation arrest time was 17.0 -37.0 min ( median time 22. 6mins) ,the time using reathing apparatus was 16.0 -260.0 hours (median time 42. 8 hours),ICU residence time was 3.0 -23. 0 days( median time 6. 6 days). Fifty-four patients got well and were discharged. One patient died of multi-organ failure postoperatively and another died of large area of acute myocardial infarction. After the operation, six cases had acute renal failure, five cases had tracheotomy, three cases had reoperation for hemorrhage,one case had retardant pericardial tamponade, one case suffered from spinal cord injury, one had cerebral hemorrhage, and five cases had refractory arrhythmias. Conclusion The new type of three branches aortic arch covered stent graft simplified the procedures of aortic arch operation and lowered the operative risk in treatment of Debakey Ⅰ aortic dissection. Properly control of blood pressure and pain before surgery, shorten circulatory arrest time, maintain good organ perfusion seem to be the key points to improve the prognosis in patients with aortic dissection.