主动脉弓降部病变的外科综合治疗

目的探讨开胸体外循环直视手术、解剖外旁路联合动脉腔内修复(endovascular aneurysm repair,EVAR)杂交手术以及完全EVAR手术治疗主动脉弓降部病变的方法及疗效。方法 2006年10月-2011年9月,收治48例主动脉弓降部病变患者。男31例,女17例;年龄28～81岁,平均52.4岁。病程1～90 d,平均10.2 d。累及弓部分支的B型主动脉夹层30例,主动脉弓降部真性动脉瘤11例,主动脉弓降部假性动脉瘤3例,主动脉弓穿透性溃疡伴壁间血肿3例,主动脉食管瘘1例。15例行开胸体外循环直视手术,12例行解剖外旁路联合EVAR杂交手术,21例行完全EVAR手术。结果开胸体外循环直视手术患者中术后发生出血1例,昏迷1例,短暂精神症状3例,肺炎4例,急性肾功能不全2例,多器官功能衰竭2例;最终3例死亡。解剖外旁路联合EVAR杂交手术患者术后1例出现右顶枕叶大面积梗死伴肺炎、肾功能衰竭。完全EVAR术后无并发症发生。术后41例获随访,随访时间2～60个月,平均28.6个月。3例患者出现左锁骨下动脉窃血综合征表现,因症状轻微,未予特殊处理,均自行缓解。其余患者均恢复正常生活。结论对于主动脉弓降部病变,采用开胸体外循环直视手术创伤大、风险高,将逐步被EVAR替代,解剖外旁路联合EVAR杂交手术是治疗此病变的重要方法,完全EVAR手术是其发展方向。

Multiple surgical treatment of complex aortic arch and descending aorta disease

Objective To investigate the methods and e ectiveness of multiple surgical treatment for complex aortic arch and descending aorta disease,including cardiopulmonary bypass operation,hybrid operation,and total endovascular aneurysm repair(EVAR).Methods Between October 2006 and September 2011,48 patients with complex aortic arch and descending aorta disease were treated.There were 31 males and 17 females,aged from 28 to 81 years(mean,52.4 years).The disease duration ranged from 1 to 90 days(mean,10.2 days).There were 30 cases of type B aortic dissection involving the aortic arch,11 cases of thoracic aortic aneurysm,3 cases of thoracic pseudoaneurysme,3 cases of penetrating aortic ulcer,and 1 case of aortoesophageal stula.Cardiopulmonary bypass operation,hybrid operation,and total EVAR were performed in 15,12,and 21 cases,respectively.Results In the patients undergoing cardiopulmonary bypass operation,the following complications occurred: 1 case of bleeding,1 case of coma,3 cases of psychiatric disorders,4 cases of pneumonia,2 cases of acute renal insu ciency,and 2 cases of multi-organ dysfunction;nally 3 patients died.In the patients undergoing hybrid operation,cerebral infarction and renal function failure occurred in 1 case.In the patients undergoing total EVAR,no complication occurred.A total of 41 patients were followed up 2 to 60 months(mean,28.6 months).Slight left subclavian steal syndrome occurred in 3 cases,but self relieved.Other patients recovered to normal life.Conclusion In the surgical treatments of complex aortic arch and descending aorta disease,cardiopulmonary bypass operation will be gradually replaced by EVAR because of the surgical trauma and risk,hybrid operation is an important technique,and total EVAR will be the future progress.