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.

Treatment strategy of aortic arch for type A acute dissection

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.