一期"杂交"手术主动脉弓替换及早期随访结果

目的 总结一期"杂交"主动脉弓部替换治疗累及主动脉弓的主动脉夹层及主动脉瘤的临床经验及早期随访结果,探讨一期"杂交"手术适应证.方法 2009年7月到2010年3月共22例累及主动脉弓的主动脉夹层或主动脉瘤病人在"杂交"手术室完成一期"杂交"主动脉弓替换手术.分别采用正中开胸,常温升主动脉至头臂动脉旁路移植,顺行主动脉弓部腔内覆膜支架置入术;和正中开胸,体外循环下升主动脉替换和(或)主动脉瓣置换和(或)冠脉旁路移植术,顺行主动脉弓部腔内覆膜支架置入术.比较体外循环组与同期采用传统深低温停循环手术行主动脉弓置换者的体外循环、主动脉阻断、ICU时间及血制品费用.结果 全组均成功同期完成手术并置入覆膜支架.常温组支架直径(40.80±1.79)mm,支架长度(189.0±14.39)mm.1例病人术后第6天突然死亡,尸检证实为远端夹层破裂.体外循环组体外循环(132.0±24.00)min,主动脉阻断(49.18±12.09)min;支架直径(33.82±0.60)mm,支架长度(187.91±6.33)mm;1例病人术后5天CT发现纵隔积液,开胸探查证实为淋巴积液;1例病人术后12天死于呼吸衰竭及肾功能衰竭."杂交"体外循环组体外循环和主动脉阻断时间明显少于传统手术数组(P＜0.05);"杂交"手术者ICU天数明显少于传统手术组(P＜0.05);"杂交"手术者使用血制品量及费用也明显少于传统手术组(P＜0.05).全组随访12～20个月,平均(14.45±2.33)个月.随访者均生存且恢复正常生活,无明显不适.CT复查支架无移位及内漏.术后早期支架段假腔闭合率100%.术后3个月远端夹层无变化,部分病人远端夹层血栓形成.结论 一期"杂交"主动脉弓替换手术安全、有效,能较传统手术明显缩短手术时间,减少手术创伤,缩短住院天数,减少输血,取得满意的早期治疗效果;但中、远期疗效尚须进一步随访.

Abstract：

Objective To summarize the clinical experience of one stage hybrid operation for aortic arch replacement and explore the indication. Methods From July,2009 to March,2010, 22 consecutive patients received one stage hybrid operation in our hybrid suite for aortic dissection or aortic aneurysm involving aortic arch. Two operative methods are used. (1)Bypass from ascending aorta to brachiocephalic arteries using midstemotomy and normothermia with antegrade aortic arch endovascular stented graft implantation. (2) Ascending aorta replacement and/or aortic valve replacement and/or coronary artery bypass grafting using midstemotomy and cardiopulmonary bypass with antegrade aortic arch endovascular stented graft implantation. Results All patients were technically successful. Angiography during the operation showed 100% patency of all the bypass grafts and no obvious translocation or endoleak of the stents. One patient in the first group died on sixth day after operation due to distal dissection rupture. There was one case of mediastinal lymph effusion in the second group and one case of death due to renal failure and respiratory failure 12 days after operation in the second group. The ICU stay and hospital stay were obviously shorter in hybrid open chest group than that in traditional open chest operation group(P ＜0.05). The blood product consumption and expenditure were also obviously less in hybrid open chest group than that in traditional open chest operation group (P ＜0.05). All the patients were followed up with a mean period of (14.45 ±2.33) months (range: 12 -20 months). All other patients were recovered with normal social life. CT showed neither endoleak nor translocation of the stented grafts. Faulse lumen closure rate at stented-graft segment is 100%. There was no obvious change of distal part of the dissection three months after operation except some thrombosis formation in some of the false lumen. Conclusion One stage hybrid operation for aortic arch replacement is safe and effective in shortening the duration of the operation and reducing the surgical trauma and risk of interval between procedures, shortening the hospital stay and reducing the blood product consumption compared with conventional operation with satisfactory early results. The midterm and long term results are still needed to be followed up.

One stage hybrid aortic arch replacement and early results

Objective To summarize the clinical experience of one stage hybrid operation for aortic arch replacement and explore the indication. Methods From July,2009 to March,2010, 22 consecutive patients received one stage hybrid operation in our hybrid suite for aortic dissection or aortic aneurysm involving aortic arch. Two operative methods are used. (1)Bypass from ascending aorta to brachiocephalic arteries using midstemotomy and normothermia with antegrade aortic arch endovascular stented graft implantation. (2) Ascending aorta replacement and/or aortic valve replacement and/or coronary artery bypass grafting using midstemotomy and cardiopulmonary bypass with antegrade aortic arch endovascular stented graft implantation. Results All patients were technically successful. Angiography during the operation showed 100% patency of all the bypass grafts and no obvious translocation or endoleak of the stents. One patient in the first group died on sixth day after operation due to distal dissection rupture. There was one case of mediastinal lymph effusion in the second group and one case of death due to renal failure and respiratory failure 12 days after operation in the second group. The ICU stay and hospital stay were obviously shorter in hybrid open chest group than that in traditional open chest operation group(P ＜0.05). The blood product consumption and expenditure were also obviously less in hybrid open chest group than that in traditional open chest operation group (P ＜0.05). All the patients were followed up with a mean period of (14.45 ±2.33) months (range: 12 -20 months). All other patients were recovered with normal social life. CT showed neither endoleak nor translocation of the stented grafts. Faulse lumen closure rate at stented-graft segment is 100%. There was no obvious change of distal part of the dissection three months after operation except some thrombosis formation in some of the false lumen. Conclusion One stage hybrid operation for aortic arch replacement is safe and effective in shortening the duration of the operation and reducing the surgical trauma and risk of interval between procedures, shortening the hospital stay and reducing the blood product consumption compared with conventional operation with satisfactory early results. The midterm and long term results are still needed to be followed up.