Stanford A型主动脉夹层的外科治疗

目的 总结Stanford A型主动脉夹层的治疗经验，评价其外科手术疗效。 方法 回顾性分析2006年10月至2013年3月兰州军区兰州总医院48例Stanford A型主动脉夹层行外科手术治疗的临床资料，其中男41例，女7例；年龄26～72 （47.6±9.2） 岁。急性Stanford A型主动脉夹层（发病至确诊＜14 d） 43例，慢性5例。主动脉瓣中重度关闭不全19例＋主动脉瓣良好、但合并马方综合征6例，行Bentall＋全弓置换＋支架象鼻术；累及主动脉根部、但瓣膜功能良好的8例行改良David＋全弓置换＋支架象鼻术；累及升主动脉10例行升主动脉＋全弓置换＋支架象鼻术；累及部分主动脉弓5例行升主动脉＋次全弓置换术。出院后于术后3、6、12个月随访，以后每年随访1次。随访内容包括：患者的生存情况、血压控制情况、有无疼痛复发、运动、活动情况和复查主动脉计算机断层扫描成像（computerized tomography arteriography，CTA）。 结果 全组体外循环时间121～500 （191.4±50.6） min，主动脉阻断时间58～212 （112.3±31.7） min；停循环＋选择性脑灌注时间26～56 （34.8±8.7） min；术后呼吸机辅助时间32～250 （76.2±35.6） h；住ICU时间3～20 （7.1±3.4） d。术后24 h胸腔引流量680～1 600 （1 092.5±236.3） ml。围术期死亡7例，病死率14.5%，其中死于多器官功能衰竭2例、低心排血量综合征2例、肾功能衰竭1例、迟发性难治性出血1例、昏迷1例。围术期发生其它并发症20例，经治疗均痊愈或好转出院。随访38例，随访率92.7%（38/41），随访时间3～48 （13.0±8.9） 个月；失访3例。随访期间36例存活，无与主动脉夹层相关的死亡，因其它慢性疾病死亡2例。无因主动脉夹层继续形成、假腔扩张行二次手术患者，术后6个月CTA检查未见吻合口渗漏及人工血管扭曲或血流不畅。 结论 根据主动脉夹层破口的位置、升主动脉直径及夹层累及范围等，选择合适的手术方式、手术时机及脏器保护策略是提高Stanford A型主动脉夹层治疗效果的关键。应用腋、股动脉联合灌注及提高术中最低温度等策略治疗Stanford A型主动脉夹层可获得良好的效果。

Surgical Treatment of Stanford Type A Aortic Dissection

Objective To summarize treatment experience and evaluate clinical outcomes of surgical therapy for Stanford type A aortic dissection （AD）. Methods Clinical data of 48 patients with Stanford type A AD who underwent surgical treatment in General Hospital of Lanzhou Military Region from October 2006 to March 2013 were retrospectively analyzed. There were 41 males and 7 females with their age of 26-72 （47.6±9.2） years. There were 43 patients with acute Stanford type A AD （interval between symptom onset and diagnosis＜14 days） and 5 patients with chronic AD. There were 19 patients with moderate to severe aortic insufficiency and 6 patients with Marfan symdrome but good aortic valve function，who all received Bentall procedure，total arch replacement and stented elephant trunk implantation. There were 8 patients with AD involving the aortic root but good aortic valve function who underwent modified David procedure，total arch replacement and stented elephant trunk implantation. There were 10 patients with AD involving the ascending aorta who received ascending aorta replacement，total arch replacement and stented elephant trunk implantation. There were 5 patients with AD involving partial aortic arch who underwent ascending aorta and hemiarch replacement. Patients were followed up in the 3rd，6th and 12th month after discharge then once every year. Follow-up evaluation included general patient conditions，blood pressure control，chest pain recurrence，mobility and computerized tomography arteriography （CTA）. ResultsCardiopulmonary bypass time was 121-500 （191.4±50.6） minutes，aortic cross-clamp time was 58-212 （112.3±31.7） minutes，and circulatory arrest and selective cerebral perfusion time was 26-56 （34.8±8.7） minutes. Postoperative mechanicalventilation time was 32-250 （76.2±35.6） hours，and ICU stay was 3-20 （7.1±3.4） days. Thoracic drainage within 24 hours postoperatively was 680-1 600 （1 092.5±236.3） ml. Seven patients （14.5%） died perioperatively including 2 patients with multiple organ dysfunction syndrome，2 patients with low cardiac output syndrome，1 patient with renal failure，1patient with delayed refractory hemorrhage，and 1 patient with coma. Twenty patients had other postoperative complicationsand were cured or improved after treatment. A total of 38 patients ［92.7% （38/41）］ were followed up for 3-48 （13.0±8.9） months，and 3 patients were lost during follow-up. During follow-up，there were 36 patients alive and 2 patients who died of other chronic diseases. There was no AD-related death during follow-up. None of the patients required reoperation for AD or false-lumen expansion. CTA at 6th month after discharge showed no anastomotic leakage，graft distortion or obstruction.Conclusion According to aortic intimal tear locations，ascending aorta diameter and AD involving scopes，appropriate surgical strategies，timing and organ protection are the key strategies to achieve optimal surgical results for Stanford type A AD. Combined axillary and femoral artery perfusion and increased lowest intraoperative temperature are good methods for satisfactory surgical outcomes of Stanford type A AD.