改良全主动脉弓置换治疗老年Stanford A型主动脉夹层

目的总结改良全主动脉弓置换治疗老年Stanford A型主动脉夹层的临床经验,并探讨其疗效。方法 39例老年Stanford A型主动脉夹层患者在深低温停循环、双侧顺行脑灌注下行外科手术。根部处理根据不同病变情况,选择不同术式,包括单纯升主动脉置换、Bentall、Wheat手术。主动脉弓部采用四分支血管行全主动脉弓置换,降主动脉内置入硬象鼻支架,并行支架开窗,完成左锁骨下动脉重建。结果全组平均体外循环时间为(180.49±30.46)min,平均停循环时间(27.22±10.58)min,平均脑灌注时间(32.42±12.36)min,平均心肌阻断时间(94.84±24.83)min。升主动脉置换17例,Wheat手术10例,Bentall手术12例。全组无术中死亡,术后住院死亡2例,脑梗塞1例,短暂性神经功能障碍3例,行肾脏透析治疗3例。全组无出血再次开胸、声音嘶哑、左上肢感觉运动功能障碍等情况。术后复查主动脉CTA弓部分支血管血流通畅,象鼻支架无内漏。无术后死亡及二次手术者。结论选择合适的手术时机及手术方式,老年Stanford A型主动脉夹层患者仍能获得满意的外科手术效果。

Modified total aortic arch replacement for acute type A aortic dissection in the elderly

Objective To study surgical outcomes of modified total aortic arch replacement for a-cute type A aortic dissection in elderly. Methods A total of 39 elderly patients with acute type A aortic dissection received surgical operation under deep hypothermic circulatory arrest and bilateral antegrade cerebral perfusion. According to the extent of different dissection,different procedures,including simple ascending aorta replacement,Bentall procedure and Wheat procedure,were adopted. The aortic arch were all reconstructed using four-branched grafts. A stented elephant trunk was inserted into the descending aor-ta. Then the left subclavian artery was reconstructed by fenestration in the stented elephant trunk. Results The mean cardiopulmonary bypass time was(180. 49 ± 30. 46)min,circulatory arrest time was(27. 22 ± 10. 58)min,cerebral perfusion time was(32. 42 ± 12. 36)min,and myocardial ischemia time was (94. 84 ± 24. 83)min. No death occurred during the operation. Two cases of in-hospital death occurred in patients undergoing our surgical procedure. Complications included one case of cerebral infarction,three cases of transient neurological abnormalities,and three cases for kidney dialysis. No patient underwent re-exploration for postoperative hemorrhage or had hoarseness as the result of recurrent nerve palsy. No pa-tient had a sensory deficit and dyskinesia of the left arm postoperatively. Postoperative aortic CT angiogra-phy showed that arch artificial vascular patency and there was no inner leakage in all patients. No death and reoperation occurred during the follow-up period. Conclusion Satisfactory prognosis could be a-chieved through selecting the appropriate surgical timing and manner of surgical procedures in elderly pa-tients with acute type A aortic dissection.