胸主动脉夹层的外科治疗

目的总结胸主动脉夹层(AD)的外科治疗经验。方法1993年至2003年4月手术治疗A型AD40例，B型20例，其中急性夹层16例。A型采用中度低温体外循环13例，深低温停循环(DHCA)和上腔静脉逆灌(RCP)27例；行升主动脉置换24例，升主动脉和半弓置换11例，升主动脉、全弓和象鼻手术5例；同期行Bentall手术18例，主动脉瓣置换8例，冠状动脉旁路移植术1例。B型采用左心转流7例，股一股转流2例，DHCA 11例；行近端降主动脉置换14例，全胸降主动脉置换或伴肋间动脉移植6例。结果全组术后死亡率10％(急性夹层18．8％，慢性夹层6．8％)，近3年降至4．4％。术后并发呼吸功能不全8例，二次开胸止血3例，延迟性心包压塞和腹腔内出血各2例，声音嘶哑3例。结论正确掌握手术指征、手术技巧和术中脑保护是手术治疗AD的关键。A型夹层的手术范围应依据内膜破裂口位置决定。

Surgical treatment of thoracic aortic dissection

Objective: To summarize the surgical experience of thoracic aortic dissection (AD). Methods: Sixty patients with AD underwent surgery from 1993 to 2003. 40 cases were type A, type B 20, acute AD in 16 cases. For patients with type A, the operation were performed by using moderate hypothermic CPB in 13 cases, deep hypothermic circulatory arrest and retrograde cerebral perfusion (DHCA RCP) in 27 cases, which included ascending aortic grafting in 24 cases, ascending and hemiarch grafting in 11, and ascending and total arch grafting with "elephant trunk" in 5. Concomitant procedures were 18 Bentall operation, 8 AVR and 1 CABG. For patients with type B, the operation were performed via left heart bypass in 7 cases, femoral to femoral bypass in 2, and DHCA in 11, which included proximal descending grafting in 14 cases, thoracic descending grafting or with intercostal arteries reimplantation in 6. Results: The overall postoperative mortality was 10% with 18.8% in the acute type and 6.8% in chronic type. In recent three years, the postoperative mortality has decreased to 4.4%. Postoperative complications included respiratory insufficiency in 8, reoperation for bleeding in 3 and abdominal bleeding in 2, and delayed cardiac temponade in 2. Conclusion: Proper surgical indication, technique and introperative brain protections are the key factors to success in AD surgery. DHCA with RCP is safe technique for type A. Procedures chosen must depend on the location of intimal tear. DHCA is also safe in type B.