三分支主动脉弓覆膜支架在Stanford A型主动脉夹层手术中的应用

目的总结三分支主动脉弓覆膜支架治疗StanfordA型主动脉夹层的临床经验。方法正中开胸，股动脉、右房插管转流，不游离主动脉弓及头臂血管，鼻温18℃，停循环，于无名动脉近端2cm部分切开升主动脉，直视下置入三分支主动脉弓覆膜支架于主动脉弓和近端降主动脉及三支头臂血管内，行左颈总动脉、右无名动脉气囊导管选择性脑灌注，吻合支架血管近端与升主动脉人工血管，恢复全身灌注。观察并发症及疗效。出院时和3个月复查CT血管造影（CTA）。结果本组无死亡，手术过程顺利，脑及右上肢停循环6-7min，左上肢及降主动脉停循环25-27min，心肌血运阻断时间81-96min，体外循环时间145-190min。术后64排CTA示1例左锁骨下动脉支架外左侧少量血流流向降主动脉，3个月时消失；术后短暂、轻度精神症状1例；二次开胸止血1例，与血管吻合无关。术后1周及3个月CTA示支架血管位置满意，各头臂血管血流通畅。结论三分支主动脉弓覆膜支架术中置人治疗A型主动脉夹层具有操作简单、并发症少、临床效果好等优点，值得临床推广应用。

The application of three branches aortic arch stent-graft placement in Stanford type A aortic dissection

Objective To summarize clinical experience of three branches aortic arch stent-graft treat- ment in Stanford type A aortic dissection. Methods We performed mid-sternal thoracotomy and femoro-cavoatrial bypass, without freeing the aortic arch and brachiocephalic vessels. Nasal temperature was controlled at 18 ℃. After circulatory arrest, ascending aorta was opened 2 cm proximal to innominate artery, and the aortic arch stentgrafts were placed into aortic arch, proximal descending aorta and three braohiocephalie vessels under direct visualization. Selective cerebral perfusion was achieved though left common carotid artery and right innominate artery. Systemic perfusion was restored after anastomosing the proximal part of stental vessels with artificial vessel for ascending aorta, complications and efficacy were observed. CT angiography （CTA） was rechecked at discharge and 3 months later. Results There was no death in this group, surgery went successfully. Circulatory arrest in brain/ right upper limb and left upper limb/descending aorta lasted 6-7 rains and 25-27 mins separately, myocardial blood flow occlusion lasted 81-96 mins, cardiopulmonary bypass lasted 145-190 rains. CTA showed few blood outside stem of left subclavian artery flew into descending aorta in one case, and disappeared 3 months later. One case had mild psychiatric symptoms after surgery. One case had thoractomy for hemostasia postoperatively, which had nothing to do with vascular anastomosis. CTA rechecked 1 week and 3 months after surgery showed position of vascular stent was right, and blood flow of each brachiocephalic artery vessels was fluent. Conclusion Treatment of three branches aortic arch stent-graft placement in Stanford type A aortic dissection, easy to operate, with fewer complications and better efficiency, is worthy of clinical application.