孙氏手术与联合三分支支架血管术中置入治疗急性Stanford A型主动脉夹层对比

目的 探讨孙氏手术、联合三分支支架血管术中置入两手术方式治疗急性Stanford A型主动脉夹层的疗效.方法 2011年1月至2013年1月我院收治的急性Stanford A型主动脉夹层患者,以孙立忠教授主动脉细化分型中AC型为入选标准,选取患者24例.孙氏手术组患者12例,单纯行升主动脉及全弓替换加支架“象鼻”手术9例,同期主动脉根部替换手术（Bentall术）2例,主动脉瓣成形1例.联合三分支支架血管术中置入组患者12例,单纯三分支支架术中置入3例,同期升主动脉替换8例,主动脉根部替换手术（Bentall术）1例.出院前、术后3个月、术后每年复查主动脉全程重建CT.结果 孙氏手术组：平均手术时间（10.00±1.60）h,平均体外循环时间（253.33±49.33）min,平均心肌阻断时间（141.41±27.58）min,选择性脑灌注时间（39.67±10.28）min.住院死亡4例,死亡原因：多脏器衰竭2例,术后肾功能衰竭1例,术后呼吸功能衰竭1例.联合三分支支架血管术中置入组：平均手术时间（7.77±2.06）h,平均体外循环时间（168.25±32.05）min,平均心肌阻断时间（79.75±29.54）min,选择性脑灌注时间（24.33±6.53）min.住院死亡2例,死亡原因：术后呼吸功能衰竭死亡1例,1例术后一直未醒,术后第5天少尿,家属放弃治疗.孙氏手术组随访（11.09±6.87）个月,无死亡及需再次手术者.联合三分支支架术中置入组随访（18.40±8.03）个月,术后死亡2例,1例术后1年胸痛发作,心脏彩超提示升主动脉明显增宽,主动脉后壁分离为两层,当即死亡;1例术后2年随访主动脉全程重建CT提示无名动脉近端内漏.结论 孙氏手术和联合三分支支架血管术中置入术是治疗大多数急性Stanford A型主动脉夹层安全有效的方法.作为一种崭新的技术手段,联合三分支支架血管术中置入简化了手术步骤,术后内漏是高危因素,对该种手术方式患者选取应有一定针对性,根据患者信息订制更加个体化支架,并且需要长期随访.

SUN'S operation and ascending aorta replacement combined with open placement of triple-branched stent graft for acute type A aortic dissection

Objective To summary the experience and improve the long term outcomes of the surgery for acute type A dissection,we performed SUN＇S operation （ascending aorta and total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta） and ascending aorta replacement combined with open placement of triple-branched stent graft for acute type A aortic dissection. Methods Records of the General Hospital of Ningxia Medical University database between 2011 and 2013 were examined. The modified classification of the aortic dissection diagnosis codes were used to select patients who underwent SUN＇S operation or ascending aorta replacement combined with open placement of triple-branchod stent graft. We selected patients with a diagnosis code for AC type dissections which was mentioned in the subtype of aortic dissection. We com- pared demographics and comorbidities, as well as adjusted complications and mortality rates, between patients un- dergoing SUN＇S operation vs open triple-branched stent graft placement. Results SUN＇S operation： the mean cardiopulmonary bypass time, aortic cross-clamp time, and average selective cerebral perfusion and lower body ar- rest time were （253.33＋49.33）rain, （141.41：l：27.58）min, （39.67＋10.28）min, respectively. The in-hospital mor- tality was 4/12 for SUN＇S Operation vs 2/12 for open triple-branched stent graft placement, respiratory complica- tions （1/12 vs 1/12）, multiorgan failure postoperatively （2/12 vs 1/12）, and acute renal failure （3/12 vs 3/12） in SUN＇S operation group and open triple-branched stent graft placement. In open triple-branched stentt graft placement, there was no sidearm graft stenosis or occlusion, but 1 space or blood flow surrounding the triple- branched stem graft following hospital discharge, and 1 ease died after leave hospital. Conclusion For patients with a diagnosis of AC type acute dissection, both SUN＇S operation group and open triple-branched stent graft placement axe effective technique with satisfactory early restdts. With the open triple-branched stent graft place- ment, extensive primary repair of the thoracic aorta may become easier and safer for acute type A aortic dissection. Careful long-term follow-up, further extensive clinical trials and personalized information customization for open triple-brancbed stent graft placement are necessary before this surgical method can become a recommended alterna- tive to surgical extensive primary repair of the thoracic aorta for acute type A aortic dissection.