摘要
目的:探讨复杂型主动脉夹层临床特点及手术经验,评估支架象鼻手术治疗主动脉夹层的效果。
方法:连续回顾性分析2006年1月至2010年3月的15例手术治疗复杂型AD患者,男性11例,女性4例。年龄32-69岁,平均50.12±12.69岁。急性期或亚急性期者9例,有高血压病史12例(80.00%),长期吸烟史9例,术前心包填塞及心源性休克或伴左侧胸腔积液4例,肾功能不全2例,术前有短暂性脑缺血发作昏迷史2例,一侧肢体麻木或一侧脉搏减弱或消失4例,行覆膜支架腔内修复术后6年复发者1例,典型Marfan综合症2例。急诊手术8例(53.3%),术前检查主动脉直径达4cm以上者12例。所有患者均在体外循环下手术。深低温停循环(DHCA)+右锁骨下动脉(右腋动脉)或+左颈总动脉选择性顺行性脑灌注(SACP),行全弓置换十支架象鼻手术6例,升主动脉置换+全弓置换+降主动脉支架象鼻手术5例:包括行复合带瓣管道置换Bentall手术2例,Wheat手术2例,行无冠窦切除根部成形(David术)1例,使用四分支血管11例,头臂血管岛片吻合人工血管2例。升主动脉+半弓置换术4例(其中Bental+主动脉弓底吻合3例,左锁骨下动脉近端吻合1例)。术后以CT检查评价手术效果。
结果:全组病人全组平均体外循环(CPB)时间196. 8±105.9min,主动脉阻断(ACC)98. 8±34.0min;选择性脑灌注(SCP) 26.7±16.9min,下半身停循环15.2±8.1m in。15例患者中术后30d内死亡2例(13. 8% ) ,一例术前为急性肾功能不全,术后出现难易控制的出血而放弃治疗,一例术后28天全身感染,最后出现多器官功能衰竭(mutilorgan dysfunction syndrome,MODS)。术后二次开胸止血3例。发生肺部感染并呼吸衰竭1例。延迟苏醒4例。急性肾功能衰竭2例,死亡1例(术前有肾功能不全者),1例经腹膜透析治愈。短暂性的神经功能障碍1例,全组均无严重神经系统并发症出现。术后住院时间2～35天,平均(11.2±8.3)天。随访13例,随访时间2～48个月(23. 6±10. 1个月) ,1例术后26个月猝死,其余患者生活质量良好。13例患者术后3~6月复查胸部CT未见明显假腔。
结论:1.快速准确地诊断、个体化的手术方案和精确的手术技术是主动脉夹层手术成功的关键。
2.支架象鼻手术是治疗复杂型AD的一种安全而有效的术式。
3.急性肾功能不全是围手术期死亡原因的重要因素。
Object: To summarize the clinical characteristics and experiment of surgical treatment of complicated aortic dissection, evaluate the effect of a surgical approach for aortic dissection with a stented elephant trunk procedure.
Method: Continuous retrospective analysis from January 2006 to March 2010 of 15 cases of surgical treatment of complex AD patients, male 11 cases, 4 females. Aged 32-69 years, mean age 50.12±12.69 years. Actue or subacute stage in 9 cases. Hypertension in 12 cases (80.00%), long-term history of smoking in 7 cases .Pericardial tamponade and cardiogenic shock with left pleural effusion in 4 cases.Acute renal failure(ARF) in 2 cases.Preoperative transient ischemic attack history or coma in 2 cases. Limb numbness of one side or the side of the pulse weakened or disappeared in 4 cases. Endovascular Repair(EVR) after 6 years in 1 case. Typical Marfan syndrome in 2 cases. Emergency surgery in 8 cases (53.3%). Aortic diameter more than 4cm in 12 cases in preoperative examinations .All patients underwent surgery on cardiopulmonary bypass (CPB).Deep hypothermic circulatory arrest (DHCA) and selective antegrade cerebral perfusion(ASCP) through right subclavian(axillary)artery or / and left common carotid artery . Total arch replacement+ stented elephant truck technique in 6 cases. Ascending aorta and root replacement + total arch replacement + elephant trunk descending aortic stent surgery in 5 cases: involving mechanical composite graft replacement ( Bentall procedure ) in 2 cases, separate replacement of aortic valve and supracommissural ascending aorta(Wheat procedure)in 2 cases, Valve-preserving partial aortic root remodeling (David II procedure) in 1 cases. Brachiocephalic vascular Island vascularized in 2 cases, four-branch vessel stent in 11 cases, Aortic arch replacement+semi-arch replacement (Bental precedure+ anastomosis of bottom of aortic arch in 3 cases, left subclavian artery proximal anastomosis in 1 case). The postoperative effect of surgery was evaluated by computed tomography (CT).
Results:The average CPB time of all patients was196. 8±105.9min;, the aortic cross-clamp time was 98. 8±34.0min, the selective cerebral perfusion time was 26.7±16.9min,the lower body arrest time was 15. 2±8.1min .Hospital mortality in 30 days was 13.8%(2/15).One patient with preoperative acute renal failure ceased treatment after postoperative uncontrollable bleeding .One died of multiple organ failure (MODS) owing to systemic infection 28d after operation. Patients with pulmonary infection postoperatively and respiratory failure in 1 cases . Delayed awakening in 4 cases. Acute renal failure in 2 cases, one was cured by peritoneal dialysis(PD). Transient neurologic dysfunction in 1 case, the whole group had no serious neurological complications. The in-hospital time is 2~35 days, with a mean of(11.2±8.3)days. The follow-up time was 2~35 months (23.6±10.1month) in 13 cases , one patient died of the sudden death , the others remaining good quality of life. Postoperative CT scans showed no obvious false lumen in13 cases in 3~6 months afer surgery.
Conclusion:1.. Quick and accurate diagnosis and individualized surgical planning and precise surgical technique is the key to the success of aortic dissection.
2. Stent elephant trunk procedure is a safe and effective procedure in surgical treatment of complex aortic dissection.
3. Acute renal failure (ARF) is an important factor in cause of perioperative period death.
引文
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