Stanford A型主动脉夹层根部重建技术的应用现状与思考

Clinical practice and thoughts on the strategy of root reconstruction for Stanford type A aortic dissection

Stanford A型主动脉夹层根部重建主要包括对主动脉窦夹层、主动脉瓣和冠状动脉开口的处理.主动脉窦部重建及升主动脉替换术较易掌握,适用于多数患者,但在治疗主动脉窦部明显扩张、内膜严重破损患者时有一定局限.主动脉根部复合替换术（Bentall手术）广泛用于窦部明显病损患者,但也舍弃了一部分质地良好的主动脉瓣,增加了不必要的人工瓣膜相关并发症.保留瓣膜的主动脉根部替换术既可切除病变管壁又能保留自身瓣膜,其中主动脉根部重塑术（Yacoub手术）操作较简单但有远期瓣环扩大可能;主动脉根部再植术（David手术）远期疗效好但手术难度大,是否适用于Stanford A型夹层尚存争议.近年来,国内外学者就不同主动脉根部重建策略进行了有益探索,为进一步提高Stanford A型主动脉夹层患者的中远期疗效奠定了基础,并推动Stanford A型主动脉夹层治疗向规范化、个体化迈进.

The strategy of root reconstruction for Stanford type A aortic dissection （AAD） includes resection of the intimal tear site,correction of concomitant aortic valve dysfunction and amendment of coronary lesion.Supracommissural tube graft replacement is a well-adopted and convenient procedure for most patients,although its application is limited when distinct sinus expansion and severe intimal damage is present.Composite valve conduit replacement （Bentall procedure） is suitable for patients with overt sinus damage.However,a fraction of patients with functional aortic valve will be unnecessarily put into risks for prosthetic complications.Valve-sparing aortic root replacement （VSRR）,which includes aortic root remodeling （Yacoub procedure） and reimplantation （David procedure） techniques,has the advantage of retaining autologous aortic valve while guaranteeing resection of damaged vessel segments.The Yacoub procedure is relatively convenient but harbors long-term risk for annulus expansion,while the David procedure demonstrates long-term benefit but may be too demanding to be operated in emergent scenario as AAD.The last decade has witnessed worldwide endeavors to investigate the treatment strategy for aortic root,especially the VSRR approach.The preliminary results are encouraging and demonstrating improvements for both mid-and long-term outcomes of AAD,which enables standardized and personalized surgical management for these patients.