右位主动脉弓伴DeBakey Ⅲ型主动脉夹层的手术治疗

Surgical Treatment of DeBakey Ⅲ Aortic DissectionInvolving Right-Sided Aortic Arch and Descending Aorta

目的 :总结右位主动脉弓、右位降主动脉、迷走左锁骨下动脉伴DeBakeyⅢ型主动脉夹层的外科治疗经验。方法 :4例右位主动脉弓、右位降主动脉、迷走左锁骨下动脉伴DeBakeyⅢ型主动脉夹层患者 ,经右后外侧切口 ,分别行部分胸降主动脉切除人工血管替换术或部分胸降主动脉切除人工血管替换加远端胸降主动脉成形术 ,并根据迷走左锁骨下动脉在头部及上肢血供中起的作用大小 ,重建左锁骨下动脉或缝闭其开口。结果 :所有患者均痊愈出院 ,无头部及左上肢缺血症状 ,无神经系统并发症。结论 :右位主动脉弓、右位降主动脉、迷走左锁骨下动脉伴DeBakeyⅢ型主动脉夹层采用右后外侧切口可获得良好的显露 ,根据降主动脉扩张范围行部分胸降主动脉切除人工血管替换术或部分胸降主动脉切除人工血管替换加远端胸降主动脉成形术可获得良好效果 ,迷走左锁骨下动脉的适当处理是避免左上肢坏死及锁骨下动脉窃血综合征的关键。

Objective:To summarize experience in surgical treatment of DeBakey Ⅲ aortic dissection involving right-sided aortic arch with right-sided descending aorta and aberrant left subclavian artery.Methods:Data of 4 cases of DeBakey Ⅲ aortic dissection involving right-sided aortic arch with right-sided descending aorta and aberrant left subclavian artery were reviewed. Descending aorta graft replacement or proximal descending aorta graft replacement plus distal descending aortoplasty were performed via right posterolateral thoracotomy. The aberrant left subclavian artery was bypassed or closed by suture according to its role in blood supply to the head and left upper limb.Results:All patients survived the operation. They had no symptoms of cerebral or left upper limb ischemia. No nervous system complications occurred.Conclusion:Right posterolateral thoracotomy can adequately expose the operation field in DeBakey Ⅲ aortic dissection involving right-sided aortic arch with right-sided descending aorta and aberrant left subclavian artery. Successful result can be achieved by descending aorta graft replacement or proximal descending aorta graft replacement plus distal descending aortoplasty based on range of extension. To appropriately dispose aberrant left subclavian artery is the key to avoid left upper limb necrosis and subclavian steal syndrome.