主动脉夹层及主动脉瘤的外科治疗26例

Surgical management of aortic dissection and aneurysm

目的结合主动脉夹层细化分型的临床应用,探讨主动脉夹层及主动脉瘤外科手术治疗的临床经验。方法26例主动脉夹层及主动脉瘤患者,在深低温停循环选择性脑灌注下,行升主动脉加全弓替换4例,全弓替换1例;分段停循环下,行全胸腹主动脉替换术1例;常温阻断加血泵法血液回收股动脉输入法,行降主动脉替换2例,股动脉、股静脉转流降主动脉人工血管替换1例;常规低温体外循环下,行Bentall术6例,Wheat术3例,Bentall加二尖瓣替换1例,Bentall加冠状动脉旁路移植术2例,升主动脉替换1例,升主动脉加部分弓替换1例,主动脉瓣成形加升主动脉替换1例;全麻下带膜支架主动脉腔内修复术2例。结果本组26例,手术早期死亡1例,病死率3.8%;术后并发严重脑功能障碍2例,昏迷时间分别为15 d,30 d,占7.6%。共随访24例,随访率92%,死亡1例。结论Stanford分型的细化对明确手术指征和确立手术预案具有指导意义。四分支人工血管的应用缩短了主动脉阻断时间,结合选择性脑灌注及分段停循环技术,降低了术后并发症。

Objective To summarize the experience in surgical management of aortic dissection and aneurysm. Methods From April 2000 to January 2006,26 patients with aortic dissection or aneurysm underwent operation. Of them 15 were categorized as having Stanford type A aortic dissection,5 Stanford type B, and 6 true aortic aneurysm （ascending aortic aneurysm in 4, aortic arch in 1, and descending aorta in 1 ）. Four patients underwent ascending aorta and aortic arch replacement under deep hypothermic circulatory arrest （DHCA） by selective cerebral petfusion, Onestage total thoracoabdominal aorta replacement was used in one patient under DHCA . Two patients received descending aorta replacement under normal thennic bypass, Bentall procedure was used in six patients （combined with mitral valve replacement in 1 case , with coronary artery bypass graft in 2 cases ）, Wheat procedure was used in three patients . Ascending aorta replacement was used in two patients （combined with partial aortic arch replacement in 1 case and with aortic valvoplasty in 1 case）. The aortic endoluminal stent - graft was used in two patients. Results One patient died, The mortality was 3.8 %. Two patients with postoperative cerebral complication recovered after 15 and 30 days postoperatively respectively,Twenty- four patients were followed up, One patient died during follow- up. Conclusions Subtyping of Stanford aortic dissection is much useful in determing the optimal surgical indication and procedure . The use of four - branch artificial vessel and selective cerebral peffusion remarkably reduces the postoperative complications. The improvement of surgical technique and cardiopulmonary bypass is the key to successfid operation.