164例胸部主动脉瘤的治疗

Treatment of 164 cases of thoracic aortic aneurysm

目的总结胸主动脉瘤的诊断和血管置换的方法及主动脉腔内隔绝术的应用。方法1995年12月至2006年12月对164例胸部主动脉瘤进行治疗，男117例，女47例；年龄27～77岁，平均54岁。其中马方综合征49例，DeBakeyⅠ型夹层动脉瘤38例，Ⅱ型18例、Ⅲ型59例。心功能（NYH分级）Ⅰ级35例，Ⅱ级55例，Ⅲ级58例，Ⅳ级16例。对马方综合征采用胸部正中切口，中低温体外循环下行Bentall手术（44例）和Wheat手术（5例）；38例DeBakeyⅠ型主动脉夹层瘤行升主动脉加全弓部血管置换术30例，升主动脉加半弓血管置换8例，其中行全胸段主动脉血管置换2例、Wheat手术25例、主动脉瓣成形术3例；59例降主动脉夹层瘤中36例经左后外侧胸部切口、左心转流下或自体血液转流下行降主动脉瘤切除、人工血管置换术；23例由采用介入的方法经股动脉置入降主动脉覆膜支架行腔内隔绝治疗。结果围术期死亡6例，余者痊愈出院。142例随访3个月～9年10个月，3例随访期内死亡，余均健康生存。结论对于胸主动脉夹层瘤应采用积极的外科治疗方法。全弓血管置换应用双侧颈动脉灌注对脑的保护效果确切，术中应用改良象鼻手术可以简化手术操作，Ⅲ型夹层瘤应用覆膜支架行腔内隔绝治疗是安全有效的方法。

Objective To summarize the diagnosis methods,artificial vessel replacement techniques in thoracic aortic aneurysm and clinical application of endovascular stent graft exclusion,Methods From December 1995 to December 2006,164 patients（117 males and 47 females）,aging from 27 to 77 years old（average 54）,with thoracic aortic aneurysm undergoing surgical treatment were re- viewed.Forty-nine of them were categorized as having Marfan syndrom,38 DeBakey typeⅠ,18 DeBakey typeⅡ,and 59 DeBakey typeⅢaortic dissection.Accoding to NYHA heart function classification, 35 cases were in Grade 1, 55 in Grade Ⅱ, 58 in Grade Ⅲ and 16 in Grade Ⅳ. Forty-nine patients with Mafan syndrom recieved moderate hypothermia cardiopulmonary bypass operation via median thoracic incision, among them Bentall procedure was applied in 44 cases and Wheat procedure in 5 cases. Thirty of the 38 patients suffering from DeBakey type Ⅰ aortic dissection underwent ascending aorta and total aortic arch replacement and 8 underwent ascending aorta and semi-aortic arch replacement. Among the 38 patients, 2 underwent total thoracic aortic artifical vessel replacement, 2 underwent Wheat procedure, and 3 underwent aortic valvuloplasty. 36 cases of the 59 patients with DeBakey type Ⅲ arotic dissection underwent desending aortic aneurysm resction and artificial vessel replacemint via left posterolateral thoracic incision, using left heart bypass or aorta to artery bypass （using Cott tubes）. The other 23 patients underwent endovascuclar stent graft exclusion in descending aorta via femoral artery. Results 6 cases died in perioperative period. The survivors were followed up 3 to 118 months, among them 3 died long-term after operation and the others were living healthily. Conclusion Aggressive apphcation of surgical treatment improves the clinical outcomes in patients suffering thoracic aortic dissecting aneurysm. Bilateral perfusion via carotid artery in total aortic arch replacement exhibited confidential cerebral protective effect. Operative procedures were simplified when using modified elephant trunk technique Endovascular stent graft exclusion in the treatment of DeBakey type Ⅲ aortic dissection is safe and effective.