Stanford A型主动脉夹层的外科治疗

Surgical Treatment of Stanford Type A Aortic Dissection

目的 分析报道StanfordA型主动脉夹层这一凶险复杂疾病的外科治疗方法。方法 2006年6月至2007年9月采用手术治疗StanfordA型主动脉夹层患者24例，经增强血管CT（CTA）、磁共振扫描（MRI）、心脏彩色多普勒（UCG）确诊。无名动脉或右腋动脉＋腔房管插管建立体外循环，涉及弓部置换的15例均采用深低温（鼻咽温度16～18℃）停循环选择性脑灌注。依据内膜破口位置、夹层累及的部位、有无主动脉瓣关闭不全采用不同的手术方式，其中Wheat术2例、David术1例、Bentall术6例、Bentall术＋半弓置换3例、Bentall术＋全弓置换＋支架象鼻5例（其中合并CABG3例）、升主动脉＋全弓置换＋支架象鼻7例。结果 平均体外循环时间（197．3±28．3）min，平均心肌阻断时间（86．1±10．8）min，深低温停循环选择性脑灌注时间（41．2±8．7）min。死亡2例（8．3％），1例患者出现一过性脑功能紊乱，1例出现声音嘶哑。结论 外科手术治疗StanfordA型主动脉夹层明显降低死亡率。消除假腔、置换病变血管、重建分支血管血供是手术原则和治疗思考顺序。手术治疗加血管内支架植入这一杂交技术成为StanfordA型主动脉夹层的经典术式。

Objective To study the surgical treatment of Stanford type A aortic dissection, a serious and complicated disease. Methods Twenty-four cases of Stanford type A aortic dissection have received surgical treatment from June 2006 to September 2007, and their diagnosis was made by CTA, MRI and UCG. Right iliac or innominant arterial cannulation and eavoatrial cannulation were used to set up cardiopulmonary bypass, and deep hypothermic circulation arrest with selective cerebral perfusion was employed in 15 cases of aortic arch replacement and（or） endovascular stent repair. Different operations were adapted according to the rupture site, dissecting extent and aortic valvular regurgitation： including Wheals opearion （2 cases）, David （one ease）, Bentall （6 cases）, Bentall＋ partial arch replacement （3 cases）, Bentall with arch replacement and stented elephant truck （5 eases）, ascending aorta and arch replacement with stented elephant truck （7 cases）. Results The average CPB time was （197.3±28.3） min, clamp time was （86.1±10.8） min, and circulation arrest time was （41.2±8.7） min. There were 2 deaths （8.30%）. Transient cerebral dysfunction occurred in one patient and voice hoarse in one patient. Conclusion Surgical treatment of Stanford type A aortic dissection significantly reduced the mortality. Surgical principle is first to eliminate false lumen, then to replace dissecting aorta and to reestablish blood supply of aortic branches. The hybrid technique of surgery and stented endovascular repair is becoming the classical procedure for Stanford type A aortic dissection.