胸主动脉B型夹层腔内修复术后逆向撕裂的外科治疗

Surgical intervention for retrograde type A aortic dissection after endovascular repair for type B aortic dissection

目的回顾分析11例胸主动脉Stanford B型夹层分离行腔内修复术后逆向撕裂为Stanford A型夹层病例，总结其特点及外科治疗经验。方法2005年4月至2008年3月，手术治疗11例腔内修复术后逆向夹层病人。7例发生于支架术3个月内，夹层破121均位于支架附着处，人工血管远端均与支架吻合；4例发生于支架术3个月后，夹层破口与支架距离较远，人工血管远端吻合口与支架无关。结果所有病人均康复出院，随访7-40个月，均生存，无严重并发症。结论发生于腔内修复术后近期（〈3个月）的A型夹层可能与腔内修复术有关，术中人工血管可与支架直接吻合。发生于术后较长时间的A型夹层是否与腔内修复术有关尚需探讨。外科手术治疗可获良好疗效，术中良好的脑保护与远端吻合口处理是手术成功的关键。

Objective The technique of endovascular repair for type B aortic dissection has been widely used because of its advantage of low invasiveness and safety. But the coraphcation of Stanford A dissection during and after this operation owing to retrograde tearing should be highly noticed because of its high mortality despite rarely happened. The present study retrospectively analyzed 11 cases of retrograde type A aortic dissection after endovascular repair for type B aortic dissection. The characteristies and surgical intervontion for these cases were summarized. Methods From April 2（DS to March 2008 , deven cases of retrograde type A aortic dissection after endovascular repair for type B aortic dissection were treated. Among them, 7 cases occurred within 3 months after endovascular repair, the intimal tear of the dissection all happened near the proximal end of the stent graft and the distal end of the vascular prosthesis was all anastomoded with the stem graft. The other 4 cases happened longer than 3 months after ondovascular repair. Neither did the intimal tear of the dissection nor the distal end of the vascular prosthesis correlate with the stent graft. All the patients received median stemomy incision. Selective cerebral perfusion through fight axillary artery under deep hypothermic circulation arrest were used when operating on aortic arch. Results All the cases recovered and were alive after following 7 to 40 months. No serious complications such as stroke, paraplegia or renal failure were found. Conclusion Retrograde type A aortic dissection happened shortly （within 3 months） after endovascular repair may be correlated with stent insertion. The vascular prosthesis can be directly anastomesed with the stent graft. It remains to be further studied whether retrograde type A aortic dissection happened longer after endovascular repair is related with the operation. Favorable effect can be achieved for this kind of patients by surgical treatment. Satisfied cerebral protection and distal anastomosis processing are the key points for the success of the operations.