解剖外人工血管旁路移植术治疗复杂主动脉缩窄

Extraanatomic aortic bypass grafting for the treatment of complex aortic coarctation

目的总结解剖外人工血管旁路移植术治疗复杂主动脉缩窄48例的手术治疗经验。方法1997年7月至2008年7月，采用解剖外人工血管旁路移植术治疗复杂主动脉缩窄48例。男34例、女14例。年龄10～58岁，平均（30±12）岁。病因有：主动脉缩窄合并心内畸形28例，主动脉缩窄合并升主动脉瘤1例，成人主动脉缩窄合并局部动脉壁钙化7例，主动脉缩窄合并弓发育不良4例，降主动脉长段或多发缩窄4例（各2例），主动脉缩窄合并局部动脉瘤形成1例，主动脉缩窄术后再狭窄合并心内畸形2例，主动脉缩窄介入术后再狭窄1例。手术方式有：升主动脉-腹主动脉旁路移植术37例，升主动脉-心包后胸降主动脉旁路移植术9例，左锁骨下动脉-降主动脉旁路移植术2例。旁路移植术应用直径8—18mm（平均直径16mm）人工血管。同期手术包括主动脉瓣置换术16例，二尖瓣成形或置换术9例，主动脉根部置换术6例，动脉导管未闭缝合术5例，升主动脉成形或置换术4例，室间隔缺损修补术3例，冠状动脉旁路移植术2例。31例于低温体外循环下完成手术。结果住院死亡1例（2．1％），死于术后感染中毒性休克。术后机械性肠梗阻2例，均为升主动脉-腹主动脉旁路移植术后，予开腹探查后痊愈。二次开胸止血3例。术后上下肢平均收缩期压差较术前明显下降，术前（65±27）mm Hg，术后（14±11）mm Hg，差异有统计学意义（P〈0．05）。随访4～73个月，平均28．9个月，无晚期死亡，无人工血管相关并发症，无再次手术。5例患者残余高血压需药物治疗。结论解剖外人工血管旁路移植术是治疗成人及青少年复杂主动脉缩窄的有效方法。升主动脉-腹主动脉旁路移植术可在非体外循环下进行，操作相对容易，应用最多。升主动脉-心包后降主动脉旁路移植术多需体外循环下完成，技术要求高。左锁骨下动脉-降主动脉旁路移植术经左后外切口，适用于无心内畸形的降主动脉缩窄。

Objective To review the experience of extraanatomic aortic bypass grafting for the treatment of complex aortic coarctation. Methods From July 1997 to July 2008, 48 consecutive patients （median age 30 years; range 10 to 58 years） with complex aortic coarctation underwent extraanatomic aortic bypass grafting. Indications include ： （ 1 ） coarctation with intracardiac anomaly （ n = 28） ; （2） coarctation with ascending aortic aneurysm （ n = 1 ） ; （3） adult coarctation with calcification of local aortic wall （ n = 7 ） ; （4） coarctation with hypoplasia aortic arch （ n = 4） ; （5） long or multiple coarctation segment （ n = 4 ） ; （6） coarctation with poststenotic aneurysm （ n=1 ） ; and （7） recurrent coarctation （ n = 3 ）. Routing of the grafts was ： ascending-to- posterior pericardial descending aorta （ n = 37 ） ; ascending-to-infrarenal abdominal aorta （n = 9 ）; left subclavian artery-to-descending aorta （n = 2）. Concomitant cardiac operations were performed in 31 patients （65%） using cardiopulmonary bypass; procedures included： aortic valve replacement in 16 ; mitral valve repair or replacement in 9 ; Bentall procedures in 6 ; patent ductus arteriosus closure in 5 ; ascending aortic replacement or plasty in 4 ; ventricular septal defect closure in 3 and coronary artery bypass surgery in 2. Results There was no operative death. One patient died of septic shock 39 days postoperatively. Two patients received laparotomy because of mechanical ileus shortly after the ascending-tosubrenal abdominal aortic bypass. Mean systolic blood pressure gradient between upper and lower extremities decreased from （ 65 ＋ 27 ） mm Hg preoperatively to （ 14 ＋ 11 ） mm Hg postoperatively （ P 〈 0. 05 ）. During a mean follow-up of 28.9 months, there were no late deaths or graft-related complications. Residual mild hypertension were observed in five patients. Conclusion Extraanatomic aortic bypass is an attractive treatment option for complex aortic coarctation in adults and adolescents. It can be performed with low morbidity and mortality. The midterm results is favorable.