一期杂交手术治疗累及主动脉弓远端的降主动脉病变

One-Stage Hybrid Operation for Treating Descending Aortic Diseases Involving Distal Aortic Arch

目的总结一期杂交手术治疗累及主动脉弓远端的B型主动脉夹层及降主动脉瘤的临床经验,探讨一期杂交手术的适应证,分析早期随访结果。方法自2008年10月至2010年5月,北京阜外心血管病医院共有16例累及主动脉弓远端的B型主动脉夹层或降主动脉瘤患者在杂交手术室完成一期杂交手术,其中男12例,女4例;年龄38.0~67.0岁（54.0±9.2岁）。B型主动脉夹层14例,降主动脉瘤累及主动脉弓1例,主动脉弓穿通性溃疡1例。急性发病10例,慢性发病6例。采用颈部切口头臂动脉旁路移植联合股动脉切口逆行主动脉腔内覆膜支架植入,其中左颈总动脉至左锁骨下动脉旁路移植4例,右颈总动脉至左颈总动脉旁路移植11例,右颈总动脉至左颈总动脉及左颈总动脉至左锁骨下动脉旁路移植1例。术后观察患者住ICU时间、住院时间、并发症发生情况;术后3个月、术后1年随访CT资料,观察支架和人工血管通畅情况。结果围术期无死亡和严重并发症发生。所有患者均成功一期完成手术,并植入覆膜支架,术中心血管造影证实各吻合口通畅,支架无明显内漏和移位。有1例患者术后出现轻度偏瘫,经对症处理后迅速好转。术后呼吸机使用时间为2.0~10.0 h（5.3±2.7 h）,住ICU时间0.0~2.0 d（1.1±0.4 d）,住院时间4.0~7.0 d（5.3±0.8 d）,血液制品（包括红细胞、血浆、血小板和白蛋白）使用费用0.0~1 016.5元（134.5±281.8元）。随访16例,随访时间3.0~26.0个月（13.0±5.1个月）,所有患者均生存,恢复正常生活。术后3个月和术后1年复查主动脉增强CT示：支架无移位和内漏,移植的人工血管通畅,远端夹层假腔无明显变化,9例患者支架远端夹层有部分血栓形成。结论一期杂交手术安全、有效,能明显缩短手术时间和住院时间,减轻患者的创伤和痛苦,降低分期手术间隔期的风险,取得了满意的效果;该术式扩大了单纯介入覆膜支架腔内治疗的适应证;杂交手术的中、远期疗效尚须进一步随访。

Objective To summarize the clinical experiences of one-stage hybrid operation for treating type-B aortic dissection and aortic aneurysm involving distal aortic arch,explore the indication for this special technique and analyze short-term follow-up results.Methods From October 2008 to May 2010,16 consecutive patients received one-stage hybrid operation in Fu Wai Hospital for aortic dissection or aortic aneurysm involving distal aortic arch.There were 12 males and 4 females.Their age ranged from 38.0 to 67.0 years（54.0±9.2 years）.There were 14 patients of type-B aortic dissection,1 patient of thoracic aortic aneurysm involving the aortic arch,and 1 patient of penetrating aortic ulcer.Among them,10 were acute ones and 6 were chronic ones.Brachiocephalic artery bypass using neck incision with retrograde endovascular stent graft implantation was used.Four patients received bypass from the left common carotid artery to the left subclavian artery;11 patients underwent bypass from the right common carotid artery to the left common carotid artery;and 1 patient had both of the bypasses.Intensive care unit（ICU） stay,hospital stay,and incidence of complications were closely monitored after operation.Computed tomography（CT） and general condition of the bypass grafts and its blood flow were followed up at three months and one year after operation. Results No death or severe complications occurred peri-operatively.All one-stage surgeries were technically successful with stent grafts implanted.Angiography during the operation showed 100% patency of all the bypass grafts and no obvious translocation or endoleakage of the stent grafts.One patient had mild paraplegia and recovered soon after treatment.Ventilation time of these patients was 2.0-10.0 hours（5.3±2.7 hours）.The ICU stay was 0.0-2.0 days（1.1±0.4 days） and hospital stay was 4.0-7.0 days（5.3±0.8 days）.The expenditure of blood products was 0.0-1 016.5 RMB（134.5±281.8 RMB）.All patients were followed up with a follow-up period of 3.0 to 26.0 months（13.0±5.1 months）.All patients recovered to normal social life.Enhanced CT scanning at three months and one year after operation showed no endoleakage or translocation of the stent grafts and 100% patency of the bypass grafts.There was no obvious change of the distal part of the dissection except some thrombosis formation in nine patients.Conclusion One-stage hybrid operation is safe and effective in shortening the duration of the operation and hospital stay,reducing the surgical trauma and sufferings of the patients,and lowering the risk of staged operations with satisfactory short-term results.This special technique may expand the indications of simple endovascular repair.The mid-and long-term results still need to be followed up.