Stanford A型主动脉夹层的外科治疗

Surgical treatment of Stanford type A aortic dissection

目的探讨Stanford A型主动脉夹层的外科治疗经验、手术时机和手术方法。方法回顾分析我科2004年1月至2010年1月外科治疗26例Stanford A型主动脉夹层的临床资料。其中升主动脉与根部置换术(Bentall手术)9例(1例行冠状动脉旁路移植术),升主动脉置换术5例,升主动脉置换+全弓置换+降主动脉支架植入术8例,升主动脉置换+半弓置换术4例。结果术后早期死亡3例,死亡原因分别为严重心律失常、多器官功能衰竭、脑死亡合并循环衰竭。术后发生呼吸功能不全2例,二次开胸止血3例,急性肾功能衰竭2例,延迟苏醒1例。随访18例患者,2例死亡,其余16例术后生活质量良好。结论外科治疗是降低Stanford A型主动脉夹层病死率的关键,手术原则为切除内膜破口及易破裂的部分主动脉,修复剥离内膜,用人工血管移植、成形或置换,重建主动脉管道,并同期处理合并的心脏瓣膜、心肌缺血病变。根据夹层破口的位置、累及范围、主动脉瓣及根部增宽情况来选择相应的术式,可为患者提供有效的治疗手段,降低死亡率。

OBJECTIVE To explore the surgical experience,timing of operative intervention,technique and clinical effects of surgical treatment for Stanford type A aortic dissention.METHODS The clinical materials and methods of operation were retrospectively reviewed for 26 patients with Stanford type A aortic dissection from Jan.2004 to Jan.2010.Replacement of the ascending aorta and the aortic root（Bentall operation） was performed in 9 cases,replacement of the ascending aorta in 5,replacement of the ascending aorta and total aortic arch combined with stented elephant trunk implantation technique in 8 and replacement of the ascending aorta and half aortic arch in 4.RESULTS There were 3 early postoperative deaths because of severe arrhythmia,multiple organ failure or brain death combined with circulatory failure.The other postoperative complications were respiratory failure（2 cases）,bleeding（3 cases）,acute renal failure（2 cases） and delayed recovery（1 case）.There were 2 later deaths and other 16 patients had good life quality during 2 months to 5 years follow-up for 18 patients.CONCLUSION Surgical treatment is critical for Stanford type A aortic dissention to reduce the mortality.The main principle of surgical therapy is to resect the tear and the aortic segment at risk,repair the dissected intima,replace or reconstruct the aorta with composite graft and simultaneously deal with the valve and myocardial ischemia disease.It can provide patients with effective treatment and reduce the mortality rate to choose a proper procedure depending on the diseased segment of the aortic and the condition of aortic valve and root.