单分支支架血管植入技术在急性A型主动脉夹层全弓替换加支架象鼻植入术中的应用

Modified total arch replacement plus stented elephant trunk implantation in acute type A aortic dissection： open single-branched stent graft placement

目的探讨单分支支架血管植入技术简化急性A型主动脉夹层全主动脉弓替换的可行性。方法2008年6月至2009年9月，福建医科大学附属协和医院心外科23例急性A型主动脉夹层患者接受升主动脉及全主动脉弓人造血管替换和单分支支架血管植入术。当体外循环鼻咽温度降至20℃时，停止下半身灌注，横断左颈总动脉并缝闭其近端开口。于左颈总动脉和无名动脉间横断主动脉弓，将单分支支架血管植入近端胸降主动脉真腔内，并将其分支植入左锁骨下动脉。应用三分支人造血管替换升主动脉和主动脉弓，并与无名动脉、左颈总动脉相连接。结果术中均能顺利地植入单分支支架血管。平均体外循环时间、心肌阻断时间、下半身停止灌注时间和选择性脑灌注时间分别为（161±32）、（97±20）、（21±4）和（31±6）min。术后无并发症，均痊愈出院。术后3个月电子束CT检查结果示：主干支架血管和分支支架血管通畅，周围无血流，单分支支架血管植入部位的主动脉夹层假腔闭合。结论应用单分支支架血管直视植入来简化急性A型主动脉夹层全主动脉弓替换是可行的；这种方法避免了常规主动脉弓替换术中较深部位的左锁骨下动脉吻合和左锁骨下动脉远端的远端人造血管一降主动脉吻合。

Objective To explore the feasibility of open single-branched stent graft placement for simplified total arch replacement in acute Stanford type A aortic dissection. Methods Between June 2008 and September 2009, 23 patients with acute Stanford type A aortic dissection underwent total arch replacement plus open single-branched stent graft placement. When core nasophageal temperature dropped to 68 °F, the perfusion to lower body was discontinued. Left common carotid artery was transected at its ostium and its proximal stump closed. The arch was transected at a predetermined line between innominate artery and left common carotid artery. Through a transverse incision, the main stent graft of single-branched stent graft was inserted into true lumen of descending aorta. And the side arm stent graft was positioned into left subclavian artery. The transected stump of arch was reconstructed by inner proximal stent-free Dacron tube of main graft and outer Teflon felt. Subsequently continuous anastomosis was made to a 3-branched Dacron tube graft. Results Open single-branched stent graft placement was technically successful in all patients. The mean cardiopulmonary bypass time, aortic cross-clamp time, lower body arrest time and selective cerebral perfusion time were （ 161 ±32）, （97 ±20）, （21＋4） and （31 ±6） rain respectively. All patients were discharged from hospital without any complication. Their computed tomographic scans at 3 months postoperatively showed that all stent grafts were fully opened and not kinked. There was neither space nor blood flow surrounding the single-branched stent graft. The false lumen of descending aorta around stem graft closed with thrombus in all cases. Conclusion Open single-branched stent graft placement is a new effective technique for simplified total arch replacement in acute type A aortic dissection. With this technique, the left subclavian artery anastomosis and distal aortic anastomosis at descending aorta can be avoided.