一期全主动脉置换术治疗广泛主动脉瘤样病变早中期结果

Single-stage repair of extensive aortic aneurysms： extended experience with total or subtotal aortic replacement

目的总结一期全主动脉置换术治疗广泛主动脉瘤样病变的早、中期结果和单中心临床经验。方法2004年2月至2011年2月，21例广泛主动脉瘤样病变的患者进行了一期全主动脉或次全主动脉置换术。男16例，女5例；年龄（34±9）岁。病因为高血压10例，马方综合征9例，其他1例；其中20例为主动脉夹层。手术采用深低温停循环顺行脑灌注技术，分段阻断病变主动脉，通过胸部正中切口，应用四分支人工血管依次置换升主动脉、主动脉弓及三支头臂血管。通过胸腹联合切口经腹膜后入路，应用另一四分支人工血管置换全胸腹主动脉至髂动脉分支处。术中对胸（T）6—12肋间动脉和腰（L）1、2动脉行动脉管法原位重建，分别将腹腔干、肠系膜上动脉、左右肾动脉和双侧髂动脉与人工血管主干和分支吻合。结果无术中死亡。术后早期1例死于肾功能衰竭，2例发生脑梗塞但无脊髓损伤所致截瘫和下肢轻瘫。随访18～84个月，出院20例患者均生存。3例重建肋间动脉的动脉管发生闭塞，但无截瘫症状。结论一期全主动脉置换术是治疗广泛主动脉病变安全而有效的方法，患者早、中期生存情况良好。

Objective Retrospectively analyze the mid-term clinical results of single-stage repair of extensive aortic aneurysms with total or subtotal aortic replacement（ T/STAR）. This study describes our experience in this operation in single cen- ter of aortic disease at Fuwai Hospital. Methods From February 2004 to February 2011, 21 patients with hypertension or Marfan syndrome underwent one-stage total or subtotal aortic replacement for aortic dissection or aortic aneurysms. 16 male and 5 female, aged （34 ＋ 9） years. Operations were performed under circulatory arrest with profound hypothermia. Patients were opened with a mid-steruotomy and a thoracoabdominal incision. Extracorporeal circulation was instituted with two arterial can- nulae and a single venous cannula in the right atrium. During cooling, the ascending aorta or aortic root was replaced. At the nasopharyngeal temperature of 20℃, the aortic arch was replaced with selective antegrade cerebral perfusion. Staged aortic oc- clusions allowed for replacement of descending thoracic and abdominal aorta. T6 to T12 intercostal arteries and L1, 2 lumbar arteries were formed to a neo-intercostal artery in place and were connected to an 8 mm branch for keeping spinal cord blood perfusion. Visceral arteries were joined into a patch and anastomosed to the end of the main graft. Left renal artery was anasto- mosed to an 8mm branch or joined to the patch. The other 10 mm branches were anastomosed to iliac arteries. Results Early mortality was 4.8% （1/21 cases）, the only one patient was dead result from renal failure and multiple organ failure. There were no postoperative spinal cord deficits occurred, two patients were stroked at day 5th and 7th respectively. Three patients were operated with tracheotomy because of respiratory insufficiency. Operation was undertaken on one patient with splenenctomy result of spleen rupture during first aortic aneurysms repair. All patients were follow-up, ranging from 18 to 84 months postoperatively, all 20 survivors were alive and had good functional status. One patient was reoperated with aortic valve replacement be- cause of massive valve insufficiency after two years. Neo- intercostal arteries were clogged in 3 patients within follow-up, and two of those patients with Marfan syndrome underwent pseudoaneurysm after intercostal arteries reconstruction. Conclusion Single-stage repair of extensive aortic aneurysms with total or subtotal aortic replacement is safely and effectively. It is feasible with acceptable surgical risks and satisfactory results. It can eliminate the risk of remnant aortic aneurysm rupture in staged total aortic replacement and has satisfactory mid-term results.