老年Stanford A型主动脉夹层外科治疗

Surgical Treatment of Stanford Type A Aortic Dissection in Elderly Patients

目的：总结老年Stanford A型主动脉夹层外科治疗经验,探讨手术方式的选择,以提高手术疗效。方法：2008年9月至2011年5月对31例老年Stanford A型主动脉夹层行手术治疗,根据夹层破口位置、累及范围、主动脉根部病变情况采取相应术式,W-heat手术2例,David＋全弓置换＋支架象鼻术3例,Bentall＋全弓置换＋支架象鼻术9例,改良Wheat＋全弓置换＋支架象鼻术1例,升主动脉＋全弓置换＋支架象鼻术16例。同时行冠状动脉旁路移植术4例,心包剥脱术1例。结果：全组体外循环（221±43）min,平均心肌阻断（132±41）min,深低温停循环（47±12）min。术后并发症12例（38.7%）,其中2例死亡,8例治愈（66.7%）,2例术后出现肾功能衰竭家属放弃治疗。全组病人出院前复查主动脉CTA,见升主动脉、弓部人工血管血流通畅,支架位置正常,无明显移位。支架远端降主动脉假腔闭合率87.1%。随访2~35个月,术后近期死亡1例（3.2%）,无再次手术者。结论：对老年StanfordA型主动脉夹层这一高危人群,术中根据其病变部位施行最佳的外科手术方式,可明显降低死亡率,改善患者预后。

Objective： To review surgical treatment experience of type A aortic dissection in elderly patients. Methods： A retrosp- ective analysis from September 2008 to May 2011 were treated in hospital aged Stanford A aortic dissection patients with 31 cases. Different surgical approaches were adopted according to the rupture site, sufferred extent of dissection, lesions situation of aortic root, including Wheat operation in 2 cases, David＋total arch＋stented elephant trunk implantation technique in 3 cases, Bentall＋total arch＋stented elephant trunk implantation technique in 9 cases, modified wheat＋ total arch＋ stented elephant trunk implantation technique in 1 case, ascending aorta＋total arch＋stented elephant trunk implantation technique in 16 cases, concomitant procedures were coronary artery bypass grafting （CABG） in 4 cases, pericardiectomy in 1 case. Results： The average CPB time of all patients was （221 ± 43 ）min; the aortic cro- ss-clamp time was （ 132± 41 ）min, deep lower temperature of the selective cerebral perfusion time was （47± 12 ）min. The in-hospital m- ortality wag 6.5%. 2 cases occure multiple organ failure after operation, family members of patients give up treatment and discharged. Review of the aorta CTA before discharge, see blood of ascending aorta and arch is unobstructed, the site of stented elephant trunk is nor- mal, no obviously displacement. The closure rate of descending thoracic aortic dissection false lumen was 87.1%. Followed 2-35 months, lease death （3.2%）, no re-operation patients. Conclusion： Precise diagnosis, suitable surgical treatment and carefully care postoperation are all important factors contributing to aged Stanford A aortic dissection patients＇ recovery.