支架象鼻开窗简化急性StanfordA型主动脉夹层手术方式

Simplified surgical procedure of stented elephant trunk fenestration in acute Stanford type A aortic dissection

目的运用支架象鼻开窗技术对急性StanfordA型主动脉夹层主动脉全弓置换术式进行简化，探讨其可行性。方法2008年8月至2011年2月，武汉大学人民医院心血管外科42例急性StanfordA型主动脉夹层患者在深低温停循环，联合双侧顺行脑灌注下行主动脉全弓置换和“开窗”支架象鼻植入术。术中停循环期间，纵行切开主动脉弓，于左颈总动脉和左锁骨下动脉之间横断主动脉弓。降主动脉内置人支架象鼻，直视下行支架象鼻开窗术，完成左锁骨下动脉血运重建，随后采用三分支人工血管完成弓部重建及升主动脉置换。结果手术顺利，平均体外循环时间为（156±42）min、心肌阻断时间（91±18）min、下半身停循环时间（20±5）min，脑灌注时间（33±7）min。全组无死亡，仅2例出现短暂性神经功能障碍。术后无出血再次开胸、声音嘶哑、左上肢感觉运动功能障碍等情况。术后检查左侧桡动脉均搏动良好，双上肢血压压差在正常范围，均痊愈出院。主动脉CT血管造影随访提示：全组左锁骨下动脉血流通畅，支架象鼻开窗处无内漏，支架象鼻植入部位夹层假腔闭合消失。结论应用支架象鼻开窗术对急性StanfordA型主动脉夹层主动脉全弓置换术式进行简化，改善手术视野、简化操作，术中吻合口出血少、止血容易，术后并发症少，近期效果良好。

Objective To study the technical feasibility of simplified total arch replacement via stented elephant trunk fenestration in the treatment of acute Stanford type A aortic dissection. Methods A total of 42 consecutive patients with acute type A aortic dissection underwent total aortic arch replacement plus fenestrate stented elephant trunk implantation under hypothermic cardiopulmonary bypass and bilateral antegrade cerebral perfusion between August 2008 to February 2011. The aortic arch was accessed longitudinally. Transection of aortic arch was performed between left common carotid artery and left subclavian artery. A stented elephant trunk was inserted in descending aorta. Then the reconstruction of left subclavian artery was made by fenestration in stented elephant trunk. Finally 3-branched graft was used to complete the reconstruction of aortic arch. Results Operations were performed successfully. The mean cardiopulmonary bypass （CPB） time was （ 156 ± 42） rain, mean aortic cross-clamp time （91 ± 18 ） rain, mean circulatory arrest time （20 ± 5 ） rain and mean antegrade cerebral perfusion （ACP） time （33 ± 7 ） min. No postoperative death occurred. The incidence of temporary neurological dysfunction was 4.8% （2/ 42）. They underwent neither re-exploration for postoperative hemorrhage nor hoarseness due to recurrent nerve palsy. Left radial arterial pulses were palpable in all of them. None had sensory deficit and dyskinesia of left arm. All their angiographic findings showed complete patency of left subclavian artery. There was neither space nor blood flow around the stented elephant trunk. The false lumen of descending aorta around elephant trunk closed and obliterated in all cases. Conclusions The above-mentioned technique of modified total aortic arch replacement provides a distinct operative field and may achieve simple but reliable anastomosis with less bleeding. Thus aortic arch replacement becomes easier and more effective.