Stanford B型主动脉夹层的外科治疗

The perioperative analysis of surgery on stanford B aortic dissection

目的总结外科治疗StanfordB型主动脉夹层的初步效果和临床经验，分析影响再次手术的危险因素。方法2009年2月至2011年12月，81例StanfordB型主动脉夹层患者接受外科手术治疗，其中男54例，女27例；年龄19-77岁，平均（41．6±11．7）岁。合并高血压48例，马方综合征15例，主动脉根部瘤7例，主动脉窦部扩张、升主动脉扩张、主动脉缩窄各1例。其中二次手术18例，三次手术4例。对再次手术的相关危险因素进行logistic回归分析。结果主动脉弓部替换加支架象鼻手术（孙氏手术）16例，同期Bentall手术7例，升主动脉替换2例，David手术1例，冠状动脉旁路移植手术1例；胸腹主动脉替换3I例；支架象鼻术24例，同期左锁骨下动脉左颈总动脉转流5例，主动脉瓣置换＋升主动脉成形3例，左锁骨下动脉重建2例，双瓣置换1例，升主动脉降主动脉人工血管转流1例；胸降主动脉替换9例；内漏修补1例。术后2例死于出血致多脏器功能衰竭，均为全胸腹主动脉替换患者，住院病死率2．5％（2／81例）。术后并发症发生率7．4％（6／81例），其中二次开胸止血3例，呼吸功能不全气管切开1例，术后食管瘘开胸探查＋空肠造瘘1例，声音嘶哑l例。全组无截瘫及卒中。Logistic回归分析表明，马方综合征是再次手术的危险因素。结论外科治疗StanfordB型主动脉夹层早期效果满意，中、远期结果需进一步随访。马方综合征是需要再次手术干预的危险因素。

Objective To summarize our clinical experience and results of Stanford type B dissection, and analyzed the risk factors of reoperation. Methods From February 2009 to December 2011, 81 patients （54 male and 27 female） of Stan- ford type B aortic dissection underwent surgical procedure in Beijing Anzhen Hospital. The mean age was 19 -77 years, aver- aged（41.6 ± 11.7 ） years. Associated with hypertension in 48 cases, Malfan syndrome in 15 case, aortic root aneurysm in 7 cases, dilation of aortic sinus and ascending aorta each in one, coaretatiou of the aorta in 1 case. Reoperation was done in 22 cases and 4 of 22 needed the third operation. The risk factors of reoperation were analyzed with Logistic regression analysis. Results Sun g procedure was operated on 16 cases, concomitant procedures included Bentall in 7 cases, David in 1, replace- ment of the ascending aorta in 2 cases, CABG in 1 case. The thoracoabdominal aortic replacement in 31 cases, the descending thoracic aortic replacement in 9 cases, the stented elephant trunk procedure in 24 cases. Concomitant procedures included the bypass from the left subclavian artery to the left common carotid artery in 5 cases, aortic valve replacement and ascending aortic plasty in 3 cases, left subclavian artery reconstruction in 2 cases, double valve replacement in 1 cases, and the bypass from as- cending aorta to descending aorta each in one, repair of internal leakage in 1 case. 2 patients underwent thoracoabdominal aorta replacement died after surgery due to multiple organ failure caused by postoperative bleeding. The hospital mortality was 2.5% （2/81 cases）. Complications occulTed in 6 patients （6/81 cases, 7.4% ） , including diastinal bleeding requiring reoperation in 3 eases, respiratory insufficiency and hoarseness each in one, postoperative esophageal fistula needed reoperation and jejunal fistulization in 1 case. No paraplegia or stroke occurred postoperatively. Logistic regression analysis shows Marfan syndrome is the risk factor of reoperation. Conclusion The surgery on Stanford B aortic dissection can achieve satisfactory clinical results and Marfan syndrome is the risk factor of reoperation. The mid- and long-term results need the further follow-up.