孙氏手术治疗急性Stanford A型主动脉夹层

The stented elephant trunk transplantation combined with total arch replacement for acute type A aortic dissection

目的总结急性StanfordA型主动脉夹层采用孙氏手术（主动脉弓部替换加支架象鼻手术）的临床经验与随访结果。方法2004年8月至2012年3月，73例急性A型夹层患者施行了孙氏手术，其中男60例、女13例，平均年龄49．6（26-79）岁。手术均采用深低温停循环、低流量选择性脑灌注技术。单纯行升主动脉替换加孙氏手术30例；主动脉根部替换（Bentall术）加孙氏手术10例，主动脉瓣及升主动脉替换加孙氏手术12例，主动脉瓣成形加孙氏手术21例（同时行主动脉窦重建16例），同期行冠状动脉旁路移植术（CABG）9例，术后通过CTA评价胸腹主动脉塑形及假腔愈合情况。结果体外循环平均（248．1±69．8）min，选择性脑灌注（38．2±10．5）min。手术死亡5例（6．85％，5／73例）。术后60例随访2个月-7．6年，术后3个月CTA复查显示，91．7％的患者主动脉夹层的假腔在膈肌水平形成血栓，患者术后1、5和7年的生存率分别是97％、87％和81％。结论孙氏手术治疗急性A型主动脉夹层安全有效且远期效果令人满意。

Objective To summarize the operative method and follow-up data of total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta （ Sun＇s procedure） for acute Stanford type A aortic dissec- tion. Methods Between August 2004 and March 2012, 73 patients with acute type A aortic dissection underwent this proce- dure. 60 males and 13 females ranging in age from 26 to 79 years （ mean age, 49.6 years）. Right axillary or femoral artery can- nulation was routinely used for cardiopulmonary bypass. Cerebral protection was achieved by bilatero-antegrade or selected brain perfusion. The stented elephant trunk was implanted through the aortic arch under hypothermic circulatory arrest. The stented el- ephant trunk was a 10 cm long self expandable graft. Patent false lumina were evaluated using computed tomography 3 months and once each year after discharge to evaluate the postoperative time course of the residual false lumen. Results Mean car- diopulmonary bypass time was （ 248.1 ± 69.8 ） min, and selected cerebral perfusion time was （ 38.2 ± 10.5 ） rain. Hospital mortality was 6.85% （5/73）. Thrombus obliteration of the residual false lumen in the descending thoracic aorta was observed in 91.7% of the aortic dissections 3 months postoperatively. The mean fallow-up time was （36.4 ± 31.6） months （ range, 2 to 91 months）. Survival at 1, 5, 7 years was 97%, 87% and 81%, respectively. Conclusion Total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta is an effective treatment and a moxe promising choice for acute type A aortic dissection.