“杂交”手术治疗弓部主动脉夹层的疗效评价

Clinical evaluation of hybrid approaches in treating aortic arch dissection

目的:评价人工血管旁路移植术结合腔内隔绝术的"杂交"手术用于主动脉弓部夹层动脉瘤的治疗效果。方法:对12例破口位于主动脉弓部的主动脉夹层动脉瘤患者进行了人工血管旁路移植术+腔内隔绝术的"杂交"手术治疗。评价该方法围手术期死亡率、并发症以及术后桥血管通畅率,进行了6～48(28±11)个月的随访观察。结果:全组1例死亡,原因为等待二期腔内手术期间发生动脉瘤破裂。1例患者因并发医源性升主动脉夹层而改行全主动脉弓置换+支架植入术,随访中1例患者出现90%人工血管狭窄,1例患者出现轻度I型内漏,经18月观察无明显变化,其余患者生存良好,未出现截瘫及其他严重并发症。结论:本文所指的"杂交"手术治疗主动脉弓部夹层动脉瘤具有良好效果。

AIM： To evaluate the clinical follow-up results of treating aortic arch dissection with the hybrid approach of bypass grafting＋thoracic endovascular aortic repair（TEVAR）.METHODS： Between December 2006 and December 2010,12 patients（ten males and two females,average age 50.3 years） with arch dissection were admitted to our institution and were treated with the hybrid approach of bypass grafting＋TEVAR.According to the classification of Criado in 2005,two cases were Z0 dissection,three were Z1 dissection,and seven were Z2 dissection.Comorbidities included aortic valve insufficiency（n=2）,coronary artery disease（n=3）,hypertension（n=10） and aberrant right subclavian artery（n=1）.Mortality and major complication rates and graft patency were evaluated.All patients were followed-up for an average of 28 months（6-48 months） until December 2012.RESULTS： One patient died while waiting for the second-stage TEVAR operation due to aneurysm rupture.One patient converted to total arch replacement＋frozen elephant trunk approach because of iatrogenic ascending aorta dissection.During follow-up,type I endoleak occurred and no obvious changes were seen in the following 18 months in one patient and 90% graft stenosis was observed in another patient.Other patients were followed-up with good stent graft shape,patent blood flow and no stent graft stenosis or migration.There were no severe complications of paraplegia or other central nervous system disorders.CONCLUSION： The hybrid approach of bypass grafting＋TEVAR extends the application field of endovascular technique to the aortic arch and is proven to be effective in treating arch dissections.This hybrid approach avoids the high risk of deep hyperthermia and cardiac arrest and simplifies the procedure.Individualized hybrid approaches should be adopted for aortic arch dissection.