胸主动脉夹层26例的手术治疗

Surgical management for aortic dissection in 26 cases

目的总结26例各型胸主动脉夹层的手术治疗经验。方法 2008年8月至2012年6月手术治疗26例胸主动脉夹层患者,男22例,女4例,年龄36～69岁,平均(51.1±12.9)岁。Stanford分型:A型10例,B型16例。A型中行升主动脉及全弓置换加术中象鼻支架植入术6例,Bentall术1例,升主动脉置换术3例;B型中行降主动脉置换术2例,降主动脉覆膜支架腔内隔绝术(EVGE)14例(其中1例2d后再行腹主动脉置换术)。6例全弓置换脑保护采用深低温停循环(DHCA)加上腔静脉逆行灌注(RCP),1例降主动脉置换下半身供血采用左心转流。术后定期复查CTA。结果 10例Standford A型患者死亡2例(20%),1例术中死于鱼精蛋白反应后大出血,另1例术中出血多,术后第1天死于多脏器衰竭,余治愈出院。16例B型患者死亡1例(6.2%),死于大出血,余均治愈出院。术后CTA显示人工血管血流通畅,支架系统位置良好,无内漏,主动脉真腔较术前明显扩大,未闭的假腔血栓形成。结论手术是挽救主动脉夹层患者的重要手段,手术方式应根据破口特点及主动脉及其瓣膜具体情况来选择。全弓置换采用DHCA+RCP脑保护效果良好。采用EVGE治疗Standford B型夹层手术时间短、创伤小、效果佳。

Objective To summarize the surgical experience of 26 cases with aortic dissection. Methods From August 2008 to June 2012,26 patients with aortic dissection underwent surgery, included 22 males and 4 females, the age was from 36 to 69 years with an average of（51.1 ± 12. 9） years, Stanford A in 10 cases, Stanford B in 16 cases. Surgical procedures in Stanford A cases included ascending and total arch replacement with stent elephant trunk surgery in 6 cases, ascending aortic replacement in 3 cases, Bentall surgery in one case. In Stanford B cases included discending aortic repalcement in 2 cases, thoracic endovascular stent-graft exclusion （EVGE） in 14 cases（abdominal aortic replacement 2 days later in one case）. The brain protections were performed under deep hypothermic circulatory arrest（DHCA）and retrograde cerebral perfusion（RCP）in ascending and total arch replacemem with stem elephant trunk surgery. The follow-up computed tomography angiography （CTA） was examinated regularly. Results Operative mortality was 20% （2/10）in Stanford A cases, one case died of protamine response,the other died of bleeding. Operative mortality was 6. 2% （1/16）in Stanford B cases,died of bleeding. Follow-up CTA displayed artificial vessel were unobstructed, the endovascular stents were fixed well with no leakage, the ture lumen enlarged and false lumen thrombosed and shrinked. Conclusions Surgery is an important method to save the patients with aortic dissection, the choise of surgical procedures depend on the location of intimal tear of aortic dissection. Proper surgical indication, technique and brain protections are the key factors of aortic dissection surgery. DHCA ＋ RCP is an effective brain protection in total arch replacement. EVGE is a minimally invasive, effective, safe surgery in treating Standford type B aortic dissection.