Stanford-A型主动脉夹层外科治疗的动脉插管策略及评价——附85例报道

Strategy and evaluation of artery cannulation for repair of acute type A aortic dissection: clinical report and reviews of experience of 85 cases

目的回顾上海交通大学附属胸科医院Stanford-A型主动脉夹层外科治疗的动脉插管策略、并发症及转归,分析插管策略的选择及相关并发症的防治。方法 2009年至2011年,共对85例主动脉夹层患者进行了直视手术治疗,分析手术中经由升主动脉、股动脉、腋动脉直接插管和腋动脉人造血管吻合插管建立体外循环的优缺点及中枢神经系统事件、出血、脏器灌注不足等相关并发症的发生率。所有患者中升主动脉置换32例,半弓替换28例,全弓加"象鼻"替换17例,升主动脉替换加去分支技术8例。采用升主动脉、股动脉和右腋动脉插管分别为22(25.9%)、35(41.2%)和28(32.9%)例,其中腋动脉人造血管吻合插管11例。结果住院期间共13例(15.3%)患者死亡,死亡原因分别为无法控制的出血、低心排、肾功能衰竭、肺部感染、脑卒中。并发症中插管部位出血和脑卒中的发生率最高,仅股动脉插管患者有脏器灌注不足发生(3/35,8.5%)。结论根据病变范围和术式及患者的个体化情况慎重选择插管位置,股动脉和锁骨下动脉均可成为可靠的插管部位,通过术前认真评估、术中仔细操作,并发症发生率可控制在较低水平。

Objective To review the cannulation strategies and associated complications in the treatment of acute type A aortic dissection （AAAD） in the Shanghai Chest Hospital, analyze the choice of cannulation site and investigate the etiology and pre）,entive procedures for the complication. Methods We examined data of 85 patients with AAAD, cannulated through ascending aorta, axillary artery （with side graft or direct cannulation） or femoral artery between January 2009 and December 2011. Neurological event, bleeding and malperfusion related to the approach and technique were retrospectively analyzed. Extension of replacement include ascending aorta （with or without aortic valve replacement, n = 32）, hemiarch （n = 28）, total arch （with or without elephant trunk technique, n = 17） and ascending arota with debranch technique （ n = 8）. Arterial access for cardiopulmonary bypass was usually via the ascending aorta in 25.9% （n=22）, femoral artery in 41.2% （n=35） and axillary artery in 32.9% （n=28）, while the axillary artery cannulation was performed using the ＂side graft technique＂ in 21.9% （n = 11 ）.Results The in-hospital mortality rate was 15.3% （n = 13 ） and the cause of death were intractable haemorrhage, low cardiac output, renal failure, pulmonary infection and stroke. Bleeding and stroke were the most common complications associated with cannulation and malperfusion was occurred only in the patients cannulated by fem- oral artery （ 3/35, 8.5% ）. Conclusion Axillary and femoral artery are safe cannulation site, which are tailored to extend of dissec- tion, operative procedure and individual patients status. The perioperative complications can be well controlled by careful assessment and accurate cannulaplacement.