全弓置换术治疗老年DeBakeyⅠ型主动脉夹层51例

Total aortic arch replacement fo DeBakey Ⅰ aortic dissection in elderly patients： a report of 51 cases

目的总结全弓置换术治疗老年DeBakeyⅠ型主动脉夹层的临床经验和疗效。方法2008年1月至2013年1月，5l例年龄≥60岁老年Ⅰ型主动脉夹层患者在深低温停循环、双侧顺行脑灌注下行全弓置换术，降主动脉行硬象鼻并开窗重建左锁骨下动脉，主动脉根部采取David术23例，Bentall手术14例；Wheat术4例，单纯升主动脉置换10例，四分支人工血管重建弓部及另外两个分支动脉。结果51例患者死亡4例，1例因心脏无法复跳手术死亡，术后死亡3例。平均体外循环（208．7±36．5）min，心肌阻断（93．5±14．3）min，停循环（40．5±9．5）min。急性肾衰竭行床旁透析4例，气管切开3例，脑梗死1例，3例短暂性脑神经功能异常。47例患者术后复查主动脉CT血管造影术（CTA）示人工血管通畅、无内漏，支架远端降主动脉假腔闭合38例。随访6～57个月后复查CTA45例，胸降主动脉夹层假腔闭合40例，无再次手术。结论全弓置换术治疗老年Ⅰ型主动脉夹层安全有效，合理的术中处理方式是手术成功的关键。

Objective To review the clinical experience and efficacy of total aortic arch replacement for elderly patients with DeBakey Ⅰ aortic dissection. Methods From January 2008 to January 2013, a total of 51 patients aged over 60 years with type Ⅰ aortic dissection underwent total arch replacement surgery in deep hypothermic circulatory arrest with bilateral antegrade cerebral perfusion. The descending aorta was treated by stent elephant trunk technique and fenestration on the trunk to reconstructing the left subclavian artery. The aortic root underwent David surgery in 23 cases, Bentall in 14 cases, Wheat in 4 cases, and simple replacement of ascending aorta in 10 cases. Aortic arch and other two branch arteries were rebuilt by 4-branched artificial vascular graft. Results In 51 patients, 4 cases died , in which 1 case died due to inability of the heart resuscitation in operation, and postoperative death occurred in 3 patients. The mean cardiopulmonary bypass time were （208.7±36.5） min, heart interruption time were （93.5±14.3） min, and circulatory arrest time were （40.5±9.5） min. Patients with acute renal failure were treated by bedside hemodialysis in 4 cases and tracheotomy in 3 cases. There were 1 case with cerebral infarction and 3 cases with transient neurological abnormalities. Postoperative aortic CT angiography in 47 cases showed that artificial vascular patency and no inner leakage in all patients, and the distal false lumen of stent in the descending aorta was closed in 38 cases. Patients were followed up for 6 to 57 months, and postoperative aortic CT angiography in showed that 40 cases with false lumen in descending thoracic aortic dissection were closed in 47 cases. No re-operation in all patients. Conclusions Total arch replacement surgery for senile patients with type Ⅰ aortic dissection is safe and effective. The reasonable operation treatment is the key to successful operation.