不同主动脉断端加固方法在急性Stanford A型主动脉夹层手术中的应用

Different End-to-end Anastomotic Methods for Surgical Treatment of Acute Stanford Type A Aortic Dissection

目的总结不同主动脉断端加固方法在主动脉夹层手术中的应用及其效果。方法2012年1月至2013年5月，共有95例主动脉夹层在南京医科大学附属南京医院接受手术治疗。根据主动脉断端的加固方法不同，将其中72例患者（23例Bentall手术患者未纳入本研究）分为3组，A组：23例，男18例、女5例，年龄（48．67±9．23）岁，其中主动脉壁内外均使用毛毡条行“三明治”加固；B组：11例，男8例、女3例，年龄（48．00±9．17）岁，仅主动脉内膜内侧使用心包条加固；C组：38例，男29例、女9例，年龄（49．20±8．57）岁，主动脉断端不进行任何加固，与人工血管直接吻合。分析并比较3组患者的术后转归情况。结果术后住院死亡8例[其中A组1例（4．35％，1／23），C组7例（18．42％，7／38）]，住院死亡率11．11％。1例（A组）死于创面广泛渗血，最后出现弥散性血管内凝血；3例（均为C组）死于术后针眼、吻合口广泛渗血，循环不能维持；4例（均为C组）术后三尖瓣重度反流，继发严重低心排血量综合征，最终导致多脏器功能衰竭而死亡。术后严重并发症包括肾功能衰竭5例，呼吸功能不全7例，严重脑梗死致偏瘫1例，轻瘫3例，延迟苏醒2例，下肢缺血坏死1例。术后胸腔引流量C组最多，A组胸腔引流量与B组比较差异无统计学意义。随访64例，随访时间1～6个月。随访期间无死亡。5例肾功能衰竭患者中只有1例定期行血液透析治疗，其余4例患者肾功能均恢复正常；1例脑梗死患者肢体功能部分恢复，可以拄拐行走；3例轻瘫患者肢体功能均恢复正常。结论主动脉夹层断端的吻合质量异常重要，术中可根据具体情况选择合适的加固方式；使用毛毡条行“三明治”加固可以减少吻合口渗血，预防吻合口撕裂所致急性心肌梗死的发生，降低术后死亡率；若主动脉夹层剥离累及冠状动脉开口，需同期行冠状动脉旁路移植术。

Objective To summarize clinical outcomes of different end-to-end anastomotic methods for surgical treatment of acute Stanford type A aortic dissection （AD）. Methods Between January 2012 and May 2013, 95 patients with acute Stanford type A AD received surgical treatment in Nanjing Hospital Affiliated to Nanjing Medical University. According to different end-to-end anastomotic methods, 72 patients were divided into 3 groups （23 patients undergoing Bentall procedure were excluded from this study）. In group A, there were 23 patients including 18 males and 5 females with their age of 48.67±9.23 years ,who received ＇sandwich＇ anastomotic technique strengthening both the inner and outer layers of the aortic wall. In group B, there were 11 patients including 8 males and 3 females with their age of 48.00± 9.17 years, who received pericardium strengthening only inner layer of the aortic wall. In group C, there were 38 patients including 29 males and 9 females with their age of 49.20 ± 8.57 years, who received artificial graft that was anastomosed directly to the aortic wall without any reinforcement. Postoperative outcomes were compared among the 3 groups. Results Eight patients （11.11%） died postoperatively including 1 patient in group A （ 1/23, 4.35%） and 7 patients in group C （7/38, 18.42%）.One patient in group A died of persistent wound errhysis and later disseminated intravascular coagulation. Three patients in group C died of persistent anastomotic incision errhysis and circulatory failure. Four patients in group C died of postopera- tive severe tricuspid regurgitation, secondary severe low cardiac output syndrome and multiple organ dysfunction syndrome. Severe postoperative complications included renal failure in 5 patients, respiratory failure in 7 patients, severe cerebral infarction and paralysis in 1 patient, paresis in 3 patients, delayed recovery of consciousness in 2 patients, and ischemic necrosis of the lower limb in 1 patient. Postoperative thoracic drainage amount in group C was significantly larger than that of the other 2 groups, and there was no statistical difference in thoracic drainage amount between group A and group B. Sixty-four patients were followed up for 1 to 6 months, and there was no late death during follow-up. Among the 5 patients with postoperative renal failure, only 1 patient needed regular hemodialysis, and renal ftmction of the other 4 patients returned to normal. One patient with cerebral infarction recovered partial limb function and was able to walk with crutches. All the 3 patients with paresis recovered their limb fimction. Conclusions Anastomotic quality of end-to-end anastomosis is of crucial importance for surgical treatment of acute Stanford type A AD. Appropriate reinforcement methods can be chosen according to individual intraoperative findings. ＇Sandwich＇ anastomotic technique can significantly reduce incision errhysis, prevent acute myocardial infarction caused by aortic anastomotic tear, and decrease postoperative mortality. If coronary ostia are involved in AD, concomitant coronary artery bypass grafting is needed.