Kommerell憩室合并主动脉夹层的外科治疗策略

Surgical strategy for treatment of Kommerell's diverticulum associated with aortic dissection

目的总结Kommerell憩室合并主动脉夹层的外科治疗策略。方法2012年11月至2018年1月,4例Kommerell憩室患者合并主动脉夹层接受手术,均为男性,年龄40~49岁,中位值44岁。患者均为右位主动脉弓合并迷走左锁骨下动脉,A型夹层1例,B型夹层3例(1例慢性)。A型夹层患者接受Bentall手术+全主动脉弓置换+象鼻支架置入术;3例B型夹层患者分别接受2型杂交全弓修复、升主动脉+全主动脉弓置换+象鼻支架置入术+胸主动脉支架置入术和升主动脉至降主动脉置换术。结果无手术死亡。呼吸机辅助13~485 h,中位值229 h;ICU停留2~27天,中位时间12天。住院死亡1例,术后出现右主支气管严重受压狭窄,术后17天因呼吸循环衰竭死亡。1例术后因气管分叉轻度受压出现刺激性咳嗽,出院前症状自行缓解。1例术后发生危重病性多发性周围神经病,经保守治疗后好转。3例出院患者已随访4、15、36个月,均生存。A型夹层患者象鼻支架远端降主动脉扩张,再次介入手术置入支架;2例B型夹层患者复查CT均显示人工血管形态良好,无吻合口瘘及假性动脉瘤形成,分支血管通畅。 结论 Kommerell憩室合并主动脉夹层需根据分型决定治疗方式,外科手术结合介入支架治疗效果确切。

Objective To summarize the experience and strategy of surgical treatment of Kommerell diverticulum and related aortic dissection aneurysm.Methods From November 2012 to January 2018, 4 patients(all males), with median age of 44(from 40 to 49) years old, underwent surgical treatment in our institution . All the patients had right-sided aortic arch and aberrant left subclavian artery. One patient had type A aortic dissection and other 3 had type B aortic dissection(one had chronic type B dissection). The patient with type A aortic dissection had Bentall procedure plus total arch replacement and frozen elephant trunk implantation. One patient with chronic type B aortic dissection received type 2 hybrid aortic arch repair. One patient with acute type B aortic dissection had ascending aorta and total arch replacement plus frozen elephant trunk implantation followed by TEVAR. The last patient underwent graft replacement of aorta, total arch and descending thoracic aorta.Results There was no operative mortality. The median mechanical ventilation time was 229(from 13 to 485) hours, the median ICU stay was 12(from 2 to 27) days. One patient died from respiratory and circulatory failure due to compression of left main bronchus on the 17th day after operation. One patient had irritating cough due to mild compression of bifucation of trachea and the symptom resolved spontaneously before discharge .One patient had critical illness polyneuropathy after operation and received mechanical ventilation therapy for 485 hours. He recovered through neurotrophic drug treatment. The median follow-up time is 15(from 4 to 36) months. The patients with type A dissection had delayed dilation of descending thoracic aorta beyond the frozen elephant trunk and received TEVAR 6 months later. The CT scans of the other two patients during follow-up time showed good morphology and patency of graft and branches. There was no anastomotic leakage and pseudoaneurysm.Conclusion The decision making of treatment of Kommerell diverticulum and related aortic dissection should be on the basis of classification of aortic dissection. Operation combined with TEVAR is safe and effective.