急性复杂型Stanford A型主动脉夹层的外科治疗

Surgical treatment for complicated acute Stanford type A aortic dissection

目的：评价急性复杂型Stanford A 型主动脉夹层手术中改良双侧选择性顺行脑保护的效果及升主动脉插管、左锁骨下动脉（LSA）“开窗”技术对手术风险的影响。方法122例急性复杂型Stanford A 型主动脉夹层患者行改良全主动脉弓置换加降主动脉内支架象鼻植入术，按照脑保护及动脉供血管插管方式分为单侧脑保护组与改良双侧脑保护组及右锁骨下动脉（RSA）插管组与主动脉插管组，比较各组的手术方式、死亡率及并发症率。部分患者采用左锁骨下动脉“开窗”技术重建血运。结果单侧脑保护组与改良双侧脑保护组总的院内死亡率分别为5．77％、2．86％，差异无统计学意义（P值为0．650）；神经系统总并发症率分别为26．92％、10．00％，差异有统计学意义（P值为0．014）。右锁骨下动脉插管组与升主动脉插管组总的院内死亡率均为4．55％，总并发症率分别为15．9％、15．2％，差异均无统计学意义（P值分别为1、0．914）。左锁骨下动脉“开窗”者术后多次复查CTA左锁骨下动脉均通畅，无左锁骨下盗血综合征发生，1例出现无需处理的少量内漏。结论改良双侧选择性顺行脑保护安全、可行、可靠；选择升主动脉插管符合生理、操作简捷，不增加手术风险；左锁骨下动脉“开窗术”简化了手术，缩短了深低温停循环时间，增加了手术安全性。

Objective To evaluate the effects of modified bilateral antegrade selective cerebralperfusion and surgical risks of ascending aorta cannulation and fenestration of the left subclavian artery（LSA）for complicated acute Standford type A aortic dissection.Methods A total of 122 consecutive patients with complicated acute Standford type A aortic dissection received modified aortic arch replacementand stented elephant trunk implantation in the ascending aorta.According to the methods of intubation andcerebral protection,patients were divided into the unilateral and bilateral cerebral protection groups andright subclavian artery（RSA）and aorta intubation groups,respectively.Surgical procedures,mortality rateand complication rate were compared between groups.Fenestration of the LSA was used to reconstruct thecirculation in some patients.Results The inhospital mortality rates of unilateral and bilateral cerebralprotection groups were 5.77% and 2.86%（P =0.650）and their neurological complication rates were26.92% and 10.00%（P =0.014）,respectively.The inhospital mortality rates of RSA and ascending aorta cannulation groups were both 4.55%（P =1）,and the complication rates were 15.9% and 15.2%（P =0.914）,respectively.Multiple reexaminations of CTA were carried out in patients receiving fenestration of the LSA,and no signs of subclavian steal syndrome were revealed.Only one patient had minor leakage and it did not need futher management.Conclusion Modified bilateral antegrade selective cerebralperfusion is a safe,feasible and reliable method.Ascending aorta cannulation is both physiological and simple without increasing surgical risks.Fenestration of the LSA can simplify procedures,shorten deep hypothermic circulatory arrest and increase surgical safety.