主动脉夹层合并下肢灌注不良临床治疗分析

Clinical analysis of aortic dissection with lower limb malperfusion

目的总结主动脉夹层合并下肢灌注不良的治疗经验。方法南京军区南京总医院2010年1月至2015年5月收治伴有下肢灌注不良的主动脉夹层患者13例，回顾分析其治疗方法及近中期随访结果。结果所有患者均接受手术。7例B型夹层患者行胸主动脉腔内修复术（TEVAR），其中4例植入裸支架；6例支架释放后造影见原发破口隔绝，真腔扩张，受累髂动脉显影良好，1例术后右下肢缺血坏死行截肢术，后因多器官功能衰竭死亡。6例A型夹层患者，2例术前评估下肢缺血症状明显，急诊行内膜开窗恢复髂动脉血流，二期行杂交手术；其余4例一期行升主动脉、主动脉弓置换＋降主动脉覆膜支架植入术，术后造影见下肢动脉恢复真腔供血。术后患者存活12例，下肢缺血症状明显缓解。所有患者均获随访，患者无胸背部剧痛及下肢缺血表现，髂动脉显影良好。结论主动脉夹层合并下肢灌注不良应尽早干预，主动脉腔内修复术可消除原发破口，恢复真腔血流，改善大部分患者的缺血症状。

Objective To explore the treatment experience of aortic dissection with lower limb malperfusion. Methods Thirteen patients with aortic dissection complicated by lower limb malperfusion were the subjects, who were admitted to our institution From Jan. 2010 to May.2015. We retrospectively reviewed the short and midterm follow-up results and managements. Results All patients underwent surgery. There were seven patients with Stanford type B aortic dissection received thoracic endovascular aortic repair （TEVAR）, 4 patients needed additional bare stenting. Among them, malperfusion of the iliac artery was improved in 6 cases after closure of the primary entry tear. Another patient died due to multiple organ failure who was performed amputation after the right lower limb ischemic necrosis. In the type A aortic dissection group, emergent fenestration was performed to restore blood flow of the iliac artery in two cases who had serious ischemic symptoms. The remaining four patients received the treatment by hybrid procedure which consisted of ascending aorta replacement, aorta arch branch vascular bypass reconstruction and TEVAR. A total ofS13 cases were followed up, twelve patientsSsurvived without severe chest pain and lower limb ischemia. CT angiography showed unobstructed blood flow of the iliac artery. Conclusion Lower limb malperfusion syndrome is associated with high mortality and should be intervened as soon as possible. Endovascular aortic repair can improve the ischemic symptoms in most patients by covering the proximal entry tear and recovery perfusion of the lower limbs.