改良全弓置换术治疗A型主动脉夹层38例

Modified Total Arch Replacement for 38 Patients with Stanford A Aortic Dissection

目的 通过对全弓置换术式进行改进、优化手术程序，以获得更好的早期临床效果。方法 回顾性分析2014年9～12月期间在我院行改良全弓置换术式38例A型主动脉夹层患者的临床资料，其中男26例、女12例，年龄52.5 （21～76） 岁。本术式采用3根动脉泵管，动脉泵管分别连接右锁骨下动脉插管、股动脉插管后进行体外循环，并经由人工血管与左颈总动脉吻合提供同步灌注；待鼻咽温降至26℃，停循环行低流量双侧脑灌注；于降主动脉置入象鼻支架并与四分叉人工血管以及动脉壁吻合，吻合完毕即恢复全身灌注；接着行主动脉根部与人工血管的吻合完成升主动脉重建，最后在心脏跳动后行左锁骨下动脉-人工血管、无名动脉-人工血管吻合。结果38例患者均手术成功，全组停循环低流量脑灌注时间（18.8±4.2） min，升主动脉阻闭时间（86.1±14.2） min，体外循环时间（178.4±71.4） min，术后清醒时间（4.7±2.0） （最短2 h），呼吸机辅助时间（38.7±19.9） h，1例患者因术后并发多脏器功能衰竭死亡；3例术前有肾功损害，术后行血液透析治疗；6例出现一过性神经系统并发症；1例出现双下肢运动功能障碍。随访1～3个月，患者均恢复良好。结论 此改良全弓置换术式缩短了停循环时间、主动脉阻闭时间和体外循环灌注时间，提供充分的内脏灌注，有效地降低脑部并发症和内脏器官损伤。

Objective To achieve a better early clinical result by modifying the total arch replacement and optimizing the procedure of operation. Method We retrospectively analyzed the clinical data of 38 patients patients with stanford a aortic dissection underwent the modifed total arch replacement in our hospital from September to December 2014. There were 26 males and 12 females with a mean age of 52.5 years ranging from 21-76 years. Three artery conduits were adopted during the surgical procedure. Right axillary artery and femoral artery cannulation were performed for cardiopulmonary bypass. The artificial graft and the left common carotid artery was anastomosed to provide simultaneous perfusion. Low rate bilateral brain perfusion began when circulation arrested at 26℃. Reperfusion restoration was obtained after the four-branch vascular graft anastomosed to the stent and aortic wall and completed the implantation of the elephant trunk. Then the aortic root and the vascular graft anastomosis were performed to reconstruct the ascending aorta. At last, the left subclavian artery and innominate artery were anastomosed to the branch of the vascular graft under the beating heart. Result All 38 operations were successful. The mean hypothermic circulatory time of the whole group was 18.8±4.2 min, the time of ascending aorta blocking was 86.1±14.2 min, the time of cardiopulmonary bypass was 178.4±71.4 min, the time of postoperative awakening was 4.7±2.0 h, the time of assisted mechanical ventilator was 38.7±19.9 h. One patient died because of multiple organ dysfunction syndrome （MODS）, 3 patients accepted the hemodialysis, 6 patients suffered from transient neurological dysfunction, 1 patient suffered from paraparesis. There was no further complication during the follow-up of 1-3 months. Conclusion The modified total aortic arch replacement can shorten the circulatory arrest time, cardiac arrest time and cardiopulmonary time, provide effective organ perfusion, and reduce the neurological complication and visceral damage.