急性主动脉夹层并下肢动脉严重缺血患者的治疗分析

Treatment analysis of patients with acute aortic dissection merged with lower limb severe artery ischemic

目的探讨急性主动脉夹层合并下肢动脉严重缺血患者的治疗效果及安全性。方法收入2013年10月至2015年1月沈阳军区总医院收治的急性主动脉夹层合并下肢动脉严重缺血患者8例,均为男性,年龄(43.6±8.4)岁,分析其治疗策略及疗效。结果 1例Stanford A型主动脉夹层患者合并主动脉瓣关闭不全,行主动脉瓣置换+人工支架象鼻手术;6例Stanford B型主动脉夹层患者行胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR);1例Stanford B型主动脉夹层患者于术前急性肾功能衰竭死亡。Stanford A型主动脉夹层患者于外科术后第4天因多脏器功能衰竭死亡;1例Stanford B型主动脉夹层于TEVAR后次日因急性肾衰竭死亡;余5例顺利出院。术后随访时间(11±5)个月。随访期间3例均病情平稳,血压控制良好,患侧下肢疼痛及麻木感消失,术后恢复良好,无截瘫等事件发生。1例右下肢活动仍受限,1例虽病情相对平稳,但活动后仍存在下肢疼痛症状,于术后6个月植入微创腹主动脉覆膜支架1枚,右髂总动脉至髂外动脉植入金属裸支架1枚。术后患者病情平稳,活动后下肢疼痛症状消失,术后3个月复查主动脉增强计算机断层扫描(CT),主动脉夹层愈合良好,双髂动脉及下肢动脉血流通畅,肾动脉可见一小破口。结论急性主动脉夹层合并下肢动脉严重缺血患者病情危重,围术期病死率高,需加强围术期管理,TEVAR后远期疗效良好。

Objectives To discuss the treatment effect and the safety of patients with acute aortic dissection merged with lower limb severe artery ischcmic. Methods From October 2013 to January 2015, there were 8 patients with acute aortic dissection merged with lower limb severe artery ischemic in Shenyang Military Region General Hospital. All the patients were men with an average age of （43.6±8.4） years old. We analyzed their treatment strategy and effect. Results One case with Stanford type A dissection merged with aortic valve regurgitation was performed aortic valve replacement and artificial support trunk operation; 6 patients with Stanford type B dissection were performed thoracic endovascular aortic repair （TEVAR） ; 1 case with Stanford type B dissection died from acute renal failure before the operation. The patient with Stanford type A dissection died from multiple organ dysfunction syndrome （MODS） 4 days after the operation ; 1 case with Stanford B dissection died from kidney failure the next day after TEVAR ; the other 5 patients left hospital safely. Postoperative follow-up duration was （ 11 ±5 ） months. During the follow-up duration, 3 patients were all steady, and the blood pressure control was good, the pain and numbness of the sick side of the lower limb disappeared, the situation after operation was well without paraplegia and other events. The movement of 1 patient＇s right lower extremity was limited. One patient＇s situation was relatively stable, but felt painful in the lower limb after exercise, and 6 months after operation, he was implanted 1 stent in abdominal aorta, and was implanted 1 stent in right common iliac artery-external iliac artery. The patient＇s situation was stable after operation, and the painful in the lower limb disappeared. Three months after operation, aortic enhancement computed tomography （CT） review showed that aortic dissection healed well, blood flow of bilateral common iliac arteries and lower limb arterieswas good, but there was a small break in the renal artery. Conclusions Patients with acute aortic dissection merged with lower limb severe artery ischemic are critically ill with high mortality. To strengthen the preoperative management can achieve good long-term curative effect of TEVAR.