累及弓部的B型夹层及弓部动脉瘤的手术方式探讨

Discussion on operation method about Stanford type B aortic dissection and aneurysm involving aortic arch

目的 讨论累及弓部的B型夹层及弓部动脉瘤手术方式及疗效.方法 总结15例病例,其中男性13例、女性2例,年龄32～75（48.17±10.62）岁,发病时间3d至3个月.13例为复杂型Standford B型夹层.2例行Hybrid手术,其中l例累及无名动脉,升主动脉未累及,在体外循环并行下行头臂干及左颈总动脉与三分支血管转移至升主动脉,1例累及左锁骨下动脉但左侧椎动脉起源于主动脉弓部,在非体外循环下行头臂干及左颈总动脉转移至升主动脉;11例行TEVAR＋烟囱手术,其中1例累及左颈总动脉,行双烟囱手术治疗.2例主动脉弓部瘤均行Hybrid手术.1例为主动脉多发弓部瘤,瘤体位于无名动脉近心端,升主动脉未受累,在非体外循环并行下行头臂干及左颈总动脉与三分支血管转移至升主动脉;1例瘤体累及左颈总动脉,行右侧腋动脉-左侧颈总动脉转流术.结果 15例手术均成功.手术时间（142±53）min,1例体外循环时间75 min,术后住院时间（16±5）d.1例“烟囱”术后出现Ⅱ型内漏（9.1％）,术后3个月复查CTA提示内漏闭合.术后均无特殊并发症,治愈出院,现均存活.术后1、3、6个月,1、2年行CTA复查,显示夹层假腔内血栓机化,真腔内径扩大,旁路血管通畅,无狭窄或闭塞.结论 TEVAR＋烟囱技术及Hybrid技术的综合应用,是处理复杂累及弓部主动脉瘤的方法,并且可以在损伤较小的情况下减少致残率及死亡率,但远期疗效需要进一步观察.

Objective Discussion on operation method about Stanford type B dissection and aneurysm involving aortic arch.Methods 15 cases were summarized,including 13 males and 2 females,aged from 32-75 （48.17±10.62）years old.13 cases were complicated with B Stanford type,2 cases of aortic arch aneurysm,onset ranges from 3 days to 3 months.13 cases of complicated Stanford B dissection;hybrid operation in 2 cases.1 case involving the innominate artery,ascending aorta were not involved,be in extracorporeal circulation parallel downward brachiocephalic stem and left common carotid artery and branch vessels transferred to the ascending aorta.1 case involving the left subclavian artery but the left vertebral artery originated from the aortic arch,be in off-pump brachiocephalic stem and left common carotid artery to ascending aorta.11 cases underwent TEVAR＋chimney operation.Including 1 cases of left common carotid artery,which were treated with double chimney operation.In 2 cases aortic arch aneurysm underwent hybrid operation;1 case of aortic arch aneurysm,involving the proximal end of innominate artery,ascending aortic is not involvement,be in off-pump parallel downward brachiocephalic stem and left neck total artery and branch vessels transferred to the ascending aorta;1 case involving the left neck total artery,be the right axillary artery and left common carotid artery bypass.Results 15 cases were successful,operation time （142±53）min,1 cases of cardiopulmonary bypass time 75 min,postoperative hospital stay （16±5）d.1 cases of ＂chimney operation＂ after the operation had type Ⅱ leakage （9.1%）,3 months after the review of CTA scan show within the closure of leakage.There were no special complications,cured and discharged from hospital.After 1,3,6 months,1,2 years to be performed CTA review,showing the dissection of false lumen reduced,true lumen diameter expansion,bypass vascular patency,without stenosis or occlusion.Conclusion TEVAR ＋ chimney technology and hybrid technology is good method to deal with the complex involvement of aortic aneurysm,and with less damage,to reduce morbidity and mortality,but long-term effect needs further observation.