老年Stanford A型急性主动脉夹层的手术治疗

Surgical treatment of Stanford type A acute aortic dissection in elderly patients

目的总结外科治疗老年Stanford A型急性主动脉夹层的临床经验,探讨手术方式及疗效。方法收集2013年6月至2016年9月手术治疗的Stanford A型急性主动脉夹层患者(年龄≥60岁)共24例,均在全麻、深低温停循环加双侧顺行脑灌注下行外科手术。根据病情采用相应术式,其中Bentall术3例;David术1例;部分弓置换+Bentall术3例;全主动脉弓置换+象鼻支架术+Bentall术12例;全主动脉弓置换+象鼻支架术+升主动脉置换5例;同期行冠脉搭桥术3例。结果 24例患者均手术成功,全组体外循环时间(192.9±37.1)min,主动脉阻断时间(120±28.72)min,脑灌注时间(36.2.±11.3)min,手术时间(544.8±91.2)min,术后近期死亡2例,1例死于肾功能不全、感染,1例死于多器官功能衰竭;术后并发脑神经功能障碍2例,肾功能不全行CRRT治疗4例,3例术后脱离呼吸机困难,同时合并肺部感染需行气管切开,术后下肢功能障碍1例,低氧血症3例,切口感染2例。随访2~38个月,其中因心包积液再次入院治疗1例,不明原因猝死1例。结论手术治疗老年Stanford A型急性主动脉夹层可以明显降低死亡率,改善患者生存质量;全主动脉弓置换+象鼻支架置入是治疗Stanford A型急性主动脉夹层的经典术式;根据病情选择恰当的外科处理可获得满意的治疗效果。

Objective To review our surgical treatment experience and analyze the surgical methods and efficacy of Stanford type A acute aortic dissection in elderly patients. Methods We recruited 24 patients aged over 60 years with Stanford type A acute aortic dissection treated surgically with deep hypothermic circulatory arrest and selective cerebral perfusion from June 2013 to September 2016. Depending on the patients＇ conditions, we selected different surgical methods, including Bentall operation in 3 cases, David operation in 1 case, partial aortic arc replacement＋ Bentall operation in 3 cases, total aortic arch replacement＋ stented elephant trunk implantation technique＋ Bentall operation in 12 cases, total aortic arch replacement ＋ stented elephant trunk implantation technique-Fascending aorta replacement in 5 cases, and concomitant coronary artery bypass grafting （CABG） in 3 cases. Results Surgical operation was successful in all the 24 patients. The average CPB time of the all patients was （192.9±37. 1）min, the aortic cross-clamp time was （120 ± 28.72）min, deep lower temperature of cerebral perfusion time was （36.2 ± 11.3）min, and operation time was （544.8± 91.2）min. Soon after the operation, two patients died of multiple organ dysfunction syndrome and renal failure complicated with infection, respectively. Postoperative complications included brain nerve dysfunction in 2 cases; renal insufficiency in 4 cases, which were later treated with CRRT; pulmonary infection and tracheotomy in 3 cases; dysfunction in lower extremities in 1 case; hyoxemia in 3 cases; and incision infection in 2 cases. All the patients were followed up for 2--38 months, one patient was hospitalized because of hydropericardium and another one died of sudden death with unclear cause. Conclusion Surgical treatment of Stanford type A acute aortic dissection can obviously decrease the mortality and improve the quality of life. Total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta is a classic clinical surgical treatment. Precise diagnosis, suitable surgical treatment and post- operative care are all important factors contributing to patients＇ recovery.