复合手术在复杂主动脉弓部病变中的应用

Application of Hybid technique in complex aortic arch lesions

目的:应用主动脉弓部分支血管重建及血管腔内修复技术(杂交技术)治疗复杂主动脉弓部病变,观察围手术期并发症如脑梗死、内漏及夹层逆撕等发生情况,探讨手术时机、弓部分支变异等。方法:回顾性研究2011年3月至2018年6月,复杂主动脉弓部病变患者46例,按病变类型分类,主动脉夹层患者32例(68.2%),弓部壁间血肿4例(9.1%),主动脉弓部瘤患者5例(11.4%),动脉瘤合并夹层患者5例(11.4%),按血管覆膜支架近端在主动脉弓部位置进行分类,Zone 0区患者5例,Zone 1区患者13例,Zone 2区患者28例;观察围手术期脑梗死、夹层逆撕、内漏、淋巴漏、喉返神经损伤、脊髓缺血及弓部解剖变异等情况,随访时间12(2,30.25)个月。结果:术后脑梗死总发生例数6例(6/46,13.0%),其中Zone 0区患者1例(1/5,20%),Zone 1区患者1例(1/13,8%),Zone 2区患者4例(4/28,15%);2例患者出现夹层逆撕情况,均为Zone 2区患者;1例Zone 1患者术后出现淋巴液漏;喉返神经损伤比例约为8.7%(4/46);发病至手术时间Zone 0区180(125,800)h,Zone 1区190(72,330)h,Zone2区100(54,200)h;3例患者(3/46,6.8%)左椎动脉起源于主动脉弓部。结论:杂交手术为治疗主动脉弓部疾病的有效方法,降低了传统体外循环及深低温停循环等方法所带来的风险,但围手术期脑梗死发生率较高;急性期手术未增加风险,手术时机选择应当个体化;椎动脉起源异常为主动脉弓部常见变异。

Objective: To observe the occurrence of perioperative complications such as cerebral infarction, endoleak, retrograde dissection tear, explore the timing of operation, and deal with the variation of some branches of the aortic arch by using partial aortic arch revascularization and endovascular repair technology(hybrid technology) in the treatment of complex aortic arch lesions. Methods: From March 2011 to June 2018, 46 patients with complex aortic arch lesions were retrospectively studied. According to the types of lesions, 32 patients with aortic dissection(68.2%), 4 patients with arch wall hematoma(9.1%), 5 patients with aortic arch aneurysm(11.4%) and 5 patients with aneurysm and dissection(11.4%). Classification according to proximal position of covered stent in aortic arch, there were 5 patients in Zone 0 area, 13 patients in Zone 1 area and 28 patients in Zone 2 area. The perioperative cerebral infarction, retrograde dissection, endo-leak, lymphatic leakage, recurrent laryngeal nerve injury, spinal cord ischemia and arch anatomical variation were observed. The follow-up period was12(2,30.25)months. Results: There were 6 cases(6/46, 13.0%) of cerebral infarction after operation, including 1 case(1/5, 20%) in Zone 0 area, 1 case(1/13, 8%) in Zone 1 area and 4 cases(4/28, 15%) in Zone 2 area, 2 cases with retrograde dissection were all Zone 2 area patients, 1 case with lymphatic leakage after Zone 1 operation, the proportion of recurrent laryngeal nerve injury was about 8.7%(4/46), and the time from onset to operation was 180(125,800)hours in Zone 0 area, 190(72,330)hours in Zone 1 and100(54,200)hours in Zone 2. Three patients(3/46, 6.8%) had left vertebral artery originating from the aortic arch. Conclusions: Hybrid surgery is an effective method for the treatment of aortic arch diseases, which reduces the risk of traditional cardiopulmonary bypass and deep hypothermic circulatory arrest, but the incidence of cerebral infarction is not infrequently during perioperative period;the operation risk is not increased in acute period, and the timing of operation should be individualized;the abnormal origin of vertebral artery is a common variation of aortic arch.