一期杂交手术治疗复杂Stanford B型主动脉夹层疗效观察

One-stage hybrid strategy for complicated Stanford B aortic dissection

目的探讨复杂Stanford B型主动脉夹层患者采用一期杂交手术治疗的临床效果及安全性。方法复杂Stanford B型主动脉夹层患者32例,均行头臂血管转流并降主动脉支架型人工血管植入术,记录手术情况及住院期间转归,随访观察远期生存情况。结果 31例顺利完成手术,1例术中支架移位、主动脉破裂死亡。术后即刻主动脉CT血管造影显示28例主动脉夹层破口封闭良好,未见残余漏,左右腋动脉及左颈总动脉转流血管通畅,主动脉弓上分支动脉血液供应良好;1例主动脉近端覆膜支架内漏,再次植入覆膜支架后内漏消失;2例覆膜支架远端未完全覆盖主动脉夹层破口,再次植入覆膜支架后破口封闭良好。31例住院期间均无肾功能衰竭发生,30例顺利出院,1例因急性脑梗死死亡。随访2~128个月,中位随访47个月,30例围术期存活患者中8例死亡,死亡原因分别为双侧腋动脉切口出现感染1例,脑梗死1例,主动脉破裂6例,余22例无转流血管狭窄、覆膜支架内漏;1、5、10年生存率分别为92.3%、74.7%、41.6%。结论一期杂交手术治疗复杂Stanford B型主动脉夹层近期疗效确切、安全性高,其远期死亡原因主要为主动脉破裂。

Objective To investigate the effect and safety of one-stage hybrid strategy in the treatment of complicated Stanford B aortic dissection. Methods Thirty-two consecutive patients with complicated Stanford B aortic dissection underwent one-stage hybrid procedure(TEVAR procedure combined with supra-arch branch vessels bypass). The operation outcomes and in-hospital prognosis were recorded, and the long-term survival rate was followed up. Results In 32 patients, 31 underwent hybrid procedure successfully and 1 died of aortic rupture caused by the displacement of the stent. CT angiography examinations were performed immediately after operation, demonstrating successful exclusions of dissection ruptures with no leakages, unobstructed blood flows in the bypassed vessels in right and left axillary arteries and left common carotid arteries, and well blood supplies of supra-aortic branches in 28 patients;the endoleak of proximal covered stent was successful excluded after re-implantation of the stent in 1 patient;the endoleaks were successful excluded after re-implantation in 2 patients with incomplete exclusions of distal aortic dissection ruptures. No renal failure occurred during hospitalization in 31 patients, 30 of them were discharged uneventfully and 1 of them died of acute cerebral infarction. Thirty discharged patients were followed up for 2 to 128 months, with the median follow-up of 47 months, during which 8 patients died of incision infection of bilateral axillary arteries in 1 patient, cerebral infarction in 1 and aortic rupture in 6;the other 22 patients were found neither obstructive bypassed vessels nor endoleak. The 1-, 5-and 10-year survival rates were 92.3%, 74.7% and 41.6%, respectively. Conclusion One-stage hybrid procedure has a good short-term efficacy and safety for complicated Stanford B aortic dissection. The main cause of long-term death is aorta rapture.