降主动脉移植术在主动脉畸形导致气管或支气管狭窄中的应用

Application of descending aortic translocation in tracheal or bronchial stenosis due to aortic deformity

目的:探讨降主动脉移植术应用于解除主动脉弓部畸形对气管或支气管造成压迫的疗效分析。方法:2017年1月至2019年7月,共应用降主动脉移植术矫治主动脉弓部畸形导致远端气管或近端支气管狭窄11例,术前均行心脏CT及纤维支气管镜检查,中位年龄55(23~540)天,中位体质量4(2.1~9.0)kg。其中特殊类型血管环导致气管或支气管狭窄5例(左弓右降2例、右弓左降3例);外院主动脉弓离断行传统弓部手术后造成左主支气管外压性狭窄2例;主动脉缩窄术后左主支气管狭窄1例;主动脉缩窄术前即有左主支气管狭窄3例;手术方式:左锁骨下动脉远侧离断降主动脉,近端缝闭,远端从右肺动脉及气管隆凸下方穿过,与升主动脉右后侧行端侧吻合,并同期矫治合并心内畸形,如气管狭窄受压解除后无改善同期行气道成形术。结果:全组无死亡,中位体外循环180(136~337)min;中位主动脉阻断51(30~84)min;中位降主动脉阻断34(21~50)min。5例气管受压有效解除,6例因压迫时间长,解除压迫后气管仍软化狭窄、同期行气道成形术,术后均顺利撤离呼吸机,患者呼吸困难症状消失;1例出现降主动脉移植后吻合口狭窄,暂未手术,其余吻合口通畅。随访(18.0±9.4)个月。结论:降主动脉移植术能有效解除主动脉弓部畸形对气管或支气管造成的压迫,中远期效果有待进一步随访。

Objective To investigate the efficacy of descending aortic translocation in relieving the compression of trachea or bronchus caused by aortic deformity.Methods From January 2017 to July 2019,a total of 11 patients with distal trachea or proximal bronchial stenosis caused by aortic deformity were treated with descending aortic translocation.Cardiac CT and fiberoptic bronchoscopy were performed before surgery.The median age was 55(23-540)days,and the body weight was 4(2.1-9.0)kg.Five patients had a special type of vascular ring(left aortic arch with right descending aorta,small aortic window with funnel chest;left aortic arch with right descending aorta and right artery ligament,vagus right subclavian artery,combined with trachea,carina and left and right bronchial stenosis in 1 case;Right aortic arch with left descending aorta,combined with tracheomalacia stenosis in 1 case;Right aortic arch with left descending aorta combined with broad tracheal stenosis and left pulmonary dysplasia in 1 case)compressed tracheal or bronchial tube in 5 cases.Three patients with left main bronchus constriction after traditional arch disconnection surgery.3 patients with left main bronchus stenosis before coarctation or interrupted aortic arch.Surgical methods:Descending aortic translocation was performed through a midline sternotomy with cardiopulmonary bypass and deep hypothermia.The proximal descending aorta was transected distal to the left subclavian artery,proximal sutures were performed,and the distal brought up though the transverse sinus caudad to the right pulmonary artery and tracheal carina,and anastomosed in end-to-end fashion to the ascending aorta,and simultaneous correction was performed with intracardiac malformations,such as airway plasty was performed at the same time without improvement after compression of tracheal stenosis.Results There was no death in the whole group.Median cardiopulmonary bypass was 180(136-337)min with an median aortic cross-clamp time of 51(30-84)min;Median absence of perfusion to the descending thoracic aorta 34(21-50)min.Tracheal compression was effectively relieved in 5 patients,and airway plasty was performed simultaneously in 6 patients due to persistent tracheal softening and stenosis.All patients had resolution of symptoms.There was only one case anastomotic stenosis after descending aortic translocation.The mean follow-up was(18.0±9.4)months.Conclusion Descending aortic translocation can effectively relieve this kind of pressure due to aortic deformity.