经胸骨上窝复合手术治疗复杂主动脉弓部病变单中心十年回顾

Application of hybrid surgery through suprasternal fossa incision in complex aortic arch lesions:A ten-year single-center review

目的:应用胸骨上窝切口血管旁路结合腔内技术治疗复杂主动脉弓部病变,探讨此方法在弓部病变临床应用的技术特点。方法:回顾性研究2010年11月至2021年7月共72例复杂主动脉弓部病变患者,平均年龄(52.9±10.7)岁,支架锚定Zone 2区61例,Zone 1区11例;其中主动脉夹层57例(79.2%),弓部壁间血肿3例(4.2%),主动脉弓部瘤6例(8.3%),动脉瘤合并夹层6例(8.3%);同期手术60例,二期手术12例;所有患者均经胸骨上窝切口行血管旁路手术;观察切口相关性淋巴漏、神经损伤、感染,支架内漏、术后脑梗、桥血管通畅等并发症发生情况,随访平均时间40月(1~120月)。结果:围手术期死亡1例(1/72,1.4%),术后血管旁路相关脑梗3例(3/72,4.2%),喉返神经损伤比例为6.9%(5/72);4例(5.5%)术后出现切口淋巴液漏;早期Ⅰ型内漏发生率为11.1%(7/72),晚期Ⅰ型内漏总发生率为4.2%(3/72);2例患者术后出现夹层逆撕,均为Zone 2区患者;术后有1例转流血管闭塞(1/72,1.4%)。结论:改良的经胸骨上窝切口血管旁路复合手术治疗复杂主动脉弓部病变具有旁路血管通畅率高,中远期效果佳,术中需注意避免淋巴管及喉返神经损伤。

Objective:To investigate the clinical characteristics of the vascular bypass through superior sternal fossa incision combined with thoracic endovascular aortic repair(TEVAR)in the treatment of complex aortic arch lesions.Methods:From November 2010 to July 2021,a total of 72 patients with complex aortic arch lesions were retrospectively studied,with an average age of(52.9±10.7)years.According to the classification of stent anchoring area,61 cases were anchored in zone 2 and 11 cases in zone 1.There were 57 cases with aortic dissection(79.2%),three with intramural hematoma of arch(3/72,4.2%),six with aortic arch aneurysm(6/72,8.3%),and five with dissection aneurysm(6/72,8.3%).All vascular bypass was performed through suprasternal fossa incision.Complications such as incision related lymphatic leakage,nerve injury,infection,stent endo-leak,postoperative cerebral infarction and bypass vascular patency were observed.The mean follow-up time was 40 months(1 month to 120 months).Results:Only one death occurred during perioperative period(1/72,1.4%).The proportion of recurrent laryngeal nerve injury was 6.9%(5/72),incision related lymphatic leakage occurred in 4 cases(5.5%).The incidence of early typeⅠinternal leakage was 11.1%(7/72),and that of late typeⅠinternal leakage was 4.2%(3/72).Two patients had retrograde dissection after operation,both were in zone 2.There was one case of bypass vascular occlusion after operation(1/72,1.4%).Conclusion:The improved vascular bypass combined with suprasternal fossa incision in the treatment of complex aortic arch lesions has high bypass vascular patency rate and good long-term effect.Attention should be paid to avoid the injury of lymphatic vessels and recurrent laryngeal nerve during the operation.