累及弓部的复杂B型主动脉夹层的外科治疗

Surgical treatment for complex type-B aortic dissection involving the arch

目的对应用术中支架联合左锁骨下动脉-左颈总动脉转流术治疗累及远端主动脉弓的复杂B型主动脉夹层的效果进行评估。方法2018年11月-2020年4月,淮北矿工总医院心胸外科对6例Stanford B型主动脉夹层累及远端主动脉弓的患者施行了术中支架联合左锁骨下动脉-左颈总动脉转流术,患者均为男性,平均年龄为51岁。6例患者均有高血压病史。弓部最大直径>40 mm,破口均位于远端主动脉弓,距离左锁骨下动脉开口距离<1.5 cm。统计体外循环时间、术中阻断时间、停循环选择性脑灌注时间、呼吸机辅助时间、围术期病死率,术后脑梗死、截瘫、二次开胸止血发生率。术后通过门诊及电话随访。分别于患者术后1周、3个月、12个月复查主动脉CT血管造影(CTA)。结果体外循环时间为80~207(145±37)min,术中阻断时间平均为34.5 min,停循环选择性脑灌注时间平均为12 min。3例患者术后呼吸机辅助时间超过24 h(分别为41、44、26 h)。平均呼吸机辅助时间为16.48 h。术后均无头晕症状,神志及精神恢复良好,未出现脑梗死、截瘫、二次开胸止血,未发生围手术期死亡,患者均顺利出院。随访时间为3~18个月不等。随访期间,患者生活状况良好。术后复查主动脉CTA,支架远端水平假腔闭塞率为100.0%(6/6)。结论对于具有手术适应证的复杂型Stanford B型夹层患者采用外科手术,手术效果和术后近期随访结果令人满意。但本组患者例数较少,且随访时间较短,远期的临床效果仍需通过长期随访进一步判断。

Objective To evaluate the efficacy of intraoperative stenting combined with left subclavian artery-left common carotid artery diversion for the treatment of complex type-B aortic dissection involving the distal aortic arch.Methods From November 2018 to April 2020,six patients with Stanford type-B aortic dissection involving the distal aortic arch received intraoperative stenting combined with left subclavian artery-left common carotid artery diversion in the Department of Cardiothoracic Surgery,Huaibei Coal Miners General Hospital.All patients were males with an average age of 51 years old and had a definite diagnosis of hypertension.The maximum diameter of the arch was greater than 40 mm,and the rupture was located in the distal aortic arch,less than 1.5 cm away from the opening of the left subclavian artery.The cardiopulmonary bypass time,intraoperative block time,selective cerebral perfusion time,ventilator-assisted time,perioperative mortality,incidence of postoperative cerebral infarction,paraplegia,and secondary thoracotomy haemostasis were analysed.All patients were followed up.Aortic CTA was reviewed 1 week,3 months,and 12 months after surgery.Results The average duration of CPB was(145±37)min,from 80 to 207 min.The average duration of intraoperative occlusion was 34.5 min,and the average duration of selective cerebral perfusion was 12 min.The duration of postoperative ventilator assistance exceeded 24 h in 3 patients(41,44,26 h,respectively).The average ventilator-assisted time was 16.48 h.No symptoms of dizziness and no cerebral infarction were observed.No incidence of paraplegia,secondary thoracotomy haemostasis,and perioperative death were found.Follow-up time ranged within 3-18 months.All patient lived well.Postoperative aortic CTA showed 100.0%(6/6)occlusion rate at the distal end of the stent.Conclusion The application of intraoperative stenting combined with left subclavian artery-left common carotid artery diversion in the treatment of patients with complex Stanford type-B dissection is safe and efficient.However,the number of patients in this group is small and the follow-up time is short,so the long-term clinical effect requires further evaluation through long-term follow-up.