杂交手术治疗急性A型主动脉夹层动脉瘤147例单中心回顾性队列研究

Hybrid surgery in the treatment of 147 patients with acute type A aortic dissection and aneurysm in a single center:A retrospective cohort study

目的探索应用杂交手术治疗Stanford A型主动脉夹层的单中心治疗方法。方法2017年3月—2020年4月,上海交通大学医学院附属仁济医院心血管外科272例Stanford A型主动脉夹层患者接受手术治疗,其中涉及主动脉弓部的手术147例,男126例、女21例。其中106例接受升主动脉置换+主动脉弓置换+支架象鼻(全弓置换组),41例采用一站式复合全弓Ⅱ型杂交手术(复合全弓组)。比较两组在手术死亡率、术后并发症发生率、手术时间、体外循环时间等方面的差异,探讨杂交手术是否真正简化了主动脉夹层全弓置换手术。结果两组术前临床资料差异无统计学意义。全弓置换组死亡率与复合全弓组的差异无统计学意义,但在输血量[(6.74±7.35)U vs.(4.65±6.87)U,P<0.05]、术后呼吸功能不全[16(15.09%)vs.2(4.88%),P<0.05]、卒中[3(2.83%)vs.0,P<0.05]、截瘫[2(1.89%)vs.0,P<0.05]发生率等方面,复合全弓组均明显优于全弓置换组。复合全弓组手术总时间并未缩短,但在体外循环时间[(175.50±55.70)min vs.(129.70±48.80)min,P<0.05]、主动脉阻断时间[(103.10±23.70)min vs.(49.70±30.10)min,P<0.05]以及避免或缩短停循环时间[(32.10±7.20)min vs.0 min,P<0.05]方面,均明显优于全弓置换组。复合全弓组术后机械通气时间[(62.60±31.70)h vs.(41.30±32.60)h,P<0.05]更短,ICU滞留时间[(124.50±61.50)h vs.(63.40±71.20)h,P<0.05]和术后住院时间[(13.50±11.20)d vs.(9.20±7.20)d,P<0.05]均明显短于全弓置换组。术后完成随访138例,平均随访时间6~38(15.8±6.4)个月。随访期两组1年和3年死亡率差异无统计学意义(P>0.05)。结论杂交手术可以缩短体外循环时间、住院时间,避免深低温停循环或缩短其时间,降低并发症发生率。杂交手术可简化急性Stanford A型主动脉夹层的弓部处理。

Objective To explore the single-center experience of hybrid therapy in treatment of Stanford type A aortic dissection,and to make a comparison of the clinical results of this hybrid therapy with total arch replacement surgery in the same period.Methods From March 2017 to April 2020,272 patients with Stanford type A aortic dissection underwent surgical treatment in our center,including 147 patients(126 males and 21 females)who received the aortic arch surgery.Among them,106 patients underwent replacement of ascending aorta+aortic arch+stent trunk(total arch replacement group),while 41 patients underwent one-stop compound total arch typeⅡhybrid surgery(compound total arch replacement group).We tried to identify whether hybrid surgery really simplified total arch replacement surgery of the aortic dissection by comparing the operative mortality,postoperative complication rate,operative time,extracorporeal circulation time,etc.Results There was no statistical difference in preoperative clinical data or death rate between the two groups.However,blood transfusion(6.74±7.35 U vs.4.65±6.87 U,P<0.05),postoperative respiratory insufficiency[16(15.09%)vs.2(4.88%),P<0.05],and apoplexy[3(2.83%)vs.0,P<0.05],paraplegia[2(1.89%)vs.0,P<0.05],in the compound total arch replacement group was significantly better than those of the total arch replacement group.The compound total arch replacement group did not shorten the total operation time,but it was significantly better in terms of extracorporeal circulation time(175.50±55.70 min vs.129.70±48.80 min,P<0.05),aortic block time(103.10±23.70 min vs.49.70±30.10 min,P<0.05),and the time of stopping the circulation or avoiding stopping the circulation(32.10±7.20 min vs.0 min,P<0.05).The postoperative mechanical ventilation time was shorter in the compound total arch group(62.60±31.70 h vs.41.30±32.60 h,P<0.05),and the time of staying in ICU(124.50±61.50 h vs.63.40±71.20 h,P<0.05)and the postoperative hospital stay(13.50±11.20 d vs.9.20±7.20 d,P<0.05)were significantly shorter than those in the total replacement group.A total of 138 patients were followed up for 6-38(15.8±6.4)months.There was no statistical difference in one-year mortality or three-year mortality(P>0.05).Conclusion Hybrid surgery shortens extracorporeal circulation time,while reduces or avoids the time of deep hypothermia circulatory arrest,the incidence of complications and the time of hospital stay.In conclusions,hybrid surgery simplifies the arch management of acute Stanford type A aortic dissection.