急性Stanford A型主动脉夹层合并下肢灌注不良的综合治疗

Comprehensive treatment of acute Stanford type A aortic dissection with limb malperfusion

目的总结分析孙氏手术优先或分支动脉开通优先治疗急性Stanford A型主动脉夹层合并下肢缺血导致灌注不良的临床效果。方法回顾性分析2020年1月至2021年12月共302例急性A型主动脉夹层患者, 收集其中17例合并下肢灌注不良患者的围手术期临床资料, 其中男16例, 女1例;平均年龄(52.6±4.2)岁。术前腔内支架开通下肢动脉3例, 术后行腔内支架开通1例, 直接行孙氏手术14例。结果急性A型主动脉夹层合并下肢灌注不良的发生率为5.6%, 全组平均体外循环时间(271.8±38.9min), 平均主动脉阻断时间(186.3±31.8)min, 平均脑灌注时间(48.75±11.3)min。术后因多器官灌注不良死亡3例, 发生率为17.6%(3/17), 2例孙氏手术后因腹腔脏器灌注不良死亡;1例孙氏手术前行髂动脉开通支架后因腹腔脏器灌注不良死亡。因大面积脑梗塞自动出院2例, 发生率为11.7%(2/17), 因骨筋膜室切开1例, 术后使用血液灌流5例。术后随访显示术前重度下肢缺血患者有下肢皮肤神经受损表现, 表现为患侧肢体无力, 麻木, 在康复医院康复治疗中, 肌力较前有好转;轻度下肢缺血患者患侧皮肤麻木有好转, 无遗留肌力障碍。结论对于轻度下肢缺血的A型主动脉夹层直接行孙氏手术效果良好;对于重度下肢缺血的A型主动脉夹层患者可先行支架开通后再行孙氏手术, 术后使用血液灌流器可以减少缺血再灌注损伤, 改善损伤预后。

Objective To explore different strategies of central repair first or malperfusion first to treat type A aortic dissection complicated with limb malperfusion.Methods From January 2020 to December 2021,302 patients were diagnosed with acute type A aortic dissection,and 17 consecutive patients were diagnosed as type A acute aortic dissection complicated with limb malperfusion and underwent Sun’s procedure.There were 16 males and 1 female with an average of(52.6±4.2)years.Surgical strategies were as follows:immediate central repair-Sun’s procedure in 14 patients,endovascular stenting followed by central repair in 3 patients,endovascular stenting after central repair in 1 patient.Results The incidence rate of limb malperfusion of acute Stanford A aortic dissection was 5.6%(17/302).Average extracorporeal circulation time was(271.8±38.9)min,average aortic cross-clamp time was(186.3±31.8)min,and the average circulatory arrest time was(48.75±11.3)min.Early mortality rate was 17.6%(3/17).Two patients were left hospital voluntarily because of cerebral infarction.One patient underwent leg incision osteofascial compartment syndrome and discharged unevently.Five patients underwent continuous renal replacement therapy and hemoperfusion.Follow-up results showed that patients with serious limb malperfusion have symptoms of nerve dysfunction including amyosthenia and sensory disturbance,but recovered gradually with rehabilitation.Conclusion Sun’s procedure is safe and feasible for type A acute aortic dissection complicated with mild limb malperfusion.For serious limb malperfusion,endovascular stent followed by Sun’s procedure is a good choice with CRRT and hemoperfusion.