人工血管旁路移植术治疗急性A型主动脉夹层合并下肢灌注不良

Extra-anatomic bypass grafting in patients with lower extremity malperfusion due to type A acute aortic dissection

目的:总结人工血管旁路移植术在急性A型主动脉夹层合并下肢灌注不良患者中的疗效。方法:2004年1月至2021年1月,896例急性A型主动脉夹层患者在南京市第一医院接受外科手术。回顾性分析临床资料,合并下肢灌注不良75例,均为急性发病。结果:男61例,女14例,年龄(50.9±11.3)岁。体外循环(181.9±27.0)min,主动脉阻断(125.7±25.0)min,下半身停循环(20.4±3.1)min。全弓手术55例,半弓手术20例。48例夹层手术后下肢动脉灌注恢复。26例夹层手术同时接受了血管旁路移植术。另1例患者在夹层手术同期行膝下截肢术。术后主要并发症包括急性肾损伤9例,呼吸机延迟拔管(≥72 h)10例,肺部感染13例,气管切开6例,轻瘫1例,卒中2例,截肢3例。ICU滞留(5.8±4.5)天,总住院(21.4±13.8)天。全组死亡9例(12%),死亡原因包括肺部感染、呼吸衰竭2例,多脏器功能衰竭3例,髂动脉破裂1例,肠坏死1例,大面积脑梗塞1例,放弃治疗1例。66例(88%)出院。随访(55.8±33.4)个月,5年生存率(96.7±4.2)%,10年生存率(56.4±16.3)%。结论:血管旁路移植术是一种可以同期处理夹层和下肢灌注不良的可行办法,操作简单、有效,远期效果满意。

ObjectiveTo summarize the efficacy of artificial blood vessel bypass grafting in patients with acute type A aortic dissection(ATAAD)complicated with lower extremity malperfusion.MethodsFrom January 2004 to January 2021,a total of 896 patients with ATAAD underwent surgical operations in Nanjing First Hospital,Among which 75 patients with lower extremity malperfusion was retrospectively analyzed.ResultsThere were 61 males and 14 females with mean age(50.9±11.3)years old.The cardiopulmonary bypass time(CPB)was(181.9±27.0)min,the cross-clamp time was(125.7±25.0)min,and the lower body circulatory arrest time was(20.4±3.1)min.Fifty-five patients had total aortic arch replacement and 20 cases had hemi-arch replacement surgery.Lower extremity arterial perfusion was restored in 48 patients after dissection surgery.Twenty-six patients underwent dissection surgery concurrently with extra-anatomic bypass grafting.The main postoperative complications were:acute kidney injury in 9 cases,delayed extubation(≥72 h)in 10,pulmonary infection in 13,tracheotomy in 6,paralysis in 1,stroke in 2 and lower limb amputation in 3.ICU stay time was(5.8±4.5)days,in-hospital time was(21.4±13.8)days.Nine patients(12%)died in the whole group:pulmonary infection,respiratory failure in 2 cases,multiple organ failure in 3 cases,iliac artery rupture in 1 case,intestinal necrosis in 1 case,severe cerebral infarction in 1 case,and giving-up in 1 case.A total of 66 patients(88%)were successfully discharged.The follow-up time was(55.8±33.4)months.The results of survival analysis showed that the 5-year survival rate was(96.7±4.2)%,and the 10-year survival rate was(56.4±16.3)%.ConclusionExtra-anatomic bypass grafting is a feasible method to solve ATAAD complicated with lower extremity malperfusion.It is simple and easy to operate,and the long-term effect is satisfactory.