Ⅱ型右位主动脉弓合并Kommerell憩室的外科治疗

Surgical repair of typeⅡright-sided aortic arch with Kommerell diverticulum

目的总结Ⅱ型右位主动脉弓(right-sided aortic arch,RAA)合并Kommerell憩室(Kommerell'sdiverticulum,KD)的外科治疗经验及效果。方法2010年5月至2020年8月,共13例Ⅱ型RAA合并KD患者在我中心接受外科手术。其中男10例,女3例,年龄(50.46±10.31)岁。所有患者均合并KD动脉瘤及迷走左锁骨下动脉(aberrantleft subclavian artery,ALSA),其中同时合并B型夹层1例、主动脉弓假性动脉瘤2例及B型主动脉壁内血肿2例。8例(61.5%)经胸骨正中切口、中低温停循环联合选择性脑灌注下行直视支架象鼻手术,术中均重建ALSA。5例(38.5%)经右后外侧切口行远端主动脉弓及胸降主动脉置换术,其中术中行ALSA重建及ALSA缝扎各1例,术前行ALSA栓塞3例。结果全组无手术死亡。术后喉返神经损伤2例。院内死亡1例(7.69%)。术后随访(5.28±3.84)年,随访率100%,随访期间无死亡。1例行直视支架象鼻手术患者术后随访发现近端吻合口漏持续存在,但无主动脉扩张及食管气管压迫。其余患者无主动脉事件、肢体缺血及食管气管压迫表现。结论外科治疗Ⅱ型RAA合并KD可获得满意的早中期效果。术前应根据主动脉病变解及是否合并动脉瘤压迫症状制订合理的手术方案。

Objective To summarize our experience and outcomes of surgical repair of type II right-sided aortic arch(RAA)with Kommerells diverticulum(KD).Methods From May 2010 to August 2020,a total of 13 patients with type II RAA and KD underwent surgery at our center.Mean age was(50.46±10.31)years,10 were male,and 3 were female.All patients had an aneurysmal KD and aberrant left subclavian artery(ALSA).Preoperative comorbidities included type B aortic dissection in 1 case,aortic arch pseudoaneurysm in 2 cases,and type B intramural hematoma in 2 cases,respectively.Eight(61.5%)patients underwent stented elephant trunk procedures under moderate hypothermic circulatory arrest combined with selective antegrade cerebral perfusion via median stermotomy,and all of them had ALSA reconstruction.Five(38.5%)patients underwent distal arch and descending thoracic aortic replacement through a right posterolateral thoracotomy,the ALSA was re-constructed or ligated in 1 each,and ALSA embolization was performed before surgery in the other 3 cases.Results No opera-tion deaths occurred.Recurrent laryngeal nerve injury occurred in 2 cases.There was 1(7.69%)in-hospital death.Follow-up was complete in 100%at mean(5.28±3.84)years.No late death occurred.A persistent anastomotic leak of the proximal arch was detected in a patient who underwent stented elephant trunk procedure,but no aortic dilatation or tracheal and esopha-geal compression was observed during fllow-up.Meanwhile,aortic events,limb ischemia,or symptoms of tracheal and esoph-ageal compression were not observed in the remaining ll patients.Conclusion Surgical repair of type I RAA with KD can a-chieve favorable early and midterm outcomes.Surgical strategies should be chosen based on the anatomy of the aorta and wheth-er it is combined with compression symptoms.