冠状动脉支架植入术后Stanford A型主动脉夹层的外科治疗

Surgical treatment of Stanford type A aortic dissection after coronary artery stenting

目的分析冠状动脉支架植入术后Stanford A型主动脉夹层患者的外科治疗方式,探讨其手术技术及手术时机。方法回顾性分析2016年4月—2019年7月首都医科大学附属北京安贞医院连续收治的1246例Stanford A型主动脉夹层患者的临床资料。纳入冠状动脉支架植入术后Stanford A型主动脉夹层患者。结果最终纳入患者19例,其中男16例、女3例,年龄35~66(54±7)岁。19例患者中急性主动脉夹层11例。AC型(DeBakeyⅠ型)主动脉夹层15例,AS型(DeBakeyⅡ型)4例。AC型患者中行孙氏手术(全弓置换+支架象鼻手术)10例,部分弓置换5例;19例患者中同期行冠状动脉旁路移植术7例,二尖瓣置换术1例;4例患者术中取出位于右冠开口的支架。本组住院死亡1例,主因术前合并脏器灌注不良,术后死于多脏器功能衰竭。18例患者经治疗后痊愈出院,平均随访30(18~56)个月,其中1例因冠状动脉吻合口漏行二次漏修补术,1例因远端夹层新发破口行胸主动脉腔内修复,1例因左主干支架闭塞急诊行经皮冠状动脉介入治疗,1例因髂动脉闭塞行股股转流。结论冠状动脉支架植入术后Stanford A型主动脉夹层的患者中,医源性主动脉夹层同期行冠状动脉旁路移植的比例高,对于广泛受累的Stanford A型主动脉夹层应当积极手术治疗。

Objective To retrospectively analyze the surgical treatment of Stanford type A aortic dissection after coronary artery stenting,and to explore the surgical techniques and surgical indications.Methods Clinical data of 1246 consecutive patients who underwent operations on Stanford type A aortic dissection from April 2016 to July 2019 in Beijing Anzhen Hospital were retrospectively analyzed.Patients with Stanford type A aortic dissection after coronary artery stenting were enrolled.Results Finally 19 patients were collected,including 16 males and 3 females with an average age of 54±7 years ranging from 35 to 66 years.There were 11 patients in acute phase,15 patients with AC(DeBakeyⅠ)type and 4 patients with AS(DeBakeyⅡ)type.In AC type,there were 10 patients receiving Sun's surgery and 5 patients partial arch replacement.Meanwhile,coronary artery bypass grafting was performed in 7 patients and mitral valve replacement in 1 patient.Stents were removed from the right coronary artery in 4 patients.In this group,1 patient died of multiple organ failure in hospital after operation combined with malperfusion of viscera.Eighteen patients recovered after treatment and were discharged from hospital.The patients were followed up for 30(18-56)months.One patient underwent aortic pseudoaneurysm resection,one thoracic endovascular aortic repair,one emergency percutaneous coronary intervention due to left main artery stent occlusion,and one underwent femoral artery bypass due to iliac artery occlusion.Conclusion Iatrogenic aortic dissection has a high probability of coronary artery bypass grafting at the same time in patients with Stanford type A aortic dissection after coronary artery stenting.Complicated type A aortic dissection after percutaneous coronary intervention should be treated with surgery aggressively.