逆向分期杂交技术在急性主动脉夹层合并远端灌注不良综合征外科治疗中的应用

Two-stage retrograde hybrid repair in the surgical treatment of acute aortic dissection complicated with distal malperfusion syndrome

目的评价逆向分期杂交技术在累及主动脉弓的急性主动脉夹层合并远端灌注不良综合征外科治疗中的效果。方法纳入2019年5月—2022年12月四川大学华西医院心脏大血管外科累及主动脉弓的急性主动脉夹层合并远端灌注不良综合征患者。所有患者通过术前评估后优先急诊介入手术改善远端灌注,限期内再行二期杂交手术修复近端主动脉病变。回顾性分析患者围术期相关临床资料及影像学数据。结果纳入5例患者,其中男4例、女1例,中位年龄58岁。其中3例以下肢缺血和肾功能不全为主要表现,2例以肠道灌注不良为主要表现。5例患者均优先采用介入手术植入覆膜支架或裸支架和必要的分支动脉处理,再二期实施杂交手术,其中包括Ⅰ型杂交2例、Ⅱ型杂交1例和Ⅲ型杂交2例,手术成功率100.0%。患者均顺利出院,灌注不良脏器功能均恢复正常,仅1例患者出院时病变下肢肌力恢复至4级。所有患者无截肢、开腹探查肠道切除及长期血液透析等不良事件发生。结论逆向分期杂交技术应用于累及主动脉弓的急性主动脉夹层合并远端灌注不良综合征的外科治疗安全、有效,有助于提高此类患者围术期生存率和改善临床结局。

Objective To evaluate the clinical efficacy of two-stage retrograde hybrid repair for acute aortic dissection involving the aortic arch complicated with distal malperfusion syndrome.Methods From May 2019 to December 2022,the patients presented with acute aortic dissection involving the aortic arch complicated with distal malperfusion syndrome treated in the Department of Cardiovascular Surgery of West China Hospital,Sichuan University were enrolled.After preoperative evaluation,all patients underwent priority emergency interventional surgery to improve distal malperfusion,and then underwent two-stage hybrid surgery to repair proximal aortic lesions.The perioperative clinical and imaging data were retrospectively analyzed.Results Five patients were collected,including 4 males and 1 female,with a median age of 58 years.The main manifestations were lower limb ischemia and renal insufficiency in 3 patients,and poor intestinal perfusion in 2 patients.All patients were given priority to interventional surgery to implant graft stents or bare stents and necessary branch artery intervention,and then successfully performed two-stage hybrid surgery,including typeⅠhybrid surgery for 2 patients,typeⅡhybrid surgery for 1 patient and typeⅢhybrid surgery for the other 2 patients,with a success rate of 100.0%.All patients were discharged successfully,and the function of the organs with poor perfusion returned to normal.Only 1 patient recovered to grade 4 muscle strength of the diseased lower limbs upon discharge.No adverse events such as amputation,exploratory laparotomy and intestinal resection or long-term hemodialysis occurred.Conclusion The application of two-stage retrograde hybrid repair in the surgical treatment of acute aortic dissection involving the aortic arch complicated with distal malperfusion syndrome is safe and effective,and is helpful to improve the perioperative survival rate,and clinical outcomes of such patients.