弓部优先重建技术在Stanford A型主动脉夹层手术中应用的近中期结果

Short and medium-term results of the use of aortic arch branch-prioritized reconstruction in Stanford type A aortic dissection

目的 总结不中断脑供血弓部优先重建技术行Stanford A型主动脉夹层手术的临床经验,探讨其脑保护的安全性和可靠性。方法 回顾性分析本中心2020年6月到2023年3月,17例患者首先横断无名动脉或左颈总动脉,将动脉管逆插入主动脉弓部后,通过“自循环”行弓部分支血管与四分支人工血管吻合完成全脑灌注,后在体外循环下完成Stanford A型主动脉夹层手术。术式包括:升主动脉置换+全弓置换+降主动脉支架植入和/或主动脉根部处理17例(同期行冠状动脉旁路术3例)。结果 全组17例手术均顺利完成,无术中死亡、无胸骨哆开及人造血管感染,经胸骨上段小切口手术无中转延长切口情况。术后清醒时间(4.23±0.73)h,1例患者因术后脑梗死、感染性休克死亡,其余患者术后无神经系统并发症,均痊愈出院。对其余16例患者分别在出院后3月、6月、1年进行了电话随访,随访率100%。无患者出现死亡、心脑血管系统并发症、再次手术干预、新发主动脉夹层、主动脉破裂、近端逆行撕裂、肾脏、脑部疾病情况。结论 采用不中断脑供血弓部优先重建技术行Stanford A型主动脉夹层手术是安全、可行的,可优先保证脑部灌注,减少术后早中期神经系统并发症的发生。

Objective To summarize the clinical experience of Stanford type A aortic dissection with non-extracorporeal circulation and priority reconstruction technique without interruption of cerebral blood supply,and to discuss the safety and reliability of its brain protection.Methods A retrospective analysis was performed on 17 Stanford Type A aortic dissection operations operated by priority reconstruction of partial branches of the arch in our center from June 2020 to March 2023,By transecting the innominate artery or the left common carotid artery,the arterial tube is reversely inserted into the aortic arch,and the branch vessels of the arch part are preferentially anastomosed with the four branch artificial vessels to ensure that the whole brain perfusion is completed before the lower body stops circulation.The surgical procedures included ascending aorta replacement + total arch replacement + descending aorta stent implantation and/or aortic root treatment in 17 cases(coronary artery bypass surgery was performed in 3 cases).Results All the 17 cases in the group were successfully completed,and there was no intraoperative death,no sternal incision or artificial blood vessel infection.There was no transextension of incision through small incision in upper sternal segment.The postoperative waking time was(4.23±0.73) h.1 patient died due to postoperative cerebral infarction and septic shock,and the other patients were cured and discharged from hospital without neurological complications.The other 16 patients were followed up by telephone at 3 months,6 months and 1 year after discharge,respectively,and the follow-up rate was 100%.None of the patients had death,cardiovascular complications,re-surgical intervention,new aortic dissection,aortic rupture,proximal retrograde tear,kidney disease,or brain disease.Conclusion It is safe and feasible to perform Stanford type A aortic dissection with priority reconstruction of arch without interruption of cerebral blood supply under non-extracorporeal circulation,which can give priority to cerebral perfusion and reduce the occurrence of early and middle postoperative neurological complications.