急性A型主动脉夹层合并肠系膜低灌注致肠缺血坏死的治疗策略

Treatment strategy of intestinal ischemic necrosis caused by acute type A aortic dissection combined with mesenteric hypoperfusion

急性A型主动脉夹层是一种严重的心血管疾病,起病快,病死率高,传统上通常在患者入院后紧急进行开放性主动脉修复术,以防止主动脉破裂而导致死亡。然而,若合并灌注不良综合征引起肠系膜上动脉低灌注会进一步导致肠坏死,严重影响手术预后甚至引起不良后果,在治疗上带来极大困难。本文结合近年来国内外研究文献,从急性A型主动脉夹层造成器官灌注不良的机制、治疗现状、手术方式的选择进行综述。文献复习结果表明,目前针对急性A型主动脉夹层合并肠系膜上动脉灌注不良的手术方式选择可采用中心型主动脉修复术;对肠系膜上动脉先进行开窗和/或支架置入,再对主动脉进行延迟开放修复;优先进行肠系膜上动脉血运重建,再行主动脉中心型修复术;中心型主动脉修复的同时,对肠系膜上动脉的远端真腔进行直接血流灌注,并且都可以取得良好的治疗效果。但在外科主动脉修复术后,仍可能出现肠缺血坏死,此时需要积极进行剖腹探查并做出相应坏死肠切除处理,才能挽救患者的生命。

Acute type A aortic dissection is a severe cardiovascular disease characterized by rapid onset and high mortality.Traditionally,urgent open aortic repair is performed after admission to prevent aortic rupture and death.However,when combined with malperfusion syndrome,the low perfusion of the superior mesenteric artery can further lead to intestinal necrosis,significantly impacting the surgery's prognosis and potentially resulting in adverse consequences,bringing great challenges in treatment.Based on recent domestic and international research literature,this paper reviews the mechanism,current treatment approaches,and selection of surgical methods for poor organ perfusion caused by acute type A aortic dissection.The literature review findings suggest that central aortic repair can be employed for the treatment of acute type A aortic dissection with inadequate perfusion of the superior mesenteric artery.The superior mesenteric artery can be windowed and(or)stented,followed by delayed aortic repair.Priority should be given to revascularization of the superior mesenteric artery,followed by central aortic repair.During central aortic repair,direct blood perfusion should be performed on the distal true lumen of the superior mesenteric artery,resulting in favorable therapeutic outcomes.The research results indicate that even after surgical aortic repair,intestinal ischemic necrosis may still occur.In such cases,prompt laparotomy and necessary necrotic bowel resection are crucial for saving the patient's life.