Stanford A型主动脉夹层患者行左锁骨下动脉激光原位开窗联合弓部去分支技术重建主动脉弓的效果分析

Analysis of the efficacy of left subclavian artery laser in situ fenestration combined with hybrid arch debranching surgery for aortic arch reconstruction in patients with Stanford type A aortic dissection

目的探讨60岁及以上Stanford A型主动脉夹层患者行左锁骨下动脉激光原位开窗联合弓部去分支技术重建主动脉弓的近中期效果。方法本研究为回顾性队列研究。回顾性分析2018年1月至2020年12月于郑州大学第一附属医院腔内血管外科行手术治疗的41例60岁及以上Stanford A型主动脉夹层患者的临床资料。男性25例, 女性16例, 年龄(67.3±5.9)岁(范围:60~75岁)。其中行左锁骨下动脉激光原位开窗联合弓部去分支技术重建主动脉弓患者19例(联合手术组), 单纯去分支杂交手术患者22例(非联合手术组)。采用独立样本t检验、χ^(2)检验和Fisher确切概率法比较两组患者临床特征的差异, 并采用Kaplan-Meier法进行生存分析, Log-rank检验比较两组的5年生存率。结果联合手术组患者体重指数高于非联合手术组[(27.1±1.6)kg/m2 比(26.9±1.9)kg/m2, t=2.766, P=0.006], 差异有统计学意义;其他一般资料的差异无统计学意义(P值均>0.05)。与非联合手术组相比, 联合手术组手术时间[(321.3±11.4)min比(329.6±7.3)min, t=-2.733, P=0.010]、锁骨下动脉重建时间[(32.4±3.0)min 比(42.4±6.0)min, t=-6.842, P<0.01]明显缩短, 差异有统计学意义;联合手术组LSA重建率高于非联合手术组(100%比72.7%, P=0.023), 差异有统计学意义。两组患者出现肺部感染、非计划二次手术、连续性肾脏替代治疗、神经系统并发症的比例及院内病死率的差异均无统计学意义(P值均>0.05);与非联合手术组相比, 联合手术组锁骨下动脉重建相关并发症发生率较低(0比27.3%, P=0.023), 差异有统计学意义。Kaplan-Meier生存分析结果显示, 联合手术组与非联合手术组5年生存率(84.2%比77.3%, χ^(2)=0.310, P=0.578)无差异。结论左锁骨下动脉激光原位开窗联合弓部去分支技术重建主动脉弓可缩短60岁及以上Stanford A型主动脉夹层患者手术时间, 提高锁骨下动脉重建成功率, 降低锁骨下动脉重建并发症发生率。

Objective:To observe the short-and mid-term efficacy of left subclavian artery(LSA)laser in situ fenestration combined with arch debranching surgery for aortic arch reconstruction in patients with Stanford type A aortic dissection aged 60 years and above.Methods:This is a retrospective cohort study.A total of 41 Stanford type A aortic dissection patients aged 60 years and above who received combined surgery in Department of Endovascular Surgery,the First Affiliated Hospital of Zhengzhou University from January 2018 to December 2020 were retrospectively analyzed.There were 25 males and 16 females,aged(67.3±5.9)years(range:60 to 75 years).Among them,19 patients underwent LSA laser in situ fenestration combined with arch debranching surgery(combined surgery group)and 22 patients underwent hybrid aortic arch debranching surgery(non-combined surgery group).Independent sample t test,χ^(2) test and Fisher exact probability method were used to compare the clinical characteristics of the two groups.Kaplan-Meier method was used for survival analysis,and the 5-year survival rate of the two groups was compared by Log-rank test.Results:Body mass index in the combined operation group was significantly higher than that in the non-combined operation group((27.1±1.6)kg/m 2vs.(26.9±1.9)kg/m 2;t=2.766,P=0.006),and the difference was statistically significant.There was no statistical significance in the comparison of other general data(all P>0.05).The operation time((321.3±11.4)minutes vs.(329.6±7.3)minutes;t=-2.733,P=0.010)and LSA reconstruction time((32.4±3.0)minutes vs.(42.4±6.0)minutes;t=-6.842,P<0.01)in the combined operation group were significantly shortened,and the difference was statistically significant.The rate of LSA reconstruction in the combined operation group(100%vs.72.7%;P=0.023)was significantly higher than that in the non-combined operation group,and the difference was statistically significant.There were no significant differences in the incidence of pulmonary infection,unplanned second operation,continuous renal replacement therapy,neurological complications and the in-hospital mortality between the two groups.Compared with the non-combined surgery group,the total complication rate related to LSA reconstruction was significantly lower in the combined surgery group(0 vs.27.3%;P=0.023).Kaplan-Meier survival analysis showed that there was no difference in 5-year survival rate between the combined operation group and the non-combined operation group(84.2%vs.77.3%;χ^(2)=0.310,P=0.578).Conclusion:Laser in situ fenestration of the LSA combined with arch debranching surgery to reconstruct the aortic arch can significantly shorten the operation and LSA reconstruction time in patients aged 60 years and above with Stanford type A aortic dissection,improve the success rate of LSA reconstruction,and reduce the occurrence rate of LSA reconstruction complications.