Stanford A型主动脉夹层合并单发左椎动脉患者术中重建左椎动脉临床观察

Left vertebral artery reconstruction during surgery for Stanford type A aortic dissection complicated with isolated left vertebral artery

目的 观察Stanford A型主动脉夹层(TAAD)合并单发左椎动脉(ILVA)患者手术治疗TAAD同期重建左椎动脉的效果,探讨其安全性。方法 回顾性分析2017年4月—2022年10月华中阜外心血管病医院行手术治疗的26例TAAD合并ILVA患者的临床资料。记录手术方案,住院期间死亡、支架内漏、神经系统并发症等发生情况。术后3个月行主动脉CT血管造影检查左椎动脉通畅、吻合口狭窄、动脉瘤和支架内漏情况。随访至2023年3月,记录主动脉相关死亡情况。结果 (1)24例中低温体外循环下行全主动脉弓置换+支架象鼻手术,其中升主动脉近端行升主动脉置换术19例,行Bentall手术5例;2例浅低温体外循环下于升主动脉近端先行升主动脉置换术,然后行弓部去分支+腔内修复术。(2) 26例术中均根据夹层累及的范围、破口位置重建左椎动脉。17例采用ILVA与左颈总动脉端侧吻合重建左椎动脉,8例在主动脉支架血管开窗重建左椎动脉及左锁骨下动脉,1例采用ILVA与左锁骨下动脉移植物端侧吻合重建左椎动脉。(3)住院期间发生Ⅰb型支架内漏1例,未再行手术,术后3个月复查支架附近假腔完全血栓化,内漏消失;余25例患者左椎动脉吻合口通畅,无支架内漏发生。术后均无神经系统并发症发生。2例发生消化道出血并多脏器功能衰竭死亡;余24例均治愈出院,术后3个月主动脉CT血管造影检查提示左椎动脉均通畅,无吻合口狭窄、动脉瘤和支架内漏发生。平均随访(43±18)个月,无主动脉相关死亡病例。结论 对TAAD合并ILVA患者,评估左椎动脉与周围血管的解剖关系、夹层累及范围后制订个体化手术方案,治疗TAAD同期重建左椎动脉安全有效,可减少围术期神经系统并发症。

Objective To observe the efficacy and safety of left vertebral artery reconstruction during surgery for Stanford type A aortic dissection(TAAD) complicated with isolated left vertebral artery(ILVA). Methods Twenty-six patients with TAAD complicated with ILVA underwent surgical treatment in Fuwai Central China Cardiovascular Hospital from April, 2017 to October, 2022, and their clinical data were retrospectively analyzed. The surgical plan, death and stent leakage during hospitalization and neurological complications were recorded. Aortic CT angiography was performed 3 months after surgery to detect left vertebral artery patency, anastomotic stenosis, aneurysm, and stent leakage. The follow-up was done till March, 2023, to record aortic related deaths. Results(1) In 26 patients, 24 underwent total arch replacement + stent trunk surgery under moderate hypothermia cardiopulmonary bypass, including ascending aorta replacement in 19 patients and Bentall surgery in 5;2 patients underwent ascending aorta replacement + arch debranching + endovascular aneurysm repair procedure under mild hypothermia cardiopulmonary bypass.(2) Left vertebral artery reconstruction was done according to the extent of dissection involvement and location of the tear, in which 17 patients underwent end-to-side anastomosis of ILVA and left common carotid artery, 8 underwent intraoperative stent graft fenestration to reconstruct left vertebral artery and left subclavian artery, and 1 underwent end-to-side anastomosis of ILVA with left subclavian artery graft.(3)Type Ⅰb stent leakage developed in 1 patient during hospitalization, and no surgery was done again. The false lumen near the stent showed complete thrombosis and the leakage disappeared 3 months after surgery. The other 25 patients had unobstructed left vertebral artery anastomosis and no stent leakage.No neurological complications occurred after surgery.During hospitalization,2 patients died of postoperative gastrointestinal bleeding and multiple organ failure,and the remaining 24 patients were cured and discharged.Aortic CT angiography 3months after surgery showed that ILVA was unobstructed in all patients,with no anastomotic stenosis,aneurysm or stent leakage.The follow-up lasted averagely for(43±18)months,showing no aortic related deaths.Conclusions The individualized surgical plan should be formulated after evaluating the relationship between left vertebral artery and other surrounding vessels and the extent of dissection involvement in TAAD patients with ILVA.To reconstruct the left vertebral artery during TAAD surgery is effective and safe,and it can reduce the occurrence of perioperative neurological complications.