中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

保留自体头臂血管的孙氏手术在急性主动脉夹层中的应用

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目的 回顾性分析一种保留自体头臂血管的孙氏手术在治疗急性 Stanford A 型主动脉夹层中的应用,探讨其手术技术及手术适应征。 方法 2011 年 8 月至 2013 年 10 月,连续收治 28 例急性 Stanford A 型主动脉夹层患者,均腋动脉插管,中低温选择顺行性脑灌注下行两血管片法保留自体头臂血管的孙氏手术,其中男 23 例,女 5 例;年龄 29~62 岁,平均(47±8) 岁。其中高血压病患者 26 例,马凡综合征患者 2 例,同期行主动脉根部替换术(Bentall 术)4 例,Bentall+MVR 1 例,主动脉窦成形 6 例。 结果 体外循环(167±35)min,心肌阻断(80±22)min,选择性脑灌注 (29±5)min,本组住院死亡 1 例,主因术后急性肝衰竭;神经系统并发症 2 例,患者 1 周后延迟苏醒,经治疗后痊愈出院。患者出院前均行主动脉 CTA 检查,自体头臂动脉显影清晰,周围无造影剂外溢,降主动脉真腔较术前明显扩大,25 例患者支架段假腔完全血栓化,2 例出现内漏。随访 36~62 个月,平均 47 个月,其中 1 例因胸腹主动脉扩张行全胸腹主动脉替换术,1 例术后 2 年余因支架人工血管远端血管破裂急诊行 TEVAR。 结论 对于头臂动脉未受累及的急性 Stanford A 型主动脉夹层患者,保留自体头臂血管的孙氏手术是安全有效的,手术死亡及相关并发症发生率较低,近中期结果良好。

Objective Retrospective study of surgical indication, technique for treating acute Stanford type A aortic dissection involving repair of the aortic arch using Sun’s procedure with preservation of autologous brachiocephalic artery. Methods From August 2011 to October 2013, 28 consecutive patients (23 male, 5 female) underwent operations on acute Stanford type A aortic dissection using Sun’s procedure with preservation of autologous brachiocephalic artery. The mean age was 47±8years (range 29~62 years), 26 cases with hypertension and 2 cases with Mafan syndrome. The right axillary artery cannulation was used for cardiopulmonary bypass, cerebral protection was achieved by unilateral antegrade brain perfusion and nasopharyngeal temperature was dropped to 22℃~25℃. Sun’s procedure with preservation of autologous brachiocephalic artery was performed in all patients, concomitant procedure include aortic root replacement (Bentall) in 4 patients, aortic root replacement and mitral valve replacement (Bentall+MVR) in 1 patient, aortic valsalva sinus plasty in 6 patients. Results The means of cardiopulmonary bypass, cross clamp and selective cerebral perfusion time were (167±37) minutes, (80±22) minutes and (29±5) minutes, respectively. One patient died postoperatively from acute hepatic failure. 2 patients suffered from transient neurologic deficit and recovered after treatment during follow-up. Computed tomography angiography (CTA) of aorta was performed on each patient before discharged from the hospital: the patency of the anastomotic site at brachiocephalic artery was identified, descending aortic true lumen was significantly expanded, there was only 2 cases with endoleak and total thrombosis of false lumen was found near stent graft with 25 cases. The average follow-up time was 47 (36~62) months, one patient with descending thoracic aortic dilatation underwent thoracoabdoninal aortic replacement, one combined with acute endometrial tear underwent thoracic endovascular aortic repair. Conclusion Sun’s procedure with preservation of autologous brachiocephalic artery is safe and effective in the treatment of acute type A dissection in cases without brachiocephalic artery involved, low mortality and complications was achieved by it, the long-term results need the further follow-up.

关键词: 主动脉夹层; 头臂动脉; 主动脉弓; 孙氏手术

Key words: aortic dissection; brachiocephalic artery; aortic arch; Sun’s procedure

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