中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

两种术式治疗 Stanford A 型主动脉夹层的病例对照研究

查看全文

目的 通过分析 Stanford A 型主动脉夹层采用孙氏手术与去分支复合手术两种不同术式治疗的近、中期疗效,总结临床经验以更好地把握两种术式的适应证。 方法 回顾性分析 2014 年 9 月至 2017 年 9 月我院确诊为 Stanford A 型主动脉夹层并于我科行相应外科手术治疗 46 例患者的临床资料,其中男 39 例、女 7 例,年龄 20~74(48.67±11.80)岁。据手术方式将患者分为孙氏手术组(26 例)和去分支复合手术组(20 例),比较两组临床结果。 结果 去分支复合手术组在体外循环(cardiopulmonary bypass time,CPB)时间、主动脉阻断(aortic cross clamp ,ACC)时间、术中尿量、术后呼吸机辅助呼吸时间、术后 24 h 引流液量、监护病房停留时间较孙氏手术组有明显优势(P<0.05)。术后暂时性神经系统功能损害发生率低于孙氏手术组(P<0.05)。术后随访时间 3~36 个月,随访率为 90.5%。孙氏手术组 1 例术后 30 d 死于肺部严重感染,去分支复合手术组 1 例患者在术后早期复查时发现内漏,6 个月后复查时内漏消失。孙氏手术组未出现内漏。随访期间所有患者均未出现脑卒中、凝血功能障碍、截瘫、上肢缺血等并发症。 结论 对于 Stanford A 型主动脉夹层,去分支复合手术虽然有术后发生内漏风险,但整体疗效较之孙氏手术有一定优越性,故而对于此型夹层的治疗可优先选择去分支复合手术。

Objective To analyze the near-term clinical efficacy of two different surgical procedures (Sun's procedure and Debranching combined endovascular stent-graft procedure)to cure Stanford type A aortic dissection, and summarize the clinical experience to help better master the indications of the two surgical procedures. Methods We retrospectively analyzed the clinical data of 46 patients with Stanford A aortic dissection in our hospital between September 2014 and September 2017. There were 39 males and 7 females at age of 20–74 (48.67±11.80) years. According to different surgical methods, the patients were divided into a Sun's procedure group (26 patients) and a debranching combined endovascular stent-graft procedure group (20 patients). Comparing the ACC time, CPB time, intraoperative urine output, postoperative mechanical ventilation time, postoperative volumes of drain, CICU time, total hospital stay and other indicators, and regular follow-up after surgery. Results The debranching combined endovascular stent-graft procedure group was significantly superior to the Sun's group in cardiopulmonary bypass time(CPB) time, aortic cross clamp(ACC) time, intraoperative urine output, postoperative mechanical ventilation time, postoperative 24 h volumes of drain, CICU time, renal function recovery of postoperative 72 h and total hospital stay(P<0.05). The incidence of transient neurological damage after operation in the debranching combined endovascular stent-graft procedure group was significantly lower than that of the Sun's procedure group(P<0.05). The follow-up time ranged from 3 to 36 months. And the follow-up rate was 90.5%. One patient in the Sun's procedure group died of serious pulmonary infection postoperative 30 days. One patient in the debranching combined endovascular stent-graft group was found to have internal leakage in the early postoperative examination and disappeared after 6 months. Sun's procedure group did not find endoleak. All patients during the follow-up time did not appear brain, coagulation disorders, stroke, paraplegia, upper limb ischemia and other complications. Conclusion For Stanford type A aortic dissection, debranching combined surgery may have the risk of postoperative endoleak, but the overall effect is superior to Sun's operation. Therefore, debranching combined surgery should be preferred for the treatment of this type of dissection.

关键词: 孙氏手术; 主动脉弓去分支; 腔内隔缘术; A 型主动脉夹层

Key words: Sun's procedure; endovascular stent-graft; debranching; stanford type A aortic dissection

登录后 ,请手动点击刷新查看图表内容。 没有账号,
1. 孙立忠, 刘志刚, 常谦, 等. 主动脉弓替换加支架" 象鼻”手术治疗Stanford A型主动脉夹层. 中华外科杂志, 2004, (13): 47-51.
2. 刘维永. 胸主动脉瘤及主动脉夹层外科治疗进展. 中国胸心血管外科临床杂志, 2003, 10(1): 50-53.
3. Zink BJ. The biology of emergency medicine: what have 30 years meant for Rosen's original concepts? Acad Emerg Med, 2011, 18(3): 301-304.
4. Griepp RB, Stinson EB, Hollingsworth JF, et al. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg, 1975, 70(6): 1051-1063.
5. Harrington DK, Walker AS, Kaukuntla H, et al. Selective antegrade cerebral perfusion attenuates brain metabolic deficit in aortic arch surgery: a prospective randomized trial. Circulation, 2004, 110(11 Suppl 1): I231-I236.
6. Preventza O, Garcia A, Cooley DA, et al. Total aortic arch replacement: A comparative study of zone 0 hybrid arch exclusion versus traditional open repair. J Thorac Cardiovasc Surg, 2015, 150(6): 1591-1598.
7. Coselli JS. Reflection of pioneers: redo thoracoabdominal aortic aneurysm repair controversies in thoracic aortic aneurysm surgery. Gen Thorac Cardiovasc Surg, 2018, ,[Epub ahead of print].
8. Saari P, Biancari F, Ihlberg L, et al. Early and midterm outcomes after endovascular treatment of degenerative aneurysms of the descending thoracic aorta: a Finnish multicenter study. J Endovasc Ther, 2013, 20(3): 257-264.
9. Melissano G, Civilini E, Bertoglio L, et al. Results of endografting of the aortic arch in different landing zones. Eur J Vasc Endovasc Surg, 2007, 33(5): 561-566.
10. Ishimaru S. Endografting of the aortic arch. J Endovasc Ther, 2004, 11(Suppl 2): I62-I71.
11. Bavaria J, Vallabhajosyula P, Moeller P, et al. Hybrid approaches in the treatment of aortic arch aneurysms: postoperative and midterm outcomes. J Thorac Cardiovasc Surg, 2013, 145(3 Suppl): S85-S90.
12. Czerny M, Funovics M, Schoder M, et al. Transposition of the supra-aortic vessels before stent grafting the aortic arch and descending aorta. J Thorac Cardiovasc Surg, 2013, 145(3 Suppl): S91-S97.
13. Gehringhoff B, Torsello G, Pitoulias GA, et al. Use of chimney grafts in aortic arch pathologies involving the supra-aortic branches. J Endovasc Ther, 2011, 18(5): 650-655.
14. Preventza O, Bakaeen FG, Cervera RD, et al. Deployment of proximal thoracic endograft in zone 0 of the ascending aorta: treatment options and early outcomes for aortic arch aneurysms in a high-risk population. Eur J Cardiothorac Surg, 2013, 44(3): 446-452.
15. Black SA, Wolfe JH, Clark M, et al. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization. J Vasc Surg, 2006, 43(6): 1081-1089.
16. Hata M, Sezai A, Yoshitake I, et al. Clinical trends in optimal treatment strategy for type A acute aortic dissection. Ann Thorac Cardiovasc Surg, 2010, 16(4): 228-235.
17. Guan XL, Wang XL, Liu YY, et al. Changes in the hemostatic system of patients with acute aortic dissection undergoing aortic arch surgery. Ann Thorac Surg, 2016, 101(3): 945-951.
18. Parikh N, Trimarchi S, Gleason TG, et al. Changes in operative strategy for patients enrolled in the International Registry of Acute Aortic Dissection interventional cohort program. J Thorac Cardiovasc Surg, 2017, 153(4): S74-S79.
19. Shono Y, Akahoshi T, Mezuki S, et al. Clinical characteristics of type A acute aortic dissection with CNS symptom. Am J Emerg Med, 2017, 35(12): 1836-1838.
20. Putanov M A, Sokolova M A, Lenkin P I, et al. Use of polypeptide neuroprotection for prevention of postoperative cognitive dysfunction after cardiac surgery: a pilot prospective randomized placebo-controlled clinical study. , 2017, 21(4): 69-78.
21. 王柏春, 刘宗泓, 孟维鑫, 等. 不同体、脑灌注方式对Stanford A型主动脉夹层患者的脑保护研究. 中国胸心血管外科临床杂志, 2013, 20(5): 529-532.
22. 彭小乐, 王晓龙, 刘愚勇, 等. 温度梯度分级对Stanford A型主动脉夹层围术期脑保护的影响. 首都医科大学学报, 2015, 36(3): 364-370.
23. Piffaretti G, Mariscalco G, Lomazzi C, et al. Predictive factors for endoleaks after thoracic aortic aneurysm endograft repair. J Thorac Cardiovasc Surg, 2009, 138(4): 880-885.
24. Saari P, Biancari F, Ihlberg L, et al. Early and midterm outcomes after endovascular treatment of degenerative aneurysms of the descending thoracic aorta: a Finnish multicenter study. J Endovasc Ther, 2013, 20(3): 257-264.
25. Buth J, Harris PL, Hobo R, et al. Neurologic complications associated with endovascular repair of thoracic aortic pathology: Incidence and risk factors. a study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg, 2007, 46(6): 1103-1110.
26. Patel HJ, Upchurch GR Jr, Eliason JL, et al. Hybrid debranching with endovascular repair for thoracoabdominal aneurysms: a comparison with open repair. Ann Thorac Surg, 2010, 89(5): 1475-1481.