Stanford A型主动脉夹层合并迷走右锁骨下动脉的外科治疗  

Surgical Repair of Stanford Type A Aortic Dissection Involving an Aberrant Right Subclavian Artery

作　　者：钟永亮[1] 朱俊明[1] 齐瑞东[1] 葛翼鹏[1] 陈雷[1] 刘巍[1] 里程楠[1] 郑军[1] 刘永民[1] 孙立忠[1] 

机构地区：[1]首都医科大学附属北京安贞医院心血管外科北京市大血管疾病诊疗研究中心北京市心肺血管疾病研究所,北京100029

出　　处：《中国胸心血管外科临床杂志》2016年第11期1055-1060,共6页Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

基　　金：国家科技支撑计划项目(2015BAI12B03);国家卫计委公益性卫生行业科研专项(201402009)~~

摘　　要：目的总结Stanford A型主动脉夹层(type A aortic dissection,TAAD)合并迷走右锁骨下动脉(aberrant right subclavian artery,ARSA)的外科治疗经验和效果。方法 2009年3月至2016年1月,我中心共收治TAAD合并ARSA患者14例。其中急性TAAD 10例,慢性TAAD 4例;男11例、女3例,平均年龄(46.07±8.45)岁。所有患者均在低温体外循环、选择性顺行性脑灌注下进行手术。13例(13/14,92.86%)行全主动脉弓置换+支架象鼻植入术(孙氏手术),1例(1/14,7.14%)行Bentall+部分弓置换术,未行ARSA重建。结果全组平均手术时间(7.89±1.80)h,体外循环时间(208.43±28.84)min,主动脉阻断时间(117.64±23.30)min,选择性脑灌注时间(30.50±10.15)min。无手术死亡。术后早期死亡2例(14.29%)。二次开胸止血1例(7.14%),一过性肾功能不全1例(7.14%),肾衰竭1例(7.14%)。平均术后随访(28.42±22.52)个月,随访率100.00%(12/12)。1例术后64个月死于心力衰竭和肾衰竭。其余患者无主动脉相关并发症。结论合并ARSA的TAAD术前应明确诊断,术中选择合理的动脉插管及脑灌注方法。同期行孙氏手术和ARSA重建治疗TAAD合并ARSA可获得满意的临床效果。Objective To summarize our experience and clinical effect of surgical treatment of Stanford type A aortic dissection （TAAD） involving an aberrant right subclavian artery （ARSA）. Methods From March 2009 to January 2016, 14 patients with TAAD involving an ARSA （acute TAAD, n--10; chronic TAAD, n=4） underwent operation under hypothermic cardiopulmonary bypass combined with selective antegrade cerebral perfusion in our center. There were 11 male and 3 female patients with a mean age of 46.07±8.45 years. A total of 13 patients （13/14, 92.86%） underwent stented elephant trunk procedure combined with total arch replacement （Sun＇s procedure）. The remaining patient （1/14, 7.14%） underwent partial aortic arch replacement combined with Bentall procedure without ARSA revascularization. Results The average operation time, cardiopulmonary bypass time, aortic cross-clamping time and selective cerebral perfusion time was 7.89±1.80 h, 208.43±28.84 min, 117.64±23.30 min, and 30.50±10.15 min, respectively. No operation-related deaths occurred. However, two （14.29%） patients died on postoperative 5 d, 7 d, respectively in hospital. One patient required repeat thoracotomy for bleeding, one suffered temporary renal dysfunction and one renal failure （this patient had renal failure before surgery）. The mean follow-up was 28.42±22.52 months with a follow-up rate of 100.00% （12/12）. One patient died of heart failure and renal failure at 64 months after operation. The others were free from any aortic complications during follow-up. Conclusions TAAD involving an ARSA should be clearly diagnosed before surgery, and treated by the optimal arterial cannulation and cerebral perfusion during operation. Repair of aortic dissection with Sun＇s procedure and revascularization of the ARSA can obtain satisfactory clinical outcomes in patients with TAAD involving an ARSA.

关 键 词：STANFORD A型主动脉夹层 迷走右锁骨下动脉 孙氏手术 

分 类 号：R654.3[医药卫生—外科学]