全弓替换支架象鼻技术治疗急性A型主动脉夹层的中远期结果  

Mid-to long-term outcomes of frozen elephant trunk and total arch replacement in patients with acute type A dissection

作　　者：张巍 马维国 郑军 潘旭东 刘永民 朱俊明 孙立忠 

机构地区：[1]首都医科大学附属北京安贞医院北京市心肺血管疾病研究所中国医学科学院阜外心血管病医院,100029

出　　处：《中华胸心血管外科杂志》2017年第9期549-556,共8页Chinese Journal of Thoracic and Cardiovascular Surgery

基　　金：国家科技支撑计划课题（2015BA112803）;卫生部公益性行业科研专项项目（201402009）

摘　　要：目的 报道全弓替换＋支架象鼻技术治疗急性A型主动脉夹层（ATAAD）的早期及中远期效果.方法 2003年4月至2012年9月,为456名累及弓部或降主动脉的ATAAD患者施行了四分支人工血管全主动脉弓替换＋降主动脉象鼻支架置入手术（孙氏手术）.男376例（82.5％）,女80例;年龄（46.3±10.5）岁;发病距手术时间（5.0±3.8）天（中位数4天,范围5h～14天）;221例患者需同期行主动脉根部或瓣膜手术（48.5％）.比较手术早期及远期结果并确认危险因素.结果 手术死亡37例（8.1％）,急性肾功能衰竭18例（3.9％）,卒中13例（2.8％）,脊髓损伤11例（2.4％）,出血开胸探查10例（2.2％）.手术死亡的危险因素为：术前脑灌注不良（相对危险度,OR 7.643,P=0.002）、脊髓（OR45.315,P=0.003）灌注不良和体外循环时间（min,OR1.014,P＜0.001）.随访（5.7±2.4）年（0.2～12.0年）,失访10例,随访率97.6％ （409/419）.远期死亡32例,远期再手术23例.全组术后5、8、10年的生存率分别为87.7％、83.1％和70.5％,再手术免除率分别为94.8％、89.3％和84.3％.远期死亡的危险因素为术后卒中（OR 14.452,P=0.014）,远期再手术的危险因素为诊断至手术的时间（天,OR1.188,P=0.024）;同期根部手术可降低患者远期死亡的风险（OR 0.377,P=0.021）,但增加患者远期再手术的风险（OR2.663,P=0.037）.竞争风险分析显示,术后3、5、8和10年死亡分别占2％、5％、10％和23％,再手术率分别为3％、5％、8％和10％,无事件生存率分别为95％、90％、82％和67％.结论 本组ATAAD患者全弓替换＋支架象鼻技术取得了良好的早期、远期生存与再手术免除率.同期根部手术不增加早期死亡率,可显著减少远期死亡的风险.Objective Continued debates exist regarding optimal surgical approach to acute type A aortic dissection （ATAAD）.This study aims to report the early and mid-to long-term outcomes of frozen elephant trunk and total arch replacement （FET ＋ TAR） technique in patients with ATAAD involving the arch and descending aorta.Methods Between April 2003 and September 2012,we performed FET ＋ TAR （the Sun procedure） for 456 patients with ATAAD （376 males,82.5%） at mean （5.0±3.8） days from symptom onset （median 4 days,range 4 hours to 14 days）.Mean age was （46 ± 10） years.Concomitant root or valve provcedures were performed in 221 patients （48.5 %）.The outcomes were compared between patients with and without root procedures and risk factors for adverse events identified using multivariate analysis.Results Operative mortality was 8.1% （37/456）.Stroke occurred in 13 eases （2.8%）,spinal cord injury in 11 （2.4%）,acute renal failure in 18 （3.0%） and reexploration for bleeding in 10 （2.2%）.Risk factors for operative mortality were preoperative malperfusion of the brain （odds ratio,OR 7.463,P =0.002） and spinal cord （OR 45.325,P =0.003） and time （min） of cardiopulmonary bypass （OR 1.014,P 〈0.001）.Follow-up was complete in 97.6% （409/419） averaging （5.7 ±2.4） years （range 0.2-12.0）.Late death occurred in 32 patients and reoperation in 23.At 5,8 and 10 years,survival 87.7%,83.1% and 70.5%,and freedom from reoperation was 94.8%,89.3% and 84.3%,respectively,which did not differ with root procedure and acuity.Postoperative stroke was risk factor for late death （OR 14.452,P =0.014）.The time from diagnosis to surgery （days） was risk factor for reoperation （OR 1.188,P =0.024）.Patients with concomitant root procedure showed a significant trend towards lower late mortality （OR 0.377,P =0.021） and increased reoperation risk （OR 2.663,P =0.037）.Competing risks analysis showed that at 3,5,8 and 10 years,mortality was 2%,5%,10% and 23%,reopera

关 键 词：主动脉夹层 心脏外科手术 随访 

分 类 号：R654.3[医药卫生—外科学]