Stanford A型主动脉壁间血肿的外科治疗  

Surgical treatment of Stanford A intramural hematoma

作　　者：刘宁宁[1] 李金东 王龙飞[1] 周子凡[1] 王珺[1] 刘永民[1] 朱俊明[1] 孙立忠[1] Liu Ningning;Li Jindong;Wang Longfei;Zhou Zifan;Wang Jun;Liu Yongmin;Zhu Junming;Sun Lizhong(Department of Cardiovascular Surgery,Beijing Anzhen Hospital of Capital Medical University,Beijing Aortic Disease Center,Beijing Institute of Heart Lung and Blood Vessel Diseases,Beijing 100029,China;Deparctment of Cardiac Surgery,Liaocheng People Hospital,Liaochen 252000,China)

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,100029 [2]山东省聊城市人民医院心外科,252000

出　　处：《中华胸心血管外科杂志》2019年第11期684-687,共4页Chinese Journal of Thoracic and Cardiovascular Surgery

基　　金：首都医科大学附属北京安贞医院院长基金(2016P05)。

摘　　要：目的探索Stanford A型主动脉壁间血肿(IMH)患者外科治疗的方法及时机。方法2015年2月至2017年8月,60例Stanford A型主动脉壁间血肿患者行手术治疗,回顾性分析其临床资料。其中男38例,女22例;年龄(51.5±6.2)岁。患者升主动脉IMH合并溃疡;升主动脉直径≥50 mm(包括血肿);升主动脉血肿厚度≥10 mm;心包积液或者胸腔积液;症状不缓解或再发或合并中度以上主动脉瓣关闭不全。其中行升主动脉替换+全主动脉弓替换并支架象鼻置入术(孙氏手术)46例,Bentall术+孙氏手术6例(其中包括左侧单椎动脉-左颈总动脉移植1例),升主动脉替换+半弓替换4例,Bentall术+半弓替换2例,升主动脉替换2例。结果术中发现主动脉内膜破损34例(56.7%)。术后1例(1.7%)死于多器官功能衰竭。术后出现低氧血症5例(8.3%);肾功能衰竭需CRRT 2例(3.3%);脑血管并发症1例(1.7%);二次开胸1例(1.7%);术后截瘫1例(1.7%);经治疗后均好转。随访3~15个月,无死亡;2例需再次手术干预行TEVAR术。近端吻合口漏2例,行介入封堵术。1、3及6个月远端血肿基本吸收率分别为68.6%、84.7%及94.8%。结论掌握好手术指征及选择合适的手术方式是外科治疗Stanford A型主动脉壁间血肿患者的关键,孙氏手术治疗A型主动脉壁间血肿近、中期临床效果较好。Objective To summarize experience and result in surgical treatment of Stanford type A intramural hematoma.Methods 60 patients with Stanford type A intramural hematoma were operated from February 2015 to August 2017.Surgery was indicated in complicated cases with penetrating ulcer or ulcer-like projection in ascending aorta,maximum aorta diameter≥50 mm,progressive maximum aortic wall thickness≥10 mm,pericardial or pleural effusion,persistent or recurrent pain.Aortic valve regurgitation.In our group,46 patients recieved ascending aorta replacement+Sun's procedure.6 patients recieved Bentall+Sun's procedure.4 patients recieved asceding aorta+hemiarch replacement.2 patients recieved Bentall+hemiarch replacement.2 patients recieved asceding aorta replacement.Results In the whole group,there was 1(1.7%)operative death because of multiple organ failure after operation.Hyoxemiaoccured in 5(8.3%)patients,2(3.3%)patients occurred new renal failure and required CRRT treatment,cerebrovascular complication occurred in 1(1.7%)patient,re-sternotomy due to bleeeding occured in 1(1.7%)patient and paraplegia occured in 1(1.7%)patient after operation.but they recoved quickly after proper treatment.During follow up period,there were 4 cases need reintervention,including TEVAR for type B dissection at 3 months and distal stent-graft new entry at 1 year.Two other reinterventions were performed for endoleak by interventional occlusion.During the follow-up,hematoma absorption rates after treatment 1、3 and 6 months were 68.6%,84.7%and 94.8%.Conclusion Given the dynamic evolution of acute type A IMH pre-operative accurate indications and the proper surgical strategy maybe the keys for success.

关 键 词：主动脉壁间血肿 外科手术 体外循环 孙氏手术 

分 类 号：R65[医药卫生—外科学]