A型主动脉壁内血肿的外科治疗:单中心106例报道  

Surgical Management of Type A Intramural Hematoma:A Single-Center Experience with 106 Cases

作　　者：史艺[1] 顿耀军 郭宏伟[1] 钱向阳[1] 于存涛[1] 孙晓刚[1] SHI Yi;DUN Yao-jun;GUO Hong-wei;QIAN Xiang-yang;YU Cun-tao;SUN Xiao-gang(Department of Cardiovascular Surgery,Fuwai Hospital,National Center for Cardiovascular Diseases,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100037,China.)

机构地区：[1]中国医学科学院,北京协和医学院国家心血管病中心,阜外医院心血管外科,北京市100037

出　　处：《中国分子心脏病学杂志》2019年第6期3113-3118,共6页Molecular Cardiology of China

摘　　要：目的总结本中心A型主动脉壁内血肿(intramural hematoma,IMH)的外科治疗经验,分析近期和远期临床结果。方法选取2012年2月至2018年4月在阜外医院接受手术治疗的A型IMH患者共106例。手术策略:出现心包填塞或其他严重并发症的患者接受急诊手术,对病情稳定的患者采取初始药物治疗和择期手术治疗。临床终点包括手术死亡和复合临床终点,复合临床终点为死亡、永久性神经损伤(卒中和截瘫)和新发的需血液滤过治疗的肾损伤。采用Logistic单因素和多因素回归分析手术死亡和复合临床终点的危险因素,采用Kaplan-Meier生存曲线评估患者的远期生存率和免于主动脉事件生存率。结果本组患者中,急性IMH 79例,亚急性IMH 27例。平均年龄(57.9±10.6)岁,58例(54.7%)为女性。1例因心包填塞行急诊手术,其余患者接受初始药物治疗和择期手术。9例患者行升主动脉置换术,18例患者行部分主动脉弓置换术,45例患者行全主动脉弓置换术及支架象鼻术,34例患者行杂交全主动脉弓置换术。其中23例患者同时合并其他手术。平均体外循环时间和主动脉阻断时间分别为(138.7±41.6)min和(79.3±27.8)min。55例(51.9%)患者术中进行低温停循环,平均持续时间为(18.5±6.1)min。手术死亡率为1.9%(2/106),7例患者出现复合临床终点。多因素回归分析显示:体外循环时间≥200 min和慢性肾脏病是复合临床终点的独立危险因素。共97例患者完成随访,平均随访时间为(30.8±16.2)个月。随访期间,3例死亡,5例发生主动脉事件。1年、3年和5年生存率分别为97.0%、95.3%和79.4%,而1年、3年和5年免于主动脉事件生存率分别为97.7%、95.3%和89.4%。急性IMH组和亚急性IMH组之间生存率和免于主动脉事件生存率均无统计学差异。结论对出现心包填塞或其他严重并发症的患者采取急诊手术,对病情稳定的患者采取初始药物治疗和择期手术治疗。�Objective To summarize the surgical experiences of patients with type A intramural hematoma(IMH)in our center,and analyze early and late outcomes.Methods From February 2012 to April 2018,106 consecutive patients underwent open surgery for type A IMH at Fuwai hospital.We adopted emergent operation for patients with cardiac tamponade or other severe complications,and recommended initial medical treatment followed by elective surgery for stable patients with type A IMH.The endpoints were defined as operative mortality and composite endpoints that included operative mortality,permanent nerve damage(stroke,paraplegia),and new-onset renal failure necessitating hemodialysis at discharge.Risk factors for operative mortality and composite endpoints were identified using univariable and multivariable logistic regression model analysis.Midand long-term survival and freedom from aortic events were analyzed using a Kaplan–Meier survival curve.Results There were 79 patients with acute IMH and 27 patients with subacute IMH.The mean age was(57.9±10.6)years,and 58 patients(54.7%)were male.Except one receiving emergent surgery for cardiac tamponade,other patients received primary medical treatment and elective surgery.The operative techniques included ascending aorta replacement in 9 patients,hemiarch replacement in 18 patients,total arch replacement with frozen elephant trunk in 45 patient and hybrid aortic arch repair in 34 patients.23 patients underwent additional procedures.The mean cardiopulmonary bypass time and cross-clamp time were(138.7±41.6)min and(79.3±27.8)min,respectively.55 patients(51.9%)underwent operation under hypothermia circulatory arrest and the mean duration was(18.5±6.1)min.The operative mortality was 1.9%and the composite endpoints occurred in 7 patients.Multivariable logistic regression analysis showed cardiopulmonary bypass time≥200 min and chronic kidney disease were risk factors for composite endpoints.The follow-up data were available for 97 survivors.The mean follow-up time was(30.8±16.2)mont

关 键 词：主动脉壁内血肿 主动脉 外科治疗 

分 类 号：R654.3[医药卫生—外科学]