急性Stanford A型主动脉夹层合并下肢缺血的外科治疗  

Surgical repair of acute Stanford type A aortic dissection with lower extremity ischemia

作　　者：董松波[1] 郑军[1] 李建荣[1] 许尚栋[1] 刘永民[1] 孙立忠[1] 潘旭东[1] Dong Songbo;Zheng Jun;Li Jianrong;Xu Shangdong;Liu Yongmin;Sun Lizhong;Pan Xudong(Department of Cardiovascular Surgery,Beijing Anzhen Hospital,Capital Medical University,Beijing Institute of Heart,Lung and Blood Vessel Diseases,Beijing 100029,China)

机构地区：[1]首都医科大学附属北京安贞医院心脏外科,北京市心肺血管疾病研究所,100029

出　　处：《中华胸心血管外科杂志》2021年第2期75-78,共4页Chinese Journal of Thoracic and Cardiovascular Surgery

基　　金：国家卫生和计划生育委员会:公益性行业科研专项项目(201402009);北京市医院管理局临床医学发展专项经费资助(ZYLX201503)。

摘　　要：目的:探讨使用缺血侧下肢股动脉及右腋动脉插管行孙氏手术在急性A型主动脉夹层合并下肢缺血外科治疗中的效果。方法:回顾性分析2017年7月至2019年5月,12例采用缺血侧股动脉人工血管及右腋动脉双插管治疗的合并下肢缺血的急性Stanford A型主动脉夹层患者资料。患者均为男性,年龄(48.4±8.4)岁。合并单侧下肢缺血11例,双侧下肢缺血1例,发病至手术时间24.00(18.50,43.25)h。使用缺血侧股动脉端侧吻合8 mm人工血管及右腋动脉双插管转机。根部操作:Bentall术5例、升主动脉替换3例、瓣交界加固及升主动脉替换4例。弓部操作为全主动脉弓替换+支架型人工血管置入12例。结果:围手术期死亡1例。体外循环(204.6±26.3)min,阻断主动脉(114.6±16.6)min,停循环(23.4±8.5)min,选择性脑灌注(33.5±11.0)min。5例患者同期行转流术:升主动脉-双股动脉转流1例;升主动脉-右股动脉转流3例;升主动脉-左股动脉转流1例。急性肾功能衰竭CRRT治疗4例,再次开胸探查止血1例,再次气管插管1例,下肢骨筋膜室综合征切开减压1例。随访(17.2±7.6)个月,随访期间无严重不良事件。结论:对于合并下肢缺血的急性Stanford A型主动脉夹层,使用缺血侧下肢股动脉人工血管及右腋动脉联合插管行孙氏手术,有助于降低围手术期死亡比例,改善预后。Objective To explore the application of cannulating the ischemic femoral and right axillary artery in Sun’s procedure for acute type A aortic dissection with lower extremity ischemia.Methods Twelve patients of acute Stanford type A aortic dissection complicated by lower extremity ischemia were analyzed retrospectively between July 2017 and May 2019,and the right axillary and ischemic femoral artery were used for cardiopulmonary bypass.All the 12 patients were male and categorized as the complicated Stanford type A aortic dissection.The mean age was(48.4±8.4)years,and the median time from symptom onset to emergency operation was 24.00(18.50,43.25)hours.Eleven patients presented with unilateral extremity ischemia,while bilateral extremity ischemia occurred in one.The prosthetic vessel,with a diameter of 8 mm,was anastomosed to the ischemic femoral artery via an end-to-side way.Both the right axillary artery and the prosthetic vessel were cannulated for CPB.For the proximal dissection in this cohort of patients,we performed Bentall procedure in 5 cases,ascending aortic replacement in 3,and the aortic valve commissure reconstruction with ascending aortic replacement in 4.Total arch replacement with stented elephant trunk implantation were carried out for arch and descending aortic lesion in 12 cases.Results Early mortality was 8.3%(1/12).The time of CPB,aortic clamp,circulatory arrest,and selective cerebral perfusion averaged(204.6±26.3)min,(114.6±16.6)min,(23.4±8.5)min,and(33.5±11.0)min,respectively.Five patients underwent concomitant bypass procedures,including:ascending aorta-bilateral femoral artery bypass in 1,ascending aorta-right femoral artery bypass in 3,ascending aorta-left femoral artery bypass in 1.Acute renal failure with continuous renal replacement therapy occurred in 4 cases,re-thoratomy for hemaostsis in 1,and re-intubation in 1.One patient developed osteofascial compartment syndrome after aortic repair,and consequent left lower extremity compartment fasciotomy was performed.The mean follow-up

关 键 词：急性A型主动脉夹层 下肢缺血 外科治疗 

分 类 号：R654[医药卫生—外科学]