急性A型主动脉夹层合并尿毒症患者的外科治疗结果及预后  

Early and late outcome of acute type A aortic dissection in dialysis dependent patients

作　　者：陆利冲[1] 葛敏[1] 陈涛[1] 陈成[1] 王志刚[1] 叶家欣[1] 王东进[1] 薛云星[1] Lu Lichong;Ge Min;Chen Tao;Chen Cheng;Wang Zhigang;Ye Jiaxin;Wang Dongjin;Xue Yunxing(Department of Cardiovascular and Thoracic Surgery,The Affiliated Drum Tower Hospital of Nanjing University Medical School,Nanjing 210008,China)

机构地区：[1]南京大学医学院附属鼓楼医院心胸外科,210008

出　　处：《中华胸心血管外科杂志》2021年第4期216-219,共4页Chinese Journal of Thoracic and Cardiovascular Surgery

基　　金：江苏十三五科教强卫工程医学重点学科(ZDXKA2016019)。

摘　　要：目的总结急性A型主动脉夹层合并终末期肾病需透析治疗的患者行手术治疗的经验及随访结果。方法2014年1月至2020年3月,共收治20例尿毒症合并急性A型主动脉夹层患者,男11例,女9例;年龄26~63岁,平均(47.8±11.3)岁。18例血液透析,2例腹膜透析,透析时间为1周~11年,平均(4.5±3.9)年。17例接受急诊手术,手术均在深低温停循环选择性脑灌注下完成,包括升主动脉替换+全弓降主动脉象鼻支架置入术5例;升主动脉替换+次全弓替换术5例,其中2例置入降主动脉象鼻支架;升主动脉替换+全弓替换+降主动脉象鼻支架置入术4例,其中1例前降支旁路移植1根;主动脉瓣成形(AVP)+升主动脉替换+次全弓替换术2例;Bentall+置入全弓降主动脉象鼻支架置入术1例。结果2例术前破裂死亡,1例保守治疗随访3个月仍生存。手术的17例患者体外循环125~401 min,平均(233.8±84.4)min;主动脉阻断81~292 min,平均(155.5±63.6)min;深低温停循环11~47 min,平均(28.2±10.8)min。术后3例院内死亡。6例出现术后并发症,包括脑梗塞2例,气管切开、脑出血、一过性截瘫和手术部位感染各1例。术后随访3~61个月,平均(11.6±14.5)个月,手术患者1年、5年生存率分别为53%、27%。结论对于透析依赖的终末期肾病合并急性A型主动脉夹层患者应及时手术治疗,药物保守治疗风险高。手术治疗近期结果满意,但远期预后不佳。Objective To summarize acute type A aortic dissection(ATAAD)is relatively uncommon in dialysis patients,and repair outcomes are not fully understood.Methods Between January 2014 and March 2020,20 patients with ATAAD required dialysis for preoperative end-stage renal disease(ESRD)were treated by our group.There were 11 male and 9 female patients at mean age of(47.8±11.3)years.The mean duration of dialysis therapy in the total 20 patients before the onset of ATAAD was(4.5±3.9)years,with 90%(18 cases)of these patients undergoing hemodialysis(rather than peritoneal dialysis).17 patients were treated emergency surgically,surgical operation were performed under deep hypothermic circulatory arrest and perfused the cerebral selective cerebral perfusion,5 cases with ascending aorta+arch fenestrated stent,5 cases with ascending aorta+hemi-arch replacement(2 cases with stent elephant trunk),4 cases with ascending aorta+arch replacement+stent elephant trunk(1 case with coronary artery bypass grafting for left anterior descending coronary artery),2 cases with aortic valvuloplasty+ascending aorta+hemi-arch replacement,1 case with Bentall+arch fenestrated stent.Results 2 patients were died from aortic ruptured before operation,1 patient treated medically was alive three months after admission.Cross-clamp,cardiopulmonary bypass,and circulatory arrest times of all the surgical patients were(233.8±84.4)min,(155.5±63.6)min and(28.2±10.8)min,respectively.The following complications occurred postoperative:3 cases died in the hospital,1 case of tracheotomy,2 cases of cerebral infarction,1 case of cerebral hemorrhage,1 case of transient paraplegia,and 1 case of surgical site infection.After a mean follow-up of(11.6±14.5)months(rang,3-61 months).the overall survival rate at 1 year and 5 years was 53%and 27%respectively.Conclusion Dialysis patients with ATAAD should be operated on urgently and medical treatment carries high risks of aortic rupture,although in-hospital mortality is acceptable,long-term mortality is poor.

关 键 词：急性A型主动脉夹层 尿毒症 终末期肾病 透析 外科治疗 

分 类 号：R654.3[医药卫生—外科学] R692.5[医药卫生—临床医学]