胸主动脉腔内修复术后再发Stanford A型主动脉夹层的外科治疗  

Surgical treatment of Stanford type A aortic dissection after thoracic endovascular aortic repair

作　　者：肖长波[1] 喻红霞[2] 毛蕾芳[1] 张力[1] 张亚飞 孙科雄 高夏[1] 武刚[1] 崔聪[1] 张向辉 陈玉新 王平凡[1] Xiao Changbo;Yu Hongxia;Mao Leifang;Zhang Li;Zhang Yafei;Sun Kexiong;Gao Xia;Wu Gang;Cui Cong;Zhang Xianghui;Chen Yuxin;Wang Pingfan(Department of Cardiovascular Surgery,Henan Chest Hospital,Zhengzhou 450001,China;Department of Ultrasound,the Second Affiliated Hospital of Zhengzhou University,Zhengzhou 450003,China)

机构地区：[1]河南省胸科医院心血管外科八病区(大血管外科病区),郑州450001 [2]郑州大学第二附属医院超声科,450003

出　　处：《中华外科杂志》2021年第6期520-524,共5页Chinese Journal of Surgery

基　　金：河南省医学科技攻关计划(2018020551,201602297)。

摘　　要：目的探讨胸主动脉腔内修复术(TEVAR)后再发Stanford A型主动脉夹层(A型夹层)的外科治疗经验。方法回顾性分析2012年2月至2020年1月河南省胸科医院心血管外科收治的58例TEVAR术后再发A型夹层患者的资料。男性40例,女性18例,年龄(57.0±6.7)岁(范围:31~71岁)。术后再发A型夹层距TEVAR的时间[M(QR)]为37 d(72.8个月)(范围:1 h至14年)。48例急诊手术,9例亚急诊手术,1例转运至手术室途中因夹层破裂死亡。57例手术患者均行主动脉根部处理。54例于深低温停循环选择性脑灌注下行全弓置换,3例(年龄>65岁)于浅低温下行弓部去分支吻合+升主动脉置换+弓降部覆膜支架植入术。结果手术时间(445±32)min(范围:382~485 min),主动脉阻断时间(103±19)min(范围:89~133 min),心肺转流时间(189±27)min(范围:162~221 min),术中出血量(665±343)ml(范围:450~1750 ml)。术后ICU停留时间5(6)d(范围:2~27 d),术后住院时间14.0(4.5)d(范围:2~36 d)。死亡3例,包括严重脑部并发症2例,严重肝功能不全合并消化道出血导致全身多器官功能衰竭1例。术后随访0.5~7.0年,1例术后3个月发生左冠状动脉吻合口漏,行再次手术,2例再次行胸腹主动脉置换,其余患者CT血管造影未见吻合口漏和支架扭曲膨胀不全。4例随访期间死亡,1例术后2年突发脑梗死。结论TEVAR术后再发A型夹层多数与支架移植物相关,积极的外科手术可获得良好的预后。Objective To examine the surgical treatment of Stanford type A aortic dissection(type A dissection)after thoracic endovascular aortic repair(TEVAR).Methods The data of 58 patients with reoccurrence of type A dissection after TEVAR admitted into the Department of Cardiovascular Surgery,Henan Chest Hospital from February 2012 to January 2020 were analyzed retrospectively.There were 40 males and 18 females,aged(57.0±6.7)years(range:31 to 71 years).The time between recurrence of type A dissection and TEVAR(M(QR))was 37 days(72.8 months)(range:1 h to 14 years).Forty-eight cases underwent emergency operation,9 cases underwent sub-emergency operation,and 1 case died of dissection rupture on the way to the operating room.All 57 patients underwent radical treatment.Fifty-four cases underwent the frozen elephant trunk technique under deep hypothermia circulatory arrest and selective cerebral perfusion,and 3 cases(>65 years old)underwent arch debranch anastomosis+ascending aorta replacement+descending arch covered stent implantation under mild hypothermia.Results The operation time was(445±32)minutes(range:382 to 485 minutes),the aortic crossclamp time was(103±19)minutes(range:89 to 133 minutes),the cardiopulmonary bypass time was(189±27)minutes(range:162 to 221 minutes),and the intraoperative blood loss was(665±343)ml(range:450 to 1750 ml).Postoperative ICU stay time was 5(6)days(range:2 to 27 days),and postoperative hospital stay was 14.0(4.5)days(range:2 to 36 days).Three cases died,including 2 cases with severe brain complications and 1 case with systemic multiple organ failure caused by severe liver insufficiency and gastrointestinal hemorrhage.Postoperative follow-up was 0.5 to 7.0 years,which showed that 1 case had left coronary artery anastomotic stoma fistula 3 months after operation and underwent reoperation,2 cases underwent thoracoabdominal aortic replacement again,and the rest of patients had no anastomotic stoma fistula and incomplete stent distortion and expansion on CT angiography.Four cases died during

关 键 词：动脉瘤 夹层 主动脉 血管内手术 支架 

分 类 号：R654.3[医药卫生—外科学]