急性A型主动脉夹层合并下肢缺血的处理策略  

Management strategy of acute aortic dissection of type A with lower limb ischemia

作　　者：陈瑞 陈涛 邵俊[1] 叶敬霆 朱继高 唐程斌 CHEN Rui;CHEN Tao;SHAO Jun;YE Jingting;ZHU Jigao;TANG Chengbin(Cadiovascular Center,Jiangsu North People′s Hospital of Jiangsu Province,Yangzhou,Jiangsu,225001)

机构地区：[1]江苏省苏北人民医院心脏大血管中心,江苏扬州225001

出　　处：《实用临床医药杂志》2023年第16期63-67,共5页Journal of Clinical Medicine in Practice

基　　金：国家自然科学基金青年项目(81702377);江苏省扬州市重点研发计划项目(社会发展)(Y2022098)。

摘　　要：目的探讨急性A型主动脉夹层合并下肢缺血的处理策略。方法回顾性分析318例急性A型主动脉夹层患者的临床资料,其中34例合并下肢灌注不良(单侧下肢缺血29例,双侧下肢缺血5例),发病至手术时间为(5.2±1.3)h。用缺血下肢股动脉缝制8~10 mm人工血管和右腋动脉双插管建立体外循环尽快恢复缺血下肢血供18例;健侧股动脉单插管16例,向患侧股动脉远端插入深静脉置管,用股动脉插管侧支与深静脉置管近端连接,恢复缺血肢体远端血供。结果34例患者中,死亡2例,其中1例因合并肠缺血坏死而死亡,另1例因术后发生骨筋膜室综合征而死亡;因急性肾功能衰竭行连续性肾替代治疗(CRRT)者17例,术后发生结肠、胆囊坏死行结肠和胆囊切除手术者1例,无再次开胸止血患者,术后因呼吸衰竭而再次气管插管者3例;随访(27.2±3.5)个月,随访期间发生股动脉人工血管闭塞6例。结论急性A型主动脉夹层合并下肢缺血致死率高,术后并发症多,术前全面评估、合理制订手术方案并积极实施手术治疗是救治成功的关键。Objective To explore management strategy of acute aortic dissection of type A with lower limb ischemia.Methods A retrospective analysis was performed in 318 patients with acute type A aortic dissection,including 34 patients with lower limb malperfusion(29 cases of unilateral lower limb ischemia and 5 cases of bilateral lower limb ischemia).The time from onset to operation was(5.2±1.3)h.A total of 18 cases of ischemic lower limb blood supply were restored by cardiopulmonary bypass(CPB)with 8 to 10 mm artificial blood vessel sewed from femoral artery and right axillary artery intubation.The healthy side femoral artery was intubated in 16 cases.A deep vein catheterization tube was inserted into the distal end of the affected femoral artery,and the lateral branch of the femoral artery cannula was connected to the proximal end of the deep vein catheterization tube to restore the blood supply to the remote end of the ischemic limb.Results Of the 34 patients,2 died,of which 1 died due to intestinal ischemic necrosis and the other died result from postoperative osteofascial compartment syndrome.There were 17 patients who underwent continuous renal replacement therapy(CRRT)due to acute renal failure,1 patient who underwent colon and gallbladder necrosis after surgery underwent colon and gallbladder resection,no patient with rethoracotomy for hemostasis,and 3 patients who underwent retracheal intubation due to respiratory failure.During the follow-up of(27.2±3.5)months,6 cases of femoral artery artificial vessel occlusion occurred.Conclusion Type A aortic dissection with lower extremity ischemia has high mortality and more postoperative complications.Comprehensive preoperative evaluation,reasonable operation plan and active operation are the key to successful treatment.

关 键 词：急性A型主动脉夹层 人工血管置换 下肢缺血 股股转流 急性肾功能衰竭 

分 类 号：R543.5[医药卫生—心血管疾病] R541[医药卫生—内科学]