【作者】 齐瑞东；

【导师】 孙立忠；

【作者基本信息】 中国协和医科大学 ， 外科学， 2007， 博士

【摘要】 随着人民生活水平的提高,心血管疾病已逐步成为发展中国家人口死亡的主要原因。主动脉夹层,特别是急性主动脉夹层,是一种致命性心血管疾病,死亡率和并发症均很高。急性Stanford A型主动脉夹层累及主动脉瓣可致急性左心衰竭、累及冠状动脉可致急性心肌梗塞、累及头臂动脉可致脑血管意外、累及腹腔脏器动脉可致急性肾功能衰竭和内脏缺血性坏死、主动脉破裂可引起急性心包填塞和失血性性休克,致患者突然死亡。外科手术治疗急性StanfordA型主动脉夹层为人们所公认。然而急性Stanford B型主动脉夹层治疗的最佳方式目前还存在争议。对无并发症的急性Stanford B型主动脉夹层,多数中心采用内科保守治疗。对有主动脉破裂征象(大量胸腔积血,出血性休克),或有主动脉破裂倾向者(高血压不能药物控制,疼痛不能药物缓解,主动脉直径短期内迅速增大),以及重要腹腔器官或下肢出现供血障碍时,采取积极手术治疗。尽管外科手术技术、麻醉体外循环技术、围手术期护理技术得到普遍提高,急性Stanford B型主动脉夹层手术死亡率仍高达29.3%。手术后假腔的存在、扩张及破裂,腹腔脏器血供障碍,是影响急性Stanford B型主动脉夹层手术疗效的主要因素。覆膜支架主动脉腔内修复术的迅速发展,明显改善了Stanford B型主动脉夹层的预后,降低了死亡率和并发症。而部分患者主动脉病变的解剖结构并不适于主动脉腔内修复术,如胸降主动脉近端严重扩张、夹层累及主动脉弓、内膜破口距左锁骨下动脉开口少于2cm、股动脉及髂动脉异常以及结缔组织病。随着象鼻手术的改进,支架象鼻手术广泛应用于主动脉瘤、Stanford A型主动脉夹层、Stanford B型主动脉夹层。临床研究结果表明,支架象鼻手术能防止Stanford A型主动脉夹层远端残存假腔扩大、器官血供障碍及远期再手术。为提高Stanford B型主动脉夹层的手术疗效,降低患者手术死亡率和并发症,提高其远期疗效,我们将支架象鼻手术进行了改良,并根据Stanford B型主动脉夹层的细化分型,针对不同亚型,采用不同的支架象鼻手术,以达到规范化治疗的目的。本文报告了支架象鼻手术在Stanford B型主动脉夹层中的应用。第一部分,总结了降主动脉替换+短支架象鼻手术在急性单纯型Stanford B型主动脉夹层中的临床应用8例,无手术死亡。术后2例患者发生脊髓损伤,1例截瘫患者于术后失访,1例轻瘫患者于术后完全恢复,无其它严重并发症发生。表明降主动脉替换+短支架象鼻手术应用于急性单纯型Stanford B主动脉夹层操作简单,能有效防止远端假腔扩张破裂,改善器官血供。第二部分,总结了降主动脉替换+短支架象鼻手术在8例慢性单纯型Stanford B型主动脉夹层中的临床应用,无手术死亡,无脊髓损伤及器官缺血并发症发生。表明支架象鼻手术应用于慢性StanfordB型主动脉夹层并不能导致器官血供障碍。相反,支架象鼻手术能够改善器官血供障碍。第三部分,总结了全主动脉弓替换+支架象鼻手术在17例复杂型StanfordB型主动脉夹层中的应用,非体外循环下手术死亡2例,1例以支架象鼻手术作准备二期行胸腹主动脉替换,无并发症发生。表明全主动脉弓替换+支架象鼻手术在深低温停循环选择性脑灌注下是安全有效的,可一期根治主动脉弓近端和远端病变,避免远端假腔扩张,改善器官血供障碍,避免夹层逆行剥离,还可简化二期手术。第四部分,总结了全主动脉弓替换+支架象鼻手术在4例单纯型Stanford B型主动脉夹层中的应用,表明该手术一方面可同期处理Stanford B型主动脉夹层和主动脉弓近端病变和/或心脏病变,避免主动脉弓形成夹层或动脉瘤;另一方面还可促进远端假腔血栓形成闭塞,提高手术疗效。最后总结性评价了支架象鼻手术在Stanford B型主动脉夹层中的应用,可改善器官供血障碍、促进远端假腔血栓形成和闭塞、简化二期手术,降低了手术死亡率和并发症,有助于提高Stanford B型主动脉夹层外科治疗的近期和远期疗效。更多还原

【Abstract】 With the development of people’s living standard, the cardiovascular disease is the key reason of death in the developing countries. Aortic dissection, especially acute aortic dissection, is a serious cardiovascular disease associated with high morbidity and mortality. It could lead to death because of acute left heart failure, acute myocardial infarction, cerebral incidence, acute renal failure, cervical organ ischemia involved with intimal tear, and acute pericardial effusion/tamponade or hemorrhagic shock due to aortic rupture. The emergency surgical treatment was required to be performed in patients with Stanford type A aortic dissection with consensus. However, the optimal mode of treatment strategy for the patients with Stanford type B aortic dissection remains some controversial presently. Aggressive medical therapy was the preferred method for the only uncomplicated patients and operative intervention was indicated if there was life threatening situations such as sign of aortic rupture (pleural effusion and hemorrhagic shock), being prone to aortic rupture (uncontrollable hypertension, refractory pain and progressive decrease of aortic diameter) and cervical organ or limb malperfusion in the patients with acute or chronic type B aortic dissection. Despite the improvements made with regard to surgical treatment, CPB technique and the nursing level of the perioperative stage, the mortality was 29% with its poor outcome. The situations such as false lumen dilation, false lumen rupture and the end-organ malperfusion might have a great influence on the operative results in patients with Stanford type B aortic dissection. Endovascualr stent graft treatment with low morbidity and mortality may be an alternative to open surgery. Some patients with type B dissection received endovascualr treatment with stented graft to cover the primary intimal tear and obliterate the false lumen, and then acquired satisfactory results. However, endovascualr stent graft placement was not suitable to the patients while there was no precise targeting of the stent landing zone and the open surgery was mandatory for these patients. Appropriate extent resection of descending aorta was confronted with surgeon and palliative procedure was performed to avoid severe complication. Limited resection of descending thoracic aorta and reconstitution of aortic layers distally by means of suture of the dissected septum to the adventitial were performed or blood flow was restored in both the true and the false channels in some time. False lumen remained patent and dilated progressively in most patients. Moreover, the patency of false lumen was a strong independence risk factor of dissected-related morbidity and mortality. With the improvement of elephant trunk, the stented elephant trunk was applicable to the patients with aortic dissection and aortic aneurysm. The elephant trunk procedure was useful for the patients with aortic dissection to promote obliteration of false lumen with thrombus formation, reverse organ malperfusion and avoid reoperation in the future. We performed the stented elephant trunk procedure for the patients with Stanford type B aortic dissection. The subtype of aortic dissection is much useful in determining the optimal procedure, operative indication and plan, estimating the prognosis.This report describes the application of stented elephant trunk in patients with Stanford type B aortic dissection according to the subtype of aortic dissection. The experience of proximal descending thoracic aortic replacement associated with short stented elephant trunk implantation for acute simple Stanford type B aortic dissection was reported in the first part. A total of 9 pateints with acute Stanford type B aortic dissection underwent this procedure. There was no death in this group. And spinal cord injuries occurred in 2 patients. One patient with paresis recovered fully during the follow-up. No other complication observed. Proximal descending thoracic aorta replacement associated with short stented elephant trunk implantation was a fine surgical procedure for the patients with acute simple type B dissection who were unsuitable for endovascualr stent graft placement. Proximal descending thoracic aortic replacement associated with short stented elephant trunk implantation for patients with chronic Stanford type B aortic dissection was reported in the second part. There was no death and severe complication in these patients. The stented elepahnat trunk procedure could not result in the spinal cord injury and organ malperfusion in patients with chronic Stanford type B aortic dissection. Otherwise, it could reverse the organ malperfusion with this procedure. Total aortic arch replacement associated with stented elephant trunk procedure for patients with complex Stanford type B aortic dissection was reported in the third part. There were 2 deaths in patients with total aortic arch replacement associated with elephant trunk procedure under off-pump. 2 patients underwent thoracoabdomianl aortic replacement during the second-staged operation. And there was no other complication. This procedure was benefit to patients with complex Stanford type B aortic dissection due to management of both proximal arch and distal arch lesions at one-staged, avoidance of false lumen dilation, reverse organ malperfusion, avoidance of retrograde dissection and simplied second staged operation. Total aortic arch replacement associated with stented elephant trunk procedure for patients with simple Stanford type B aortic dissection was reported in the fourth part. It could manage simple Stanford type B aortic dissection associated with aortic root, ascending aorta lesions at one-staged and promote obliteration of false lumen with thrombus formation, reverse organ malperfusion and avoid reoperation with this procedure. Finally, we analyzed the data of patients with type B dissection who received stented elephant trunk implantation and summarized our experience.更多还原