以内膜破口位置为导向的非全主动脉弓置换术治疗Stanford A型主动脉夹层
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摘要
目的:探讨以内膜破口位置为导向的非全主动脉弓置换术治疗急性Stanford A型主动脉夹层的策略。方法:入选2010年3月至2017年6月我院手术治疗急性Stanford A型主动脉夹层患者275例, 179例为主动脉弓部无破口的Stanford A型主动脉夹层,其中,65例以内膜破口位置为导向行升主动脉或近端半主动脉弓置换手术(AAR组),114例行全主动脉弓置换孙氏手术(TAR组)。记录两组围术期临床数据和并发症,术后随访3个月～7年,记录生存率和再次手术干预情况,进行生存分析比较。结果:TAR组和AAR组比较,体外循环时间[(208.62±57.82)min vs(114.71±26.22)min]、心脏停灌注时间([95.55±27.92)min vs(77.32±17.89)min]、停循环时间([21.27±7.28)min vs 0 min]、术后有创通气时间([71.86±68.06)min vs(35.86±17.03) min]、重症监护病房时间[(7.33±3.73)d vs(4.46±1.48)d],差异均有统计学意义(P<0.05);AAR组术后血制品的消耗、急性肾损害及一过性脑功能障碍发生率均低于TAR组,差异有统计学意义(P<0.05);两组患者的围术期死亡率(9.65%vs 4.62%)差异无统计学意义(P>0.05);随访时间3个月至7年,两组患者的远端血管残余夹层发生率、远期生存率差异均无统计学意义。两组60岁以上患者的术后30天死亡率(12.50%vs8.70%)、远期全因死亡率(14.29%vs 6.25%)和远期血管病变再干预率(0%vs 0%),差异均无统计学意义(P>0.05)。结论:以内膜破口位置为导向的非全主动脉弓置换术有较高的围术期安全性,远期疗效与全主动脉弓置换术接近,适用于治疗破口位于升主动脉的Stanford A型主动脉夹层和老年患者。
Objectives: To explore the efficacy and outcome of tear-oriented ascending/hemiarch replacement strategy for patients with acute type A aortic dissection.Methods: Data from 275 patients with acute Stanford A aortic dissection, who hospitalized and operated from March 2010 to June 2017 in our institute, were analyzed. 197 patients were identified without an arch tear, 65 patients(48 males, aged [51.42±14.80] years old) underwent tear-oriented ascending/hemiarch replacement surgery(AAR group), and 114 patients(89 males, aged [50.42±12.31] years old) received total arch replacement using a tetrafurcate graft with stented elephant trunk implantation(TAR group). The perioperative clinical data and complications were collected, patients were followed up from 3 months to 7 years, survival and surgical intervention situation were compared between the AAR and TAR groups. Results: The time of extracorporeal circulation, cardiac arrest, hypothermic circulatory arrest, postoperative invasive ventilation and ICU time of group TAR and AAR were(208.62±57.82) min,(95.55±27.92) min,(21.27±7.28) min,(71.86±68.06)min,(7.33±3.73)d and(114.71±26.22) min,(77.32±17.89)min, 0 min,(35.86±17.03)min,(4.46±1.48)d respectively, the difference was statistically significant( P<0.05). In group AAR, there were significantly fewer blood transfusion, lower incidence of acute kidney injury and temporary neurological dysfunction than those in group TAR(P<0.05). The 30-day mortality rate of group TAR and AHR were 9.65% and 4.62%( P>0.05). During the follow-up, the incidences of late mortality rate and residual aortic dissection rate of group TAR and AHR were similar. Among the patients aged over 60 years, the rates of 30-day and late mortality in group TAR and AAR were 12.50%、8.70% and 14.29%、6.25%(P>0.05).Conclusions: Tear-oriented ascending/hemiarch replacement is related fewer perioperative complications than total aortic arch replacement and long-term outcome is similar between the two strategies. Tear-oriented ascending/hemiarch replacement is thus a suitable procedure for patients with Stanford A aortic dissection with rupture in the ascending aorta and elderly patients.
Objectives: To explore the efficacy and outcome of tear-oriented ascending/hemiarch replacement strategy for patients with acute type A aortic dissection.Methods: Data from 275 patients with acute Stanford A aortic dissection, who hospitalized and operated from March 2010 to June 2017 in our institute, were analyzed. 197 patients were identified without an arch tear, 65 patients(48 males, aged [51.42±14.80] years old) underwent tear-oriented ascending/hemiarch replacement surgery(AAR group), and 114 patients(89 males, aged [50.42±12.31] years old) received total arch replacement using a tetrafurcate graft with stented elephant trunk implantation(TAR group). The perioperative clinical data and complications were collected, patients were followed up from 3 months to 7 years, survival and surgical intervention situation were compared between the AAR and TAR groups. Results: The time of extracorporeal circulation, cardiac arrest, hypothermic circulatory arrest, postoperative invasive ventilation and ICU time of group TAR and AAR were(208.62±57.82) min,(95.55±27.92) min,(21.27±7.28) min,(71.86±68.06)min,(7.33±3.73)d and(114.71±26.22) min,(77.32±17.89)min, 0 min,(35.86±17.03)min,(4.46±1.48)d respectively, the difference was statistically significant( P<0.05). In group AAR, there were significantly fewer blood transfusion, lower incidence of acute kidney injury and temporary neurological dysfunction than those in group TAR(P<0.05). The 30-day mortality rate of group TAR and AHR were 9.65% and 4.62%( P>0.05). During the follow-up, the incidences of late mortality rate and residual aortic dissection rate of group TAR and AHR were similar. Among the patients aged over 60 years, the rates of 30-day and late mortality in group TAR and AAR were 12.50%、8.70% and 14.29%、6.25%(P>0.05).Conclusions: Tear-oriented ascending/hemiarch replacement is related fewer perioperative complications than total aortic arch replacement and long-term outcome is similar between the two strategies. Tear-oriented ascending/hemiarch replacement is thus a suitable procedure for patients with Stanford A aortic dissection with rupture in the ascending aorta and elderly patients.
引文
[1]Tsai TT,Trimarchi S,Nienaber CA.Acute aortic dissection:perspectives from the International Registry of Acute Aortic Dissection(IRAD)[J].Eur J Vasc Endovasc Surg,2009,37(2):149-159.DOI:10.1016/j.ejvs.2008.11.032.
[2]Sun L,Qi R,Zhu J,et al.Repair of acute type A dissection:our experiences and results[J].Ann Thorac Surg,2011,91(4):1147-1152.DOI:10.1016/j.athoracsur.2010.12.005.
[3]孙立忠.急性A型主动脉夹层的外科治疗[J].心血管外科杂志(电子版),2014,3(3):105-108.
[4]易定华,段维勋,中国主动脉夹层诊疗现状与展望[J].中国循环杂志,2013,28(01):1-2.DOI:10.3969/j.issn.1000-3614.2013.01.001.
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[6]Colli A,Carrozzini M,Francescato A,et al.Acute DeBakey Type I aortic dissection without intimal tear in the arch:is total arch replacement the right choice?[J].Interact Cardiovasc Thorac Surg,2017,26(1):1-7.DOI:10.1093/icvts/ivx229.
[7]Shimizu K,Ito M,Kanetsuki K,et al.Influence of an operative strategy on outcomes of acute type a aortic dissection cases[J].Kyobu Geka,2016.69(4):252-256.
[8]刘宁宁,孙立忠.主动脉弓部重建相关问题的研究进展[J].中华外科杂志.2017,55(4):311-315.DOI:10.3760/cma.j.issn.0529-5815.2017.04.015.
[9]Rylski B,Beyersdorf F,Kari F A,et al.Acute type A aortic dissection extending beyond ascending aorta:Limited or extensive distal repair[J].J Thorac Cardiovasc Surg,2014,148(3):949-954.DOI:10.1016/j.jtcvs.2014.05.051.
[10]Aizawa K,Kawahito K,Misawa Y.Long-term outcomes of tearoriented ascending/hemiarch replacements for acute type A aortic dissection[J].Gen Thorac Cardiovasc Surg,2016,64(7):403-408.DOI:10.1007/s11748-016-0648-x.
[11]Kim JB,Chung CH,Moon DH,et al.Total arch repair versus hemiarch repair in the management of acute DeBakey type I aortic dissection[J].Eur J Cardiothorac Surg,2011,40(4):881-887.DOI:10.1016/j.ejcts.2010.12.035.
[12]Li B,Ma WG,Liu YM,et al.Is extended arch replacement justified for acute type A aortic dissection?[J].Interact Cardiovasc Thorac Surg,2015,20(1):120-126.DOI:10.1093/icvts/ivu323.
[13]Omura A,Miyahara S,Yamanaka K,et al.Early and late outcomes of repaired acute DeBakey type I aortic dissection after graft replacement[J].J Thorac Cardiovasc Surg,2016,151(2):341-348.DOI:10.1016/j.jtcvs.2015.03.068.
[14]Uchida N,Ishihara H,Shibamura H,et al.Midterm results of extensive primary repair of the thoracic aorta by means of total arch replacement with open stent graft placement for an acute type Aaortic dissection[J].J Thorac Cardiovasc Surg,2006,131(4):862-867.DOI:10.1016/j.jtcvs.2005.08.061.
[15]吴怡锦,范瑞新,曾嵘,等.A型主动脉夹层患者术后呼吸功能不全死亡的相关危险因素分析[J].中国循环杂志,2014,29(9):710-713.DOI:10.3969/j.issn.1000-3614.2014.09.014.
[16]Preventza O,Garcia A,Kashyap SA,et al.Moderate hypothermia≥24 and≤28°C with hypothermic circulatory arrest for proximal aortic operations in patients with previous cardiac surgery[J].Eur J Cardiothorac Surg,2016,50(5):949-954.DOI:10.1093/ejcts/ezw163.
[17]Rice RD,Sandhu HK,Leake SS,et al.Is total arch replacement associated with worse outcomes during repair of acute type a aortic dissection?[J].Ann Thorac Surg,2015,100(6):2159-2165;discussion 2165-2166.DOI:10.1016/j.athoracsur.2015.06.007.
[18]Nienaber CA,Clough RE.Management of acute aortic dissection[J].L a n c e t,2 0 1 5,3 8 5(9 9 7 0):8 0 0-8 11.D O I:1 0.1 0 1 6/S 0 1 4 0-6736(14)61005-9.
[19]Melby SJ,Zierer A,Damiano RJ,Jr,et al.Importance of blood pressure control after repair of acute type a aortic dissection:25-year follow-up in 252 patients[J].J Clin Hypertens(Greenwich),2013,15(1):63-68.DOI:10.1111/jch.12024.
[20]钱宏,蒙炜,胡佳,等.弓部内膜无破口的Stanford A型主动脉夹层患者行近端外科手术重建的早中期随访结果[J].四川大学学报(医学版),2015,46(4):645-647.
[21]Oda T,Minatoya K,Sasaki H,et al.Surgical Indication for chronic aortic dissection in descending thoracic and thoracoabdominal aorta[J].Circ Cardiovasc Interv,2017,10(2):e004292.DOI:10.1161/CIRCINTERVENTIONS.116.004292.
[22]Sun LZ,Qi RD,Chang Q,et al.Surgery for acute type A dissection using total arch replacement combined with stented elephant trunk implantation:experience with 107 patients[J].J Thorac Cardiovasc Surg,2009,138(6):1358-1362.DOI:10.1016/j.jtcvs.2009.04.017.
[23]Rylski B,Suedkamp M,Beyersdorf F,et al.Outcome after surgery for acute aortic dissection type A in patients over 70 years:data analysis from the German Registry for Acute Aortic Dissection Type A(GERAADA)[J].Eur J Cardiothorac Surg,2011,40(2):435-440.DOI:10.1016/j.ejcts.2010.11.073.
[24]Kondoh H,Satoh H,Daimon T,et al.Outcomes of limited proximal aortic replacement for type A aortic dissection in octogenarians[J].J Thorac Cardiovasc Surg,2016,152(2):439-446.DOI:10.1016/j.jtcvs.2016.03.093.
[25]Zhang H,Lang X,Lu F,et al.Acute type A dissection without intimal tear in arch:proximal or extensive repair?[J].J Thorac Cardiovasc Surg,2014,147(4):1251-1255.DOI:10.1016/j.jtcvs.2013.04.029.
[26]孙立忠,李建荣.我国Stanford A型主动脉夹层诊疗进展与挑战[J].中华外科杂志,2017,55(4):241-244.DOI:10.3760/cma.j.issn.0529-5815.2017.04.001.
[2]Sun L,Qi R,Zhu J,et al.Repair of acute type A dissection:our experiences and results[J].Ann Thorac Surg,2011,91(4):1147-1152.DOI:10.1016/j.athoracsur.2010.12.005.
[3]孙立忠.急性A型主动脉夹层的外科治疗[J].心血管外科杂志(电子版),2014,3(3):105-108.
[4]易定华,段维勋,中国主动脉夹层诊疗现状与展望[J].中国循环杂志,2013,28(01):1-2.DOI:10.3969/j.issn.1000-3614.2013.01.001.
[5]Larsen M,Trimarchi S,Patel HJ,et al,Extended versus limited arch replacement in acute type A aortic dissection[J].Eur J Cardiothorac Surg,2017,52(6):1104-1110.DOI:10.1093/ejcts/ezx214.
[6]Colli A,Carrozzini M,Francescato A,et al.Acute DeBakey Type I aortic dissection without intimal tear in the arch:is total arch replacement the right choice?[J].Interact Cardiovasc Thorac Surg,2017,26(1):1-7.DOI:10.1093/icvts/ivx229.
[7]Shimizu K,Ito M,Kanetsuki K,et al.Influence of an operative strategy on outcomes of acute type a aortic dissection cases[J].Kyobu Geka,2016.69(4):252-256.
[8]刘宁宁,孙立忠.主动脉弓部重建相关问题的研究进展[J].中华外科杂志.2017,55(4):311-315.DOI:10.3760/cma.j.issn.0529-5815.2017.04.015.
[9]Rylski B,Beyersdorf F,Kari F A,et al.Acute type A aortic dissection extending beyond ascending aorta:Limited or extensive distal repair[J].J Thorac Cardiovasc Surg,2014,148(3):949-954.DOI:10.1016/j.jtcvs.2014.05.051.
[10]Aizawa K,Kawahito K,Misawa Y.Long-term outcomes of tearoriented ascending/hemiarch replacements for acute type A aortic dissection[J].Gen Thorac Cardiovasc Surg,2016,64(7):403-408.DOI:10.1007/s11748-016-0648-x.
[11]Kim JB,Chung CH,Moon DH,et al.Total arch repair versus hemiarch repair in the management of acute DeBakey type I aortic dissection[J].Eur J Cardiothorac Surg,2011,40(4):881-887.DOI:10.1016/j.ejcts.2010.12.035.
[12]Li B,Ma WG,Liu YM,et al.Is extended arch replacement justified for acute type A aortic dissection?[J].Interact Cardiovasc Thorac Surg,2015,20(1):120-126.DOI:10.1093/icvts/ivu323.
[13]Omura A,Miyahara S,Yamanaka K,et al.Early and late outcomes of repaired acute DeBakey type I aortic dissection after graft replacement[J].J Thorac Cardiovasc Surg,2016,151(2):341-348.DOI:10.1016/j.jtcvs.2015.03.068.
[14]Uchida N,Ishihara H,Shibamura H,et al.Midterm results of extensive primary repair of the thoracic aorta by means of total arch replacement with open stent graft placement for an acute type Aaortic dissection[J].J Thorac Cardiovasc Surg,2006,131(4):862-867.DOI:10.1016/j.jtcvs.2005.08.061.
[15]吴怡锦,范瑞新,曾嵘,等.A型主动脉夹层患者术后呼吸功能不全死亡的相关危险因素分析[J].中国循环杂志,2014,29(9):710-713.DOI:10.3969/j.issn.1000-3614.2014.09.014.
[16]Preventza O,Garcia A,Kashyap SA,et al.Moderate hypothermia≥24 and≤28°C with hypothermic circulatory arrest for proximal aortic operations in patients with previous cardiac surgery[J].Eur J Cardiothorac Surg,2016,50(5):949-954.DOI:10.1093/ejcts/ezw163.
[17]Rice RD,Sandhu HK,Leake SS,et al.Is total arch replacement associated with worse outcomes during repair of acute type a aortic dissection?[J].Ann Thorac Surg,2015,100(6):2159-2165;discussion 2165-2166.DOI:10.1016/j.athoracsur.2015.06.007.
[18]Nienaber CA,Clough RE.Management of acute aortic dissection[J].L a n c e t,2 0 1 5,3 8 5(9 9 7 0):8 0 0-8 11.D O I:1 0.1 0 1 6/S 0 1 4 0-6736(14)61005-9.
[19]Melby SJ,Zierer A,Damiano RJ,Jr,et al.Importance of blood pressure control after repair of acute type a aortic dissection:25-year follow-up in 252 patients[J].J Clin Hypertens(Greenwich),2013,15(1):63-68.DOI:10.1111/jch.12024.
[20]钱宏,蒙炜,胡佳,等.弓部内膜无破口的Stanford A型主动脉夹层患者行近端外科手术重建的早中期随访结果[J].四川大学学报(医学版),2015,46(4):645-647.
[21]Oda T,Minatoya K,Sasaki H,et al.Surgical Indication for chronic aortic dissection in descending thoracic and thoracoabdominal aorta[J].Circ Cardiovasc Interv,2017,10(2):e004292.DOI:10.1161/CIRCINTERVENTIONS.116.004292.
[22]Sun LZ,Qi RD,Chang Q,et al.Surgery for acute type A dissection using total arch replacement combined with stented elephant trunk implantation:experience with 107 patients[J].J Thorac Cardiovasc Surg,2009,138(6):1358-1362.DOI:10.1016/j.jtcvs.2009.04.017.
[23]Rylski B,Suedkamp M,Beyersdorf F,et al.Outcome after surgery for acute aortic dissection type A in patients over 70 years:data analysis from the German Registry for Acute Aortic Dissection Type A(GERAADA)[J].Eur J Cardiothorac Surg,2011,40(2):435-440.DOI:10.1016/j.ejcts.2010.11.073.
[24]Kondoh H,Satoh H,Daimon T,et al.Outcomes of limited proximal aortic replacement for type A aortic dissection in octogenarians[J].J Thorac Cardiovasc Surg,2016,152(2):439-446.DOI:10.1016/j.jtcvs.2016.03.093.
[25]Zhang H,Lang X,Lu F,et al.Acute type A dissection without intimal tear in arch:proximal or extensive repair?[J].J Thorac Cardiovasc Surg,2014,147(4):1251-1255.DOI:10.1016/j.jtcvs.2013.04.029.
[26]孙立忠,李建荣.我国Stanford A型主动脉夹层诊疗进展与挑战[J].中华外科杂志,2017,55(4):241-244.DOI:10.3760/cma.j.issn.0529-5815.2017.04.001.