50位Stanford A型主动脉夹层的“孙式手术”病例的临床分析
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摘要
目的：Stanford A型主动脉夹层病情危险,往往需要急症手术治疗,但术后早期的死亡率较高。尽管冷冻象鼻手术在Stanford A型主动脉夹层患者上取得较好的临床效果,但由于操作过于复杂,因此始终存在争议。孙氏手术作为最近提出的一种新术式——四分支人工血管主动脉弓替换+支架“象鼻”手术技术,可以治疗Stanford A型主动脉夹层以及累及主动脉弓的复杂型Stanford B型主动脉夹层的治疗。本研究的目的总结分析自2012年12月至2014年三月50例临床上采用升主动脉及全弓替换加支架“象鼻”手术治疗Stanford A型主动脉夹层的临床资料,探讨影响临床结果的相关因素以及孙氏手术的作用。
方法：2012年12月—2014年3月,对山东省立医院心外科连续收治的50例Stanford A型主动脉夹层患者患者行孙氏手术,其中男41例、女9例,平均年龄43.66±6.99(32-58)岁。术前诊断中常规行心电图、胸片、CTA、心脏超声及磁共振检查。手术均在中度或深低温(18℃-25℃)停循环、低流量选择性脑灌注下进行,四分支人工血管(Maquet)重建升主动脉及全弓+支架人工血管植入降主动脉。应用HTK液保护心肌。收集术前、术中、术后的临床数据,应用SPSS19.0统计分析,从而探讨不同的因素与术后早期死亡率的相关性。
结果：3例(6%)患者死亡,其中2例死于多脏器功能衰竭、1例因为术前存在的脑血管疾病。2例(4%)患者发生中枢神经损害及脊髓损伤。术后早期死亡率的高危因素分别是：既往脑血管病、急性心功能衰竭、脊髓灌注不良、内脏灌注不良和体外循环时间。
结论：：孙氏手术治疗Stanford A型主动脉夹层有较低的死亡率。病人既往有脑血管病、脊髓灌注不良、内脏灌注不良和长时间的体外循环时间是术后早期死亡率的高危因素。
Background:Stanford Type A aortic dissection (STAAD) is a life threatening situation which needs emergent surgery. Postoperative early morbidity and mortality rate is still very high in STAAD. Although Frozen Elephant Trunk procedure has shown acceptable clinical results up till now but conflicts are still there about the use of this complex technique in such STAAD patients. The Sun's procedure is a new surgical treatment for patients with STAAD. This procedure includes complete arch replacement with a tetrafurcated graft and a newly designed/modified open stented frozen elephant trunk graft implantation into the descending aorta (DA), as a treatment choice for wide spread aortic dissections (AD) or aortic aneurysms including ascending aorta (AscA), aortic arch (AA) and descending aorta (DscA). The aim of our study is to clinically analyze50patients who underwent Sun's procedure with (STAAD) from December2012, to March2014. The principal goal of our study is to analyze factors that influence patient's outcome and to investigate the role of Sun's procedure in the future treatment of type A aortic dissection.
Materials&Methods:This prospective study was conducted at the Department of Cardiovascular surgery Shandong Provincial Hospital, Shandong University, Jinan, Shandong, P. R. China from December2012to March2014. In this study we included50patients, who underwent the Sun's procedure. Among these50patients,41(82.0%) were males and9(18.0%) were females. Their mean age was43.7±7years, ranged from32to58years old. Electrocardiography (ECG), Chest X-Ray (CXR), Computed Tomography Angiography (CTA), Echocardiography (Echo) and Magnetic Resonance Imaging (MRI) were used before surgery to validate the diagnosis, to choose an appropriate aortic graft, stented graft, according to the location, type and size of the lesion and assess the degree of dissection. The procedures were carried out under cardiopulmonary bypass with moderate or deep hypothermia(18℃～25℃),brief circulatory arrest and low flow rate selective cerebral perfusion. A Tetrafurcated aortic graft (Maquet) were used to reconstruct the ascending aorta and aortic arch, a stented graft (Cronus) were deployed into descending aorta as standard Sun's procedure. The HTK solution was used for myocardial protection.The collected preoperative, intraoperative and postoperative data were analyzed by using SPSS19.0through univariate and multivariate analysis of clinical records of50patients who underwent the Sun's procedure to reveal the relation among preoperative and intraoperative variables and early mortality. Results:During our clinical study3(6%,3/50) patients died early, due to multi-organ failure in2patients (66.6%), infection and renal failure in1(33.3%). Neurologic deficit and spinal cord injury happened in2patients (4%,2/50).(Five significant risk factors for early mortality were identified by univariate and multivariate analysis:preexisting cerebrovascular disease (P=0.00), multiple organ failure (P=0.00), infection (P=0.014), renal failure (P=0.001) and to some extent cross clamp time also>104Minutes (P=0.051).
Conclusions:Sun's procedure showed a lower mortality rate in50patients with STAAD. Patients with preexisting cerebrovascular disease, spinal cord malperfusion, visceral malperfusion and long cardiopulmonary bypass time are at a higher risk of early mortality.
方法：2012年12月—2014年3月,对山东省立医院心外科连续收治的50例Stanford A型主动脉夹层患者患者行孙氏手术,其中男41例、女9例,平均年龄43.66±6.99(32-58)岁。术前诊断中常规行心电图、胸片、CTA、心脏超声及磁共振检查。手术均在中度或深低温(18℃-25℃)停循环、低流量选择性脑灌注下进行,四分支人工血管(Maquet)重建升主动脉及全弓+支架人工血管植入降主动脉。应用HTK液保护心肌。收集术前、术中、术后的临床数据,应用SPSS19.0统计分析,从而探讨不同的因素与术后早期死亡率的相关性。
结果：3例(6%)患者死亡,其中2例死于多脏器功能衰竭、1例因为术前存在的脑血管疾病。2例(4%)患者发生中枢神经损害及脊髓损伤。术后早期死亡率的高危因素分别是：既往脑血管病、急性心功能衰竭、脊髓灌注不良、内脏灌注不良和体外循环时间。
结论：：孙氏手术治疗Stanford A型主动脉夹层有较低的死亡率。病人既往有脑血管病、脊髓灌注不良、内脏灌注不良和长时间的体外循环时间是术后早期死亡率的高危因素。
Background:Stanford Type A aortic dissection (STAAD) is a life threatening situation which needs emergent surgery. Postoperative early morbidity and mortality rate is still very high in STAAD. Although Frozen Elephant Trunk procedure has shown acceptable clinical results up till now but conflicts are still there about the use of this complex technique in such STAAD patients. The Sun's procedure is a new surgical treatment for patients with STAAD. This procedure includes complete arch replacement with a tetrafurcated graft and a newly designed/modified open stented frozen elephant trunk graft implantation into the descending aorta (DA), as a treatment choice for wide spread aortic dissections (AD) or aortic aneurysms including ascending aorta (AscA), aortic arch (AA) and descending aorta (DscA). The aim of our study is to clinically analyze50patients who underwent Sun's procedure with (STAAD) from December2012, to March2014. The principal goal of our study is to analyze factors that influence patient's outcome and to investigate the role of Sun's procedure in the future treatment of type A aortic dissection.
Materials&Methods:This prospective study was conducted at the Department of Cardiovascular surgery Shandong Provincial Hospital, Shandong University, Jinan, Shandong, P. R. China from December2012to March2014. In this study we included50patients, who underwent the Sun's procedure. Among these50patients,41(82.0%) were males and9(18.0%) were females. Their mean age was43.7±7years, ranged from32to58years old. Electrocardiography (ECG), Chest X-Ray (CXR), Computed Tomography Angiography (CTA), Echocardiography (Echo) and Magnetic Resonance Imaging (MRI) were used before surgery to validate the diagnosis, to choose an appropriate aortic graft, stented graft, according to the location, type and size of the lesion and assess the degree of dissection. The procedures were carried out under cardiopulmonary bypass with moderate or deep hypothermia(18℃～25℃),brief circulatory arrest and low flow rate selective cerebral perfusion. A Tetrafurcated aortic graft (Maquet) were used to reconstruct the ascending aorta and aortic arch, a stented graft (Cronus) were deployed into descending aorta as standard Sun's procedure. The HTK solution was used for myocardial protection.The collected preoperative, intraoperative and postoperative data were analyzed by using SPSS19.0through univariate and multivariate analysis of clinical records of50patients who underwent the Sun's procedure to reveal the relation among preoperative and intraoperative variables and early mortality. Results:During our clinical study3(6%,3/50) patients died early, due to multi-organ failure in2patients (66.6%), infection and renal failure in1(33.3%). Neurologic deficit and spinal cord injury happened in2patients (4%,2/50).(Five significant risk factors for early mortality were identified by univariate and multivariate analysis:preexisting cerebrovascular disease (P=0.00), multiple organ failure (P=0.00), infection (P=0.014), renal failure (P=0.001) and to some extent cross clamp time also>104Minutes (P=0.051).
Conclusions:Sun's procedure showed a lower mortality rate in50patients with STAAD. Patients with preexisting cerebrovascular disease, spinal cord malperfusion, visceral malperfusion and long cardiopulmonary bypass time are at a higher risk of early mortality.
引文
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