36 例急性Stanford A 型主动脉夹层动脉瘤的外科治疗体会

目的:总结急性Stanford A型主动脉夹层动脉瘤的外科治疗体会。方法:选择36例急性Stanford A型主动脉夹层动脉瘤患者,根据病变夹层破口的位置、累及范围、有无合并主动瓣关闭不全选择相应的手术方式,观察患者治疗后的临床疗效并随访治疗6个月后的临床预后。结果:3例患者术中死亡,术中死亡率为8.3%,平均手术时间156.7±56.7min,平均阻断时间98.5±32.7min,平均选择性脑灌注时间56.1±20.7min,术后平均ICU住院时间6.2±3.8d,术后平均总计住院时间25.4±7.3d;术后6个月后随访,3例患者死亡,其余30例患者恢复满意,生活质量与治疗前相比,均得到显著提高。结论:急性Stanford A型主动脉夹层动脉瘤患者应积极施行早期外科治疗,术前快速准确诊断,根据患者病情制定相应的手术方案,术后采取措施避免术后并发症。     

复杂型Stanford B型主动脉夹层腔内修复术中左锁骨下动脉重建方式分析

目的:总结复杂型Stanford B型主动脉夹层中左锁骨下动脉重建的经验和方法。方法:2010年4月至2016年5月,共有43例复杂型Stanford B型主动脉夹层采用腔内修复术治疗,并均重建左锁骨下动脉,其中右腋动脉-左腋动脉人工血管旁路18例,开窗技术14例,烟囱技术11例。结果:均成功手术,无术中死亡,术后造影显示支架敷贴良好,定位准确,左锁骨下动脉血流通畅。术后无头晕症状,双上肢血压差均在15 mmHg之内。1例术后5天并发逆行性A型夹层猝死。肾功能衰竭2例,行透析治疗后治愈。随访38例,失访4例,随访时间2~33月(17.0士5.2月),1例患者术后45天猝死;术后3月、1年复查主动脉CTA均示支架无移位。1例I型内漏,术后8月复查CTA示内漏消失;1例术后9月人工血管内血栓形成,中段狭窄约40%;2例并发支架远端动脉瘤形成。结论:腋动脉人工血管旁路术、开窗技术、烟囱技术进行左锁骨下动脉重建,联合主动脉腔内修复术治疗复杂型Standford B型主动脉夹层,可以取得满意的临床效果。     

80岁以上老年人冠状动脉旁路移植术合并瓣膜置换手术的临床分析

目的:总结老年患者行冠状动脉旁路移植术(CABG)合并瓣膜置换(VR)手术的特点及经验。方法:上海交通大学附属第一人民医院心血管外科2001年11月至2010年3月对60例年龄大于80的患者施行冠状动脉搭桥+瓣膜置换手术,男33例,女27例。年龄80-87岁,平均年龄(83.77±2.45)岁。均为冠心病合并瓣膜病变患者。其中36例患者行冠状动脉旁路移植+二尖瓣置换手术,15例患者行冠状动脉旁路移植+主动脉瓣置换手术,9例患者行冠状动脉旁路移植+双瓣置换手术,同时8例患者行三尖瓣成形手术,3例患者行射频消融手术,1例升主动开成形术。置换生物瓣膜者51例,置换机械瓣膜者9例。CABG平均搭桥(2.13±0.75)根,搭桥材料为左乳内动脉与大隐静脉。结果:全组早期死亡9例(15%),1例死于术后出血,1例死于多器官功能衰竭,7例死于术后心衰。早期生存51例(85%),出现术后并发症10例,其中2例发生胸腔积液,1例心包填塞,3例肺部感染,1例心房扑动后发生室颤,3例二次开胸止血。给予相应对症治疗后痊愈出院。门诊随访49例,随访时间1～60个月,心功能I级2例、Ⅱ级29例、Ⅲ级18例、Ⅳ级0例(NYHA分级)。结论:对老年患者行冠脉搭桥+瓣膜置换手术,只要掌握手术适应证,充分作好术前准备、术中及术后处理,手术治疗可以取得良好效果。     

马凡综合征合并急性Standford A 型夹层的外科治疗

目的:评价外科治疗马凡综合征合并急性Standford A型夹层的效果。方法:回顾性分析2007年7月至2010年7月外科治疗12例马凡综合征合并急性Standford A型夹层病例的临床资料。采用改良Mini-root手术方式代替Bentall手术。结果:主动脉阻断时间69～103 min,平均(78.7±28.6)min,体外循环时间79～122 min,平均(98.3±23.8)min。术后早期存活11例,死亡1例,死亡率8.3%。术后随访时间2～37个月,平均(18.2±8.6)个月,其中1例术后24月发生急性腹主动脉夹层,予以实施腔内支架隔绝术成功以治愈出院。术后与术前左心室舒张末径分别为45～58 mm,平均(50.2±5.6)mm和53～69 mm,平均(61.3±4.6)mm(P<0.01)。结论:马凡综合征合并急性Standford A型夹层一经确诊则需急诊手术,及时的外科手术是治疗该病的有效方法,而且应用改良Mini-root手术方式疗效满意。     

36例急性StanfordA型主动脉夹层动脉瘤的外科治疗体会

目的：总结急性StanfordA型主动脉夹层动脉瘤的外科治疗体会。方法：选择36例急性StanfordA型主动脉夹层动脉瘤患者,根据病变夹层破口的位置、累及范围、有无合并主动瓣关闭不全选择相应的手术方式,观察患者治疗后的临床疗效并随访治疗6个月后的临床预后。结果：3例患者术中死亡,术中死亡率为8．3％,平均手术时间156．7±56．7min,平均阻断时间98．5±32．7min,平均选择性脑灌注时1．756．1±20．7min,术后平均ICU住院时间6．2±3．8d,术后平均总计住院时间25．4±7．3d;术后6个月后随访．3例患者死亡,其余30例患者恢复满意,生活质量与治疗前相比,均得到显著提高。结论：急性Stanford A型主动脉夹层动脉瘤患者应积极施行早期外科治疗,术前快速准确诊断,根据患者病情制定相应的手术方案,术后采取措施避免术后并发症。     

91例主动脉夹层动脉瘤的临床治疗体会

目的:依据临床经验,熟练运用开放手术、腔内修复术及杂交手术方法治疗各类主动脉夹层动脉瘤。方法:收集2009年7月~2013年1月在我院手术治疗的主动脉夹层动脉瘤患者共91例,StanfordB型夹层动脉瘤36例(其中21例降主动脉瘤、9例腹主动脉及双髂动脉瘤行腔内覆膜支架隔绝术,6例行腹主动脉人工血管置换术),StanfordA型夹层动脉瘤55例(其中单纯Sun,s手术12例伴Bentall术6例,Bentall术伴部分主动脉弓人工血管置换36例,1例行Ⅱ型的主干与分支动脉人工血管转流+介入腔内隔绝降主动脉及左半弓杂交术),分别以不同的手术方法给予治疗。结果:顺利治愈出院85例,死亡6例,4例因全弓置换术后出现难以控制的大出血、肠坏死、肾功能不全、少尿等并发症而死亡,2例死于Bentall术后严重多功能脏器急性衰竭,1例杂交手术术后出现高血压伴神经系统并发症,1例伴肺部感染及低心排综合征,给予对症治疗后效果不佳,有2例出现肾功能不全,经过透析治愈。腔内修复术后有神经系统的并发症2例,下肢的功能障碍2例,少量内漏4例,以上并发症均经对症治疗后痊愈。术后随访76例,时间3~12个月,除2例于术后第9个月死亡、1例因脑梗塞、脑血管意外等与手术无关的疾病而死亡,2例因吻合口动脉瘤或动脉瘤破裂大出血死亡外,余患者生活状态良好,心功能在I~Ⅱ级。结论:根据主动脉瘤疾病的临床特点和定位诊断,合理选择和运用治疗方法使手术操作变得更为迅速、安全和方便,同时能够取得良好的临床治疗效果。     

经胸超声胸骨右缘切面对Stanford A型主动脉夹层诊断价值的研究

目的:通过经胸超声心动图获取胸骨右缘升主动脉长短轴切面观察Stanford A型主动脉夹层患者的升主动脉结构,探讨对该类患者进行检查时该切面的应用价值。方法:31例经CTA或手术证实为A型主动脉夹层的连续性患者,超声心动图检查除常规通过胸骨左缘切面观察升主动脉结构外,均做胸骨右缘切面以进一步观察升主动脉结构,包括最大内径,有无撕脱内膜及内膜活动情况,同时应用常规胸骨左缘切面和胸骨右缘切面对A型主动脉夹层能够清晰显示出的病例比例加以比较。结果:胸骨左缘切面能够清晰显示升主动脉结构9例,占比例29%。胸骨右缘切面能够清晰显示升主动脉结构20例,比例65%。将两种切面结合能够清晰显示升主动脉结构的比例升高到74%。胸骨右缘肋间切面测得的升主动脉最大径线数值与CTA结果的一致性更好。结论:胸骨右缘肋间切面对A型主动脉夹层显示的清晰度更好,有助于临床诊断,具有重要的参考价值,值得临床广泛推广。     

马凡综合征合并急性StandfordA型夹层的外科治疗

目的：评价外科治疗马凡综合征合并急性StandfordA型夹层的效果。方法：回顾性分析2007年7月至2010年7月外科治疗12例马凡综合征合并急性StandfordA型夹层病例的临床资料。采用改良Mini—root手术方式代替Bentall手术。结果：主动脉阻断时间69～103min,平均（78．7±28．6）min,体外循环时间79～122min,平均（98．3±23．8）min。术后早期存活11例,死亡1例,死亡率8.3％。术后随访时间2～37个月,平均（18．2±8．6）个月,其中1例术后24月发生急性腹主动脉夹层,予以实施腔内支架隔绝术成功以治愈出院。术后与术前左心室舒张末径分别为45～58mm,平均（50.2±5．6）mnq和53～69mm,平均（61．3±4．6）mm（P〈0．01）。结论：马凡综合征合并急性Standford A型夹层一经确诊则需急诊手术,及时的外科手术是治疗该病的有效方法,而且应用改良Mini—root手术方式疗效满意。     

覆膜支架腔内修复术对Stanford B型主动脉夹层动脉瘤患者术后血清血管内皮生长因子、核因子-κB水平的影响

目的:分析覆膜支架腔内修复术对Stanford B型主动脉夹层动脉瘤患者术后血清血管内皮生长因子(VEGF)、核因子-κB(NF-κB)水平的影响。方法:选取2015年6月～2017年6月空军军医大学第一附属医院收治的150例Stanford B型主动脉夹层动脉瘤患者,根据治疗方法不同分为两组。对照组(75例)采用药物治疗,观察组(75例)采用覆膜支架腔内修复术治疗,对比两组治疗前后血清血管内皮生长因子(VEGF)、核因子-KB(NF-κB)、白细胞介素-1β(IL-1β)、干扰素-γ(IFN-γ)、急性生理和慢性健康状况(Acute physiology and chronic health evaluation,APACHEⅡ)评分、SF-36量表评分的变化,并发症(内漏、动脉栓塞、左上肢乏力、支架后移等)发生情况,再次手术或介入治疗发生率及病死率。结果:治疗后,观察组血清VEGF、NF-κB、IL-1β、IFN-γ水平显著低于对照组(P0.05);两组治疗后APACHEⅡ评分均较治疗前降低,SF-36量表评分均较治疗前升高,且观察组APACHEⅡ与SF-36量表评分改善程度大于对照组(P0.05);观察组并发症总发生率4%、再次手术或介入治疗发生率为5.33%,病死率为1.33%,均显著低于对照组(17.33%、21.33%、10.67%,P0.05)。结论:覆膜支架腔内修复术能显著提高Stanford B型主动脉夹层动脉瘤患者生活质量与生存率,并发症与再治疗发生率,改善其病情,可能降低VEGF、NF-κB水平有关。     

Fibulin-5在主动脉夹层血管壁中表达异常

目的:研究Stanford A型主动脉夹层(aortic dissection,AD)升主动脉和正常升主动脉血管组织中Fibulin-5表达的差异。方法:收集Stanford A型AD患者手术中切除的升主动脉血管组织标本12例(AD组),多器官捐献患者升主动脉血管12例(对照组)。采用EVG染色观察主动脉中膜弹性纤维形态结构;应用SP免疫组织化学法及Western blot法对标本组织中的Fibulin-5进行检测分析。结果:AD组主动脉中膜弹性纤维形态和排列不规则、破碎、丢失,结构紊乱。免疫组织化学显示Fibulin-5阳性表达见于主动脉壁平滑肌细胞胞质中,AD组与对照组比较,Fibulin-5表达明显较少。Western blot蛋白印迹示AD组Fibulin-5表达明显减少,差异有统计学意义(P0.05)。结论:Fibulin-5在AD主动脉中膜中表达下调,可能在AD的发生中发挥作用。     

Acute myocardial infarction due to an acute type A aortic dissection involving the left main coronary artery

We report a case of anterior myocardial infarction due to a Stanford type A aortic dissection involving the left main trunk of the coronary artery. Acute myocardial infarction due to extension of an acute Stanford type A aortic dissection is an infrequent but devastating situation. In our case a spontaneous aortocoronary dissection involving the Valsalva sinus and the ascending aorta with a history of hypertension is the most plausible cause. Emergent aortic replacement and revascularisation was performed. (Neth Heart J 2007;15:263-4.)     

Hybrid thoracic stent graft repair of a complex type B aortic dissection in a patient who presented three weeks after repair of a type a aortic dissection

Long-term management after repair of a type A aortic dissection includes aggressive medical therapy and routine surveillance with serial imaging to ensure thrombosis of the false lumen. Retained patency of the false lumen can lead to either the development of a false lumen aneurysm with a subsequent rupture or extension of dissection. Typically such events occur late, usually months after repair, and are treated with either a conventional one-stage open thoracoabdominal repair or a two-stage "elephant trunk" procedure. However, most patients who undergo such procedures experience major complications and the procedure-related mortality rate is high. We present a unique case of a 61-year-old woman who presented with a ruptured type B aortic dissection 3 weeks after repair of a type A aortic dissection. She underwent an emergent thoracotomy and primary repair of the ruptured aorta followed by concomitant arch debranching and thoracic stent graft placement. Simultaneous surgical debranching with a median sternotomy and endovascular repair with stent grafts is an attractive hybrid approach in patients who present with an acute rupture of a false lumen aneurysm soon after initial repair of an aortic dissection, a situation in which a conventional repair is not feasible. This report emphasizes that hybrid thoracic stent graft repair should be considered for such high-risk patients in the near future as it offers them relatively lower morbidity and mortality compared with what is seen with conventional repairs.     

Stentless aortic valve implantation through an upper manubrium-limited V-type ministernotomy

In this piece of work, we attempt to highlight our approach and early experience with minimally invasive aortic valve replacement with aortic Freedom Solo stentless bioprosthesis performed through an upper manubrium-limited ministernotomy in the second intercostal space. The novel suturing technique is required for stentless aortic bioprosthesis implantation, and this, in its turn, will predetermine and influence the surgeon's choice for operative access. In our department, the feasibility of the approach was first assessed; aortic valve was replaced by stentless bioprosthesis in a total of 23 patients (mean age 57 ± 12 years). In all cases, a cardiopulmonary bypass was established by a central ascending aorta cannulation and peripheral percutaneous venous cannula insertion. This approach was found to be technically reproducible and safe. The surgical technique used is described in this article.     

Blunt Traumatic Aortic Injury of Right Aortic Arch in a Patient with an Aberrant Left Subclavian Artery

Right-sided aortic arch (RAA) is a rare congenital developmental variant present in about 0.1 percent of the population. This anatomical anomaly is commonly associated with congenital heart disease and complications from compression of mediastinal structures. However, it is unknown if patients are at a higher risk of blunt thoracic aortic injury (BTAI). We report a case of a 20-year-old man admitted to the hospital after being hit by an automobile. Computed tomographic scan revealed an RAA with an aberrant left subclavian artery originating from a Kommerell’s diverticulum. A pseudo-aneurysm was also seen along the aortic arch. A diagnosis of blunt traumatic aortic injury was made. The patient was successfully treated with a 26mm Vascutek hybrid stentgraft using the frozen elephant trunk technique.A literature review of the pathophysiology of BTAI was performed to investigate if patients with right-sided aortic arch are at a higher risk of suffering from BTAI. Results from the review suggest that although theoretically there may be a higher risk of BTAI in RAA patients, the rarity of this condition has prevented large studies to be conducted. Previously reported cases of BTAI in RAA have highlighted the possibility that the aortic isthmus may be anatomically weak and therefore prone to injury. We have explored this possibility by reviewing current literature of the embryological origins of the aortic arch and descending aorta.     

Management of a right aberrant subclavian artery during complex hybrid stent-graft procedures: a rare and complex issue

A 76-year-old man with an ascending arch and proximal descending aortic aneurysm underwent a complex aortic replacement through a sternotomy with ligation of a right aberrant subclavian artery (RASA) distal to the right vertebral artery. The second-stage procedure was performed with a stent-graft deployed within the elephant trunk. At 6- and 12-month follow-up, the RASA was opacified by the patent right vertebral artery. Under ultrasound guidance, the patient's RASA stump was occluded by coils. Management of an RASA during complex hybrid stent-graft procedures is discussed.     

Combined replacement of the ascending aorta and the aortic valve in 42 consecutive patients: A comparison of composite graft techniques and conventional techniques over one year

During 1978, 42 consecutive patients underwent simultaneous aortic valve and ascending aorta replacement in our institution. Seventy-one percent were at low risk despite a high incidence of dissection. Twenty-nine percent were high-risk patients requiring repeat or concomitant cardiac procedures, mostly on an emergency basis. Depending upon the extent of the disease at the aortic root, either of two surgical approaches was used: (1) conventional aortic valve and supracoronary ascending aorta replacement, with or without right coronary artery ostium reimplantation, or (2) insertion of a composite graft containing an aortic valve prosthesis, with reconstruction of both coronary arteries. Preservation of coronary ostia was possible in 85% of the patients, and composite grafts were used in 15%. The conventional method was associated with a higher percentage of survivors. This technique was found to be satisfactory unless severe dilatation or complete destruction of the aortic annulus made composite grafting necessary. The latter technique was associated with fewer re-explorations for postoperative hemorrhage. Both procedures were equally effective, resulting in an operative mortality of 10% in uncomplicated situations. Surgery appeared to offer the only chance of survival for the high-risk group, and half of these patients were salvaged.