Sun Li-Zhong, Qi Rui-Dong, Chang Qian, Zhu Jun-Ming, Liu Yong-Min, Yu Cun-Tao, Lv Bin, Zheng Jun, Tian Liang-Xin, Lu Jin-Guo
Department of Cardiovascular Surgery, Cardiovascular Institute and Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
J Thorac Cardiovasc Surg. 2009 Dec;138(6):1358-62. doi: 10.1016/j.jtcvs.2009.04.017. Epub 2009 May 31.
In patients with acute type A dissection, it is controversial whether to use a more aggressive strategy with extended aortic replacement to improve long-term outcome or to use a conventional strategy with limited ascending aortic or hemiarch replacement to circumvent a life-threatening situation.
Between April 2003 and June 2007, 107 patients (17 women, 90 men; mean age, 45 +/- 11 years; range, 17-78 years) with acute type A dissection underwent total arch replacement combined with stented elephant trunk implantation under hypothermic cardiopulmonary bypass and selective cerebral perfusion. Computed tomography was performed to evaluate the residual false lumen in the descending aorta during follow-up.
Thirty-day mortality was 3.74% (4/107 patients), and in-hospital mortality was 4.67% (5/107 patients). Spinal cord injury was observed in 3 patients (1 patient with left lower-extremity paraparesis and 2 patients with paraplegia). Cerebral infarction was observed in 3 patients, ventilator support exceeding 5 days was required in 9 patients, and rebleeding was observed in 4 patients. During a mean follow-up of 35 +/- 14 months, 3 patients died and 3 patients were lost to follow-up. On postoperative computed tomography, complete thrombus formation was observed around the stented elephant trunk in 95% of patients (95/100) and at the diaphragmatic level in 69% of patients (69/100).
Low morbidity and mortality were achieved using total arch replacement combined with stented elephant trunk implantation. These encouraging surgical results and postoperative outcomes favor this more aggressive procedure for acute type A dissection.
在急性A型主动脉夹层患者中，对于采用更积极的策略进行广泛主动脉置换以改善长期预后，还是采用传统策略进行有限的升主动脉或半弓置换以规避危及生命的情况，仍存在争议。
2003年4月至2007年6月期间，107例急性A型主动脉夹层患者（17例女性，90例男性；平均年龄45±11岁；范围17 - 78岁）在低温体外循环和选择性脑灌注下接受全弓置换联合带支架象鼻植入术。在随访期间进行计算机断层扫描以评估降主动脉内的残余假腔。
30天死亡率为3.74%（4/107例患者），住院死亡率为4.67%（5/107例患者）。观察到3例患者发生脊髓损伤（1例左下肢轻瘫，2例截瘫）。观察到3例患者发生脑梗死，9例患者需要呼吸机支持超过5天，4例患者发生再出血。在平均35±14个月的随访期间，3例患者死亡，3例患者失访。术后计算机断层扫描显示，95%的患者（95/100）在带支架象鼻周围观察到完全血栓形成，69%的患者（69/100）在膈肌水平观察到完全血栓形成。
全弓置换联合带支架象鼻植入术实现了较低的发病率和死亡率。这些令人鼓舞的手术结果和术后结局支持对急性A型主动脉夹层采用这种更积极的手术方法。
