胸主动脉腹主动脉瘤的开放性重建。
Open reconstruction of thoracoabdominal aortic aneurysms.
机构信息
Division of Cardiovascular Surgery, Department of Surgery, Kobe Graduate School of Medicine, Kobe, Japan.
出版信息
Ann Cardiothorac Surg. 2012 Sep;1(3):373-80. doi: 10.3978/j.issn.2225-319X.2012.09.05.
Technical details of our strategy for reconstructing the thoracoabdominal aorta are presented. Between October 1999 and June 2012, 152 patients underwent surgery for thoracoabdominal aortic aneurysms (Crawford classification type I =21, type II =43, type III =73, type IV =15). Mean age was 64.6±13.9 years. Sixty-three (41.4%) patients had aortic dissection, including acute type B dissection in 2 (1.2%) and ruptured aneurysms in 17 (11.2%). Eight (5.3%) patients had mycotic aneurysms, and 3 (2.0%) had aortitis. Emergent or urgent surgery was performed in 25 (16.4%) patients. Preoperative computed tomography (CT) scan or magnetic resonance (MR) angiography detected the Adamkiewicz artery in 103 (67.8%) patients. Cerebrospinal fluid drainage (CSFD) was performed in 115 (75.7%) patients and intraoperative motor evoked potentials were recorded in 97 (63.8%). One hundred and seven (70.4%) patients had reconstruction of the intercostal arteries from T7 to L2, 35 of which were reconstructed with the aortic patch technique and 72 with branched grafts. The mean number of reconstructed intercostal arteries was 3.1±2.5 pairs. Mild hypothermic partial cardiopulmonary bypass at 32-34 °C was used in 105 (69.1%) patients, left heart bypass was used in 4 (2.6%), and deep hypothermic cardiopulmonary bypass below 20 °C was used in 42 (27.6%). Thirty-day mortality was 9 (5.9%), and hospital mortality was 20 (13.2%). Independent risk factors for hospital mortality were emergency surgery (OR 13.4, P=0.003) and aortic cross clamping over 2 hours (OR 5.7, P=0.04). Postoperative spinal cord ischemia occurred in 16 (10.5%, 8 patients with paraplegia and 8 with paraparesis). Risk factors for developing spinal cord ischemic complications were prior surgery involving either the descending thoracic or the abdominal aorta (OR 3.75, P=0.05), diabetes mellitus (OR 5.49, P=0.03), and post-bypass hypotension <80 mmHg (OR 1.06, P=0.03). Postoperative survival at 5 years was 83.6±4.5%; 5-year survival was 47.5±8.6% in patients with spinal cord ischemia and 88.9±10.4% in those without spinal cord ischemia.
我们介绍了重建胸腹主动脉的技术细节。1999 年 10 月至 2012 年 6 月期间，152 例患者接受了胸腹主动脉瘤手术（Crawford 分类 I 型=21，II 型=43，III 型=73，IV 型=15）。平均年龄为 64.6±13.9 岁。63 例（41.4%）患者有主动脉夹层，其中急性 B 型夹层 2 例（1.2%），破裂性动脉瘤 17 例（11.2%）。8 例（5.3%）患者有感染性动脉瘤，3 例（2.0%）有动脉炎。25 例（16.4%）患者进行了急诊或紧急手术。103 例（67.8%）患者术前 CT 扫描或磁共振血管造影术（MR 血管造影术）发现了肋间动脉。115 例（75.7%）患者行脑脊液引流（CSFD），97 例（63.8%）患者术中记录运动诱发电位。107 例（70.4%）患者重建 T7 至 L2 的肋间动脉，其中 35 例采用主动脉补片技术重建，72 例采用分支移植物重建。重建的肋间动脉平均数量为 3.1±2.5 对。105 例（69.1%）患者采用 32-34°C 低温部分心肺转流，4 例（2.6%）采用左心转流，42 例（27.6%）采用 20°C 以下深低温心肺转流。30 天死亡率为 9（5.9%），院内死亡率为 20（13.2%）。院内死亡的独立危险因素是急诊手术（OR 13.4，P=0.003）和主动脉阻断时间超过 2 小时（OR 5.7，P=0.04）。术后脊髓缺血发生在 16 例（10.5%，8 例截瘫，8 例截瘫）。发生脊髓缺血并发症的危险因素包括先前涉及降胸或腹主动脉的手术（OR 3.75，P=0.05）、糖尿病（OR 5.49，P=0.03）和术后体外循环后低血压<80mmHg（OR 1.06，P=0.03）。术后 5 年生存率为 83.6±4.5%；脊髓缺血患者 5 年生存率为 47.5±8.6%，无脊髓缺血患者为 88.9±10.4%。
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