Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases & Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
Department of Radiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases & Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
J Thorac Cardiovasc Surg. 2015 Nov;150(5):1160-5. doi: 10.1016/j.jtcvs.2015.07.089. Epub 2015 Aug 1.
Complete or partial supra-aortic debranching, after thoracic endovascular aortic repair, is appealing treatment for complicated acute type B dissection (ABAD) with aortic arch involvement (AAI) because of reduced surgical trauma. However, unsatisfactory outcomes have been reported. We retrospectively reviewed our experience of left subclavian artery (LSCA) transposition with stented elephant trunk (SET) implantation for complicated ABAD with distal AAI.
From April 2011 to December 2014, 19 patients (all men; mean age: 44 years) who had complicated ABAD and distal AAI underwent LSCA transposition with SET implantation via a median sternotomy under hypothermic cardiopulmonary bypass with selective cerebral perfusion. Preoperative renal dysfunction was observed in 3 patients, visceral ischemia in 2 patients, and lower-limb ischemia in 1 patient.
No in-hospital deaths occurred. Seventeen patients required mechanical ventilation for <24 hours, and 2 cases for <48 hours. The mean time of mechanical ventilation and duration of stay in the intensive care unit was 18 ± 6 hours and 44 ± 16 hours, respectively. Ischemia of the viscera and lower limbs after surgery was ameliorated. Continuous renal replacement therapy was not required in 3 patients who had preoperative renal dysfunction. Complete thrombosis of the false lumen at the distal end of the SET was observed in 17 of 18 (94.4%) patients during follow-up.
This method preserves autologous brachiocephalic vessels, excludes the false lumen, promotes thrombosis and remodeling of the distal aorta, and repairs proximal aortic lesions simultaneously. Satisfactory surgical outcomes and follow-up results were achieved using LSCA transposition with SET implantation.
对于累及主动脉弓（AAI）的复杂急性 B 型夹层（ABAD），在胸主动脉腔内修复术后行全主动脉弓去分支术或部分去分支术是一种有吸引力的治疗方法，因为它减少了手术创伤。然而，已有报道称该方法的效果并不理想。我们回顾性分析了采用左锁骨下动脉（LSCA）移位联合支架象鼻（SET）植入治疗累及远端 AAI 的复杂 ABAD 的经验。
2011 年 4 月至 2014 年 12 月，19 例（均为男性；平均年龄：44 岁）复杂 ABAD 合并远端 AAI 的患者在体外循环低温和选择性脑灌注下经正中开胸行 LSCA 移位联合 SET 植入术。术前 3 例患者存在肾功能不全，2 例患者存在内脏缺血，1 例患者存在下肢缺血。
无院内死亡病例。17 例患者需要机械通气<24 小时，2 例患者需要机械通气<48 小时。机械通气的平均时间和重症监护病房的停留时间分别为 18±6 小时和 44±16 小时。术后内脏和下肢缺血得到改善。术前存在肾功能不全的 3 例患者未进行连续性肾脏替代治疗。18 例（94.4%）患者在随访期间观察到 SET 远端假腔完全血栓形成。
该方法保留了自体头臂血管，排除了假腔，促进了远端主动脉的血栓形成和重塑，并同时修复了近端主动脉病变。采用 LSCA 移位联合 SET 植入术取得了满意的手术效果和随访结果。
