Zou L W, Liu Y F, Liu H, Chen B, Jiang J H, Shi Y, Guo D Q, Xu X, Dong Z H, Fu W G
Departments of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, Fudan University, National Clinical Research Center for Interventional Medicine, Shanghai 200030, China.
Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510510, China.
Zhonghua Wai Ke Za Zhi. 2024 Mar 1;62(3):235-241. doi: 10.3760/cma.j.cn112139-20230926-00141.
To explore the surgical strategies and clinical efficacy for aortic dissection combined with refractory superior mesenteric artery (SMA) ischemia. This is a retrospective case series study. Clinical data of 24 patients with aortic dissection and refractory SMA ischemia admitted to the Department of Vascular Surgery, Zhongshan Hospital, Fudan University from August 2010 to August 2020 were retrospectively collected. Of the 24 patients, 21 were males and 3 were females, with an age of (50.3±9.9) years (range: 44 to 72 years).Among them, 9 cases were Stanford type A aortic dissection, and 15 cases were type B. All patients underwent CT angiography upon admission, and based on imaging characteristics, they were classified into three types. Type Ⅰ: severe stenosis/occlusion of the SMA true lumen only; Type Ⅱ: stenosis of the true lumens in the descending aorta and SMA (isolated type); Type Ⅲ: stenosis of the true lumens in the thoracoabdominal aorta and SMA (continuation type). Surgical procedures, complications, mortality, and reintervention rates were recorded. Among the 24 patients, 17 (70.8%) were classified as Type Ⅰ, 4 (16.7%) as Type Ⅱ, and 3 (12.5%) as Type Ⅲ. Fourteen cases of Type Ⅰ underwent thoracic endovascular aortic repair combined with SMA stent implantation. Additionally, 3 Type Ⅰ and 1 Type Ⅱ patients underwent only SMA reconstruction (with one case of chronic TAAD treated with iliac artery-SMA bypass surgery). Moreover, 3 Type Ⅱ and 3 Type Ⅲ patients underwent descending aorta combined with SMA stent implantation. There were 5 patients (20.8%) who underwent small bowel resection, either in the same sitting or in a staged procedure. During hospitalization, 4 patients died, resulting in a mortality rate of 16.7%. Among these cases, two patients succumbed to severe intestinal ischemia resulting in multiple organ dysfunction syndrome. The follow-up duration was (46±9) months (range: 13 to 72 months). During the follow-up, 2 patients died, unrelated to intestinal ischemia. The 5-year freedom from reintervention survival rate was 86.1%, and the 5-year cumulative survival rate was 82.6%. Patients with aortic dissection and refractory SMA ischemia have a high perioperative mortality. However, implementing appropriate surgical strategies according to different clinical scenarios can reduce mortality and alleviate intestinal ischemia.
探讨主动脉夹层合并难治性肠系膜上动脉（SMA）缺血的手术策略及临床疗效。这是一项回顾性病例系列研究。回顾性收集了2010年8月至2020年8月复旦大学附属中山医院血管外科收治的24例主动脉夹层合并难治性SMA缺血患者的临床资料。24例患者中，男性21例，女性3例，年龄（50.3±9.9）岁（范围：44至72岁）。其中，Stanford A型主动脉夹层9例，B型15例。所有患者入院时均行CT血管造影，并根据影像学特征分为三型。Ⅰ型：仅SMA真腔严重狭窄/闭塞；Ⅱ型：降主动脉和SMA真腔狭窄（孤立型）；Ⅲ型：胸腹主动脉和SMA真腔狭窄（延续型）。记录手术方式、并发症、死亡率及再次干预率。24例患者中，17例（70.8%）为Ⅰ型，4例（16.7%）为Ⅱ型，3例（12.5%）为Ⅲ型。14例Ⅰ型患者行胸主动脉腔内修复术联合SMA支架植入术。此外，3例Ⅰ型和1例Ⅱ型患者仅行SMA重建术（1例慢性主动脉夹层患者行髂动脉-SMA旁路手术）。另外，3例Ⅱ型和3例Ⅲ型患者行降主动脉联合SMA支架植入术。5例患者（2项8%）在同一次手术或分期手术中接受了小肠切除术。住院期间，4例患者死亡，死亡率为16.7%。其中，2例患者死于严重肠缺血导致的多器官功能障碍综合征。随访时间为（46±9）个月（范围：13至72个月）。随访期间，2例患者死亡，与肠缺血无关。5年无再次干预生存率为86.1%，5年累积生存率为82.6%。主动脉夹层合并难治性SMA缺血患者围手术期死亡率较高。然而，根据不同临床情况实施恰当的手术策略可降低死亡率并缓解肠缺血。
