"杂交"手术治疗DeBakey Ⅰ型主动脉夹层
"잡교"수술치료DeBakey Ⅰ형주동맥협층
Hybrid procedure without deep hypothermic circulatory arrest for DeBakey type Ⅰ aortic dissection
  • 万方数据
    中华胸心血管外科杂志 중화흉심혈관외과잡지
    Chinese Journal of Thoracic and Cardiovascular Surgery
    2011年 6期 327-330,326 ,共5页

    景华%李德闽%胡小南%李忠东%董国华%罗立国%申翼%许飚%钱建军%张晓华%程晓峰%吴海卫

    경화%리덕민%호소남%리충동%동국화%라입국%신익%허표%전건군%장효화%정효봉%오해위

    动脉瘤,夹层/外科学%血管假体置人%心肺转流术%"杂交"手术 動脈瘤,夾層/外科學%血管假體置人%心肺轉流術%"雜交"手術
    동맥류,협층/외과학%혈관가체치인%심폐전류술%"잡교"수술
    Aneurysm,dissection/surgery%Blood vessel prosthesis implantation%Cardiopulmonary bypass%Hybrid procedure
    目的 总结应用无深低温停循环的升主动脉置换、升主动脉-主动脉弓分支血管旁路、腔内隔绝的"杂交"手术治疗DeBakey Ⅰ型主动脉夹层的方法和经验.方法 2009年1月至2010年6月,39例、平均年龄(55±16)岁的DeBakey Ⅰ型主动脉夹层病人进行无深低温停循环的"杂交"手术.病人经股动脉、右腋动脉插管灌注,先于常规体外循环下行升主动脉和主动脉瓣置换,再采用四分支人工血管、"Y"形人工血管或单根人工血管行升主动脉-主动脉弓分支血管旁路手术,再经股动脉逆行径路数字减影血管造影(DSA)下或术中顺行径路食管超声定位下行主动脉弓-降主动脉腔内隔绝术.结果 全组均手术成功,升主动脉处理时8例行单纯升主动脉人工血管置换,20例行Bentall手术(其中冠状动脉移位采用Carbrol法11例),11例行Wheat手术;升主动脉-主动脉弓分支血管旁路手术采用四分支人工血管16例、"Y"形人工血管15例、单根人工血管序贯法8例;主动脉弓-降主动脉腔内隔绝术采用DSA下股动脉逆行径路36例,术中人工血管分支顺行径路3例,均使用1枚支架.体外循环(61±22)min,主动脉阻断(48±18)min.术后(30±9)h拔除气管插管,24 h胸液小于300 ml,无偏瘫、截瘫、严重感染、凝血障碍等并发症.所有病人均治愈出院,平均术后(21±6)天出院.术后随访1～15个月,平均(8.4±7.2)个月,病人均健康生存,无脏器功能不全.术后3个月行CT主动脉血管成像检查,显示膈肌水平假腔闭合率为91.2%.结论 常温体外循环下升主动脉置换、升主动脉-弓部血管旁路、腔内隔绝的"杂交"手术治疗DeBakey Ⅰ型主动脉夹层,简化了DeBakey Ⅰ型主动脉夹层外科治疗方法,该手术方法避免了深低温停循环,减少了术后并发症,提高了外科治疗效果.
    목적 총결응용무심저온정순배적승주동맥치환、승주동맥-주동맥궁분지혈관방로、강내격절적"잡교"수술치료DeBakey Ⅰ형주동맥협층적방법화경험.방법 2009년1월지2010년6월,39례、평균년령(55±16)세적DeBakey Ⅰ형주동맥협층병인진행무심저온정순배적"잡교"수술.병인경고동맥、우액동맥삽관관주,선우상규체외순배하행승주동맥화주동맥판치환,재채용사분지인공혈관、"Y"형인공혈관혹단근인공혈관행승주동맥-주동맥궁분지혈관방로수술,재경고동맥역행경로수자감영혈관조영(DSA)하혹술중순행경로식관초성정위하행주동맥궁-강주동맥강내격절술.결과 전조균수술성공,승주동맥처리시8례행단순승주동맥인공혈관치환,20례행Bentall수술(기중관상동맥이위채용Carbrol법11례),11례행Wheat수술;승주동맥-주동맥궁분지혈관방로수술채용사분지인공혈관16례、"Y"형인공혈관15례、단근인공혈관서관법8례;주동맥궁-강주동맥강내격절술채용DSA하고동맥역행경로36례,술중인공혈관분지순행경로3례,균사용1매지가.체외순배(61±22)min,주동맥조단(48±18)min.술후(30±9)h발제기관삽관,24 h흉액소우300 ml,무편탄、절탄、엄중감염、응혈장애등병발증.소유병인균치유출원,평균술후(21±6)천출원.술후수방1～15개월,평균(8.4±7.2)개월,병인균건강생존,무장기공능불전.술후3개월행CT주동맥혈관성상검사,현시격기수평가강폐합솔위91.2%.결론 상온체외순배하승주동맥치환、승주동맥-궁부혈관방로、강내격절적"잡교"수술치료DeBakey Ⅰ형주동맥협층,간화료DeBakey Ⅰ형주동맥협층외과치료방법,해수술방법피면료심저온정순배,감소료술후병발증,제고료외과치료효과.
    Objective Some major procedures for DeBakey type Ⅰ aortic dissection used to be performed with deep hypothermic circulatory arrest, which had been associated with more complications than seen with standard extracorporeal circulation. We reviewed the cases who received the treatment for DeBakey type Ⅰ aortic dissection by hybrid procedure without deep hypothermic circulatory arrest. The procedure consisted of ascending aorta replacement, ascending aorta-aortic arch branch vascular bypass reconstruction and endovascular graft exclusion. Methods From January 2009 to June 2010, 39 patients [mean age (55 ±16) years] who had DeBakey Ⅰ aortic dissection underwent hybrid procedure without deep hypothermic circulatory arrest. The femoral artery and right axillary artery were cannulated for perfusion. The ascending aorta and/or aortic valves were replaced under conventional extracorporeal circulation with Bentall procedure or Wheat procedure. The aortic arch branch vessels were dissected and the proximal part was sealed. Then the ascending aorta-aortic arch branch vascular bypasses were constructed with 4-bifurcation vascular grafts, Y-shape bifurcated vascular grafts or artificial vessels. Finally the endovascular grafts were deployed via the femoral incisions monitored dynamically with DSA, or via the ascending aortic bifurcated vessels monitored with transesophageal echocardiography. Results The operation succeeded in all 39 patients. Eight patients underwent ascending aorta replacement without aortic valve replacement or prosthesis, 20 patients underwent Bentall procedure ( Carbrol procedure were used in 11 cases), and 11 underwent Wheat procedure. For ascending aorta-aortic branch vascular bypass reconstruction, sequential anastomoses were performed in 8, Y-shaped bifurcated grafts were used in 15, and 4-bifurcated grafts were employed in 16 patients. The endovascular stent grafts were deployed via the former femoral incisions in 36 patients and via ascending aortic bifurcated vessels in 3. The cardiopulmonary bypass time was (61 ±22) minutes, the aortic crossclamp time was (48 ±18) minutes, and the post-operative intubation time was (30 ±9) hours. The thoracic drainage from each patient was less than 300 ml in 24 hours. No complication, such as hemiplegia, paraplegia, severe infections, renal failure or coagulation disorder, was observed. The duration of hospitalization was (21 ±6) days. No hospital death occurred. Follow-up was performed 1 to 15 months [mean (8.4 ±7.2) months] postoperatively. All patients survived without any organ dysfunction at follow up. The CTA examination 3 months after operation revealed that the false lumens had been closed in 91.2% of the patients. Conclusion Our findings indicated that the hybrid procedure, which combining ascending aorta replacement,ascending aorta-aortic arch branch vascular bypass reconstruction and endovascular graft exclusion under conventional extracorporeal circulation, may be an option for avoiding the possible complications associated with profound hypothermic circulatory arrest. The novel hybrid operation may improve the surgical outcomes and provide a simplified surgical approach for the treatment of DeBakey Ⅰ aortic dissection.
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