CAJ | 학술논문

目的探讨Stanford A型主动脉夹层近端主动脉替换术后残余主动脉夹层的手术时机和手术方式.方法 2009年3月至2011年11月,连续收治16例Stanford A型主动脉夹层术后残余夹层的患者,男13例,女3例；年龄23 ～ 61岁,平均44岁.其中8例为马方综合征.中低温停循环、低流量顺行脑灌注下行孙氏手术(主动脉弓替换+支架象鼻术).其中单纯行孙氏手术12例；同期行主动脉根部替换术(Bentall手术)3例,主动脉根部替换术+冠状动脉旁路移植术(Bentall+ CABG)1例,冠状动脉吻合口漏修补术1例,二尖瓣置换术(MVR)1例.结果再次手术距离首次手术时间(66±40)个月.体外循环(193±49)min,心肌阻断(90±28) min,选择性脑灌注(22±10) min.术后气管插管(17±10)h.无住院死亡.术后并发症4例,其中左下肢轻瘫1例随访期间好转；开胸止血、乳糜胸和胸骨后感染各1例,均于治疗后痊愈出院.患者出院前均行主动脉CT血管造影检查,示人工血管血流通畅,降主动脉真腔较术前明显扩大,支架段假腔血栓形成.随访3～42个月,平均17个月.1例术后3个月因远端夹层破裂死亡,1例术后6个月行全胸腹主动脉替换术,1例因胸降主动脉扩张合并内膜残余破口行胸主动脉腔内修复术.结论 Stanford A型主动脉夹层升主动脉替换术后残余夹层的患者,当主动脉弓扩张速度超过0.5 cm/年,或直径扩张至5 cm以上(或扩张至4.5 cm但合并弓部破口或马方综合征)时,应再次接受手术治疗,孙氏手术治疗安全有效,手术死亡及相关并发症发生率较低,近期结果良好.
목적 탐토Stanford A형주동맥협층근단주동맥체환술후잔여주동맥협층적수술시궤화수술방식.방법 2009년3월지2011년11월,련속수치16례Stanford A형주동맥협층술후잔여협층적환자,남13례,녀3례；년령23 ～ 61세,평균44세.기중8례위마방종합정.중저온정순배、저류량순행뇌관주하행손씨수술(주동맥궁체환+지가상비술).기중단순행손씨수술12례；동기행주동맥근부체환술(Bentall수술)3례,주동맥근부체환술+관상동맥방로이식술(Bentall+ CABG)1례,관상동맥문합구루수보술1례,이첨판치환술(MVR)1례.결과 재차수술거리수차수술시간(66±40)개월.체외순배(193±49)min,심기조단(90±28) min,선택성뇌관주(22±10) min.술후기관삽관(17±10)h.무주원사망.술후병발증4례,기중좌하지경탄1례수방기간호전；개흉지혈、유미흉화흉골후감염각1례,균우치료후전유출원.환자출원전균행주동맥CT혈관조영검사,시인공혈관혈류통창,강주동맥진강교술전명현확대,지가단가강혈전형성.수방3～42개월,평균17개월.1례술후3개월인원단협층파렬사망,1례술후6개월행전흉복주동맥체환술,1례인흉강주동맥확장합병내막잔여파구행흉주동맥강내수복술.결론 Stanford A형주동맥협층승주동맥체환술후잔여협층적환자,당주동맥궁확장속도초과0.5 cm/년,혹직경확장지5 cm이상(혹확장지4.5 cm단합병궁부파구혹마방종합정)시,응재차접수수술치료,손씨수술치료안전유효,수술사망급상관병발증발생솔교저,근기결과량호.
Objective To discuss the timing and procedures of reoperations on the residual aortic dissection after initial ascending aortic operations on Stanford type A aortic dissection.Methods From March 2009 to November 2011,16 consecutive patients(13 males,3 females) underwent reoperations on the residual aortic dissection.The mean age was 44 years(23-61 years),8 cases was associated with Marfan syndrome.The right axillary artery or femoral artery cannulation was used for cardiopulmonary bypass,cerebral protection was achieved by unilateral antegrade brain perfusion and nasopharyngeal temperature was dropped to 20℃-25℃.The Sun's procedure (total arch replacement with stented elephant trunk implantation) was performed in all patients,concomitant procedure include aortic root replacement (Bentall procedune) in 3 patients,aortic root replacement and coronary artery bypass grafting (Bentall + CABG) in 1 patient,the coronary artery anastomotic leakage repair in 1 patient,mitral valve replacement (MVR) in 1 patient.Results The interval between two operations averaged(66 ±40)months.The means of cardiopulmonary bypass,cross clamp and selective cerebral perfusion times were(193 ± 49)minutes,(90 ±28) minutes and(22 ± 10) minutes,respectively.The mean time to tracheal extubation was(17 ± 10) hours.All patients survived from the operation.One patient suffered from temporary left lower limb paralysis and recovered after treatment during follow-up.Computed tomography angiography (CTA)of aorta was performed on each patient before discharged from the hospital:descending aortic true lumen was significantly expanded,thrombosis of false lumen was found near stent graft.The average follow-up time was 17 (3-42) months,one patient died of aortic rupture 3 months later,one patient underwent total thoracoabdominal aorta replacement 6 months later,one patient with descending thoracic aortic dilatation combined with endometrial tear underwent thoracic endovascular aortic repair.Conclusion Reoperation should be performed as the following condition:the annual growth rate of residual aortic diameter exceeds 0.5 cm/year,the maximal aortic diameter exceeds 5 cm.The Sun's procedure (total arch replacement with the elephant trunk implantation) is safe and effective in the treatment of residual aortic dissection,low mortality and complications was achieved by it,the mid-and long-term results need the further follow-up.