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《心脏杂志》[ISSN:1009-7236/CN:61-1268/R]

期数:

2017年第2期

页码:

213-216

栏目:

临床研究

出版日期:

2016-11-25

文章信息/Info

Title:

Total arch replacement for type A aortic dissection complicated with brachiocephalic artery dissection

作者:

王显悦; 董文鹏; 童 光; 毕生辉; 张 本; 王晓武; 张卫达

（广州军区总医院、第二军医大学临床医学院心脏外科中心，广东 广州 510010）

Author(s):

WANG Xian-yue;  DONG Wen-peng;  TONG Guang;  BI Sheng-hui;  ZHANG Ben;  WANG Xiao-wu;  ZHANG Wei-da

(Department of Cardiovascular Surgery, General Hospital, Guangzhou Military Area Command, Guangzhou 510010, Guangdong, China)

关键词:

主动脉夹层; 选择性顺行脑灌注; 全弓置换术

Keywords:

type A aortic dissection;  antegrade selective cerebral perfusion;  total arch replacement

分类号:

R614

DOI:

-

文献标识码:

A

摘要:

目的 观察累及弓部分支血管的A型主动脉夹层（AAD）全弓置换手术效果。方法 将2010年1月~2015年12月于我中心治疗的68例夹层累及弓部血管的AAD患者设为弓部组，并抽取同期弓部血管正常的60例AAD患者作为对照组。弓部组中33例患者术前伴脑部症状，包括昏迷2例，一过性意识丧失6例，嗜睡、语言和感觉障碍等25例（症状组）；35例患者未见明显脑部症状（无症状组）。两组患者均行AAD全弓置换手术治疗。观察以下术中和术后指标，包括：症状组和无症状组选择性顺行脑灌注(ACP)时间，弓部破口、永久性神经功能缺损（PND）和一过性神经功能缺损(TND)和院内死亡例数以及出院前NIHSS评分；弓部组和对照组手术中情况：包括手术时间、体外循环时间、ACP时间、心脏停搏时间，以及双侧选择性顺行脑灌注（BACP）和单侧选择性顺行脑灌注（UACP）例数，主动脉病变情况包括中度以上主动脉瓣返流（AR）、弓部破口例数；弓部组和对照组手术后恢复情况，包括ICU时间，再次开胸止血、长期机械通气、血滤治疗、气管切开、肺部感染、PND、TND和院内死亡例数。结果 全部AAD患者均完成手术操作，症状组和无症状组患者ACP时间无显著差异；与无症状组比较，症状组患者术中探查破口位于主动脉弓部、PND和TND例数以及院内死亡发生例数较多，患者出院前NIHSS评分较高（P<0.05）。弓部组和对照组患者在术中BACP和UACP方式选择、术中探查中度以上AR例数上无显著差异。与对照组比较，弓部组手术和体外循环时间、ACP和心脏停搏时间较长，术中探查破口位于主动脉弓部例数较多（P< 0.05，P<0.01）。两组患者再次开胸止血、气管切开、肾功能不全血滤治疗及院内死亡例数无显著差异。与对照组比较，弓部组患者ICU滞留时间较短，长期机械通气、肺部感染、PND和TND例数较多（P<0.05，P<0.01）。结论 累及弓部分支血管的AAD患者手术操作复杂，全弓置换术后脑部并发症发生率较高，其中术前存在脑部症状者手术风险更大。

Abstract:

AIM To investigate total arch replacement for type A aortic dissection complicated with brachiocephalic artery dissection. METHODS Sixty eight patients (arch group) with type A aortic dissection (AAD) complicated with brachiocephalic artery dissection from January 2010 January 2016 were analyzed and another 60 patients with type A aortic dissection with normal brachiocephalic artery were grouped as control group. In the arch group, 38 patients had cerebral symptoms (SPT group) including two with coma, six with syncope and 25 complicated with somnolence, language and sensory disturbance and another 35 patients with no cerebral symptoms (NSPT group) in the arch group. All patients underwent total arch replacement. Clinical files from the SPT group and NSPT group were compared in terms of antegrade selective cerebral perfusion (ACP) time, frequency of arch tear, permanent neurologic deficit (PND), temporary neurologic deficit (TND), hospital death and NIHSS score before discharge from hospital. Surgical records from the arch group and control group were compared in terms of surgical time, cardiopulmonary bypass time, ACP time and cardiac arrest time, frequency of BACP and UACP, arch tear and moderate to severe aortic valve regurgitation (AR). Postoperative records from the arch group and control group were compared in terms of ICU time and frequency of re-operation for bleeding, ventilation>7 days, renal failure necessitating ultrafiltration, tracheotomy, pulmonary infection, PND and TND and hospital death. RESULTS All patients successfully achieved total arch replacement. There was no statistical difference in ACP time between SPT group and NSPT group. Compared with NSPT group, SPT group had more frequency of arch tear, permanent neurologic deficit (PND) and temporary neurologic deficit (TND), and hospital death and NIHSS score (P<0.05). Compared with control group, arch group had longer operating time, cardiopulmonary bypass time and cardiac arrest time, and more frequency of arch tear (P<0.05, P<0.01). There was no difference between arch group and control group in frequency of re-operation for bleeding, tracheotomy, postoperative renal failure needing ultrafiltration and hospital death. Compared with control group, arch group had a longer ICU time, higher frequency of long ventilation, pulmonary infection, PND and TND (P<0.05, P<0.01). CONCLUSION Surgery for AAD complicated with brachiocephalic artery dissection is complex and the incidence of postoperative cerebral complications is high. Preoperative cerebral symptoms lead to poorer prognosis.

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备注/Memo

备注/Memo:

收稿日期：2016-03-24.
基金项目：广州市科技计划项目资助（2011J4100021）；全军重大项目资助（2010gxjso31）；国家自然科学基金项目资助(81500298，81400223)； 广东省自然科学基金项目资助(2014A030310473)
通讯作者：张卫达，主任医师，主要从事心脏大血管疾病研究 Email：xzwk_ZWD@hotmail.com
作者简介：王显悦，主治医师，博士生 Email：37680138@qq.com

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更新日期/Last Update: 2016-10-11