摘要目的 探索Stanford A型主动脉壁间血肿(IMH)患者外科治疗的方法及时机.方法 2015年2月至2017年8月,60例Stanford A型主动脉壁间血肿患者行手术治疗,回顾性分析其临床资料.其中男38例,女22例;年龄(51.5±6.2)岁.患者升主动脉IMH合并溃疡;升主动脉直径≥50 mm(包括血肿);升主动脉血肿厚度≥10 mm;心包积液或者胸腔积液;症状不缓解或再发或合并中度以上主动脉瓣关闭不全.其中行升主动脉替换+全主动脉弓替换并支架象鼻置入术(孙氏手术)46例,Bentall术+孙氏手术6例(其中包括左侧单椎动脉-左颈总动脉移植1例),升主动脉替换+半弓替换4例,Bentall术+半弓替换2例,升主动脉替换2例.结果 术中发现主动脉内膜破损34例(56.7％).术后1例(1.7％)死于多器官功能衰竭.术后出现低氧血症5例(8.3％);肾功能衰竭需CRRT 2例(3.3％);脑血管并发症1例(1.7％);二次开胸1例(1.7％);术后截瘫1例(1.7％);经治疗后均好转.随访3～15个月,无死亡;2例需再次手术干预行TEVAR术.近端吻合口漏2例,行介入封堵术.1、3及6个月远端血肿基本吸收率分别为68.6％、84.7％及94.8％.结论 掌握好手术指征及选择合适的手术方式是外科治疗Stanford A型主动脉壁间血肿患者的关键,孙氏手术治疗A型主动脉壁间血肿近、中期临床效果较好.

abstractsObjective To summarize experience and result in surgical treatment of Stanford type A intramural hematoma.Methods 60 patients with Stanford type A intramural hematoma were operated from February 2015 to August 2017.Surgery was indicated in complicated cases with penetrating ulcer or ulcer-like projection in ascending aorta,maximum aorta diameter≥50 mm,progressive maximum aortic wall thickness≥i0 mm,pericardial or pleural effusion,persistent or recurrent pain.Aortic valve regurgitation.In our group,46 patients recieved ascending aorta replacement + Sun's procedure.6 patients recieved Bentall + Sun's procedure.4 patients recieved asceding aorta + hemiarch replacement.2 patients recieved Bentall + hemiarch replacement.2 patients recieved asceding aorta replacement.Results In the whole group,there was 1 (1.7％) operative death because of multiple organ failure after operation.Hyoxemiaoccured in 5(8.3％) patients,2(3.3％) patients occurred new renal failure and required CRRT treatment,cerebrovascular complication occurred in 1 (1.7％)patient,re-sternotomy due to bleeeding occured in 1 (1.7％) patient and paraplegia occured in 1 (1.7％) patient after operation.but they recoved quickly after proper treatment.During follow up period,there were 4 cases need reintervention,including TEVAR for type B dissection at 3 months and distal stent-graft new entry at 1 year.Two other reinterventions were performed for endoleak by interventional occlusion.During the follow-up,hematoma absorption rates after treatment 1、3 and 6 months were 68.6％,84.7％ and 94.8％.Conclusion Given the dynamic evolution of acute type A IMH pre-operative accurate indications and the proper surgical strategy maybe the keys for success.