摘要目的 总结支架象鼻加升主动脉至股动脉旁路移植术治疗瘤样扩张病变的Stanford A型主动脉夹层或主动脉瘤的临床经验,探讨手术适应证的选择、慢性主动脉夹层瘤样扩张病变的手术治疗策略并总结早期随访结果.方法 2006年2月至2011年11月,19例Stanford A型主动脉夹层或主动脉瘤伴全主动脉瘤样扩张的患者接受了支架象鼻加升主动脉至股动脉旁路移植术.其中男性14例,女性5例；平均年龄(42±8)岁,平均体质量(70±15)kg.除1例为全主动脉真性动脉瘤外,其余均为Stanford A型主动脉夹层.其中马方综合征患者8例.患者行直视支架象鼻术及主动脉弓部人工血管替换,升主动脉到股动脉的人工血管旁路移植.结果 手术无死亡；乳糜胸1例,治疗后好转,截瘫1例.心外转流时间(176 ±42) min,主动脉阻断时间(88±25) min,深低温低流量时间(23±8)min,术后下肢血压正常.术后随访(22±19)个月,无死亡病例,术后早期支架段假腔闭合率100％,术后3～6个月CT随访示降主动脉较术后早期无明显扩张.2例已成功完成二期(次)全降主动脉替换术.结论 支架象鼻加升主动脉至股动脉旁路移植术治疗主动脉夹层重度瘤样扩张病变安全有效,能有效缓解因真腔小导致的下肢及内脏供血不足,可能延缓降主动脉假腔扩张速度,为二期常温全降主动脉替换打下基础.

abstractsObjectives To summarize the clinical experience of stented elephant trunk with femoral artery bypass grafting procedure to treat severe aneurysmal dilation of Stanford A aortic dissection or aortic aneurysm.To study the surgical indication and surgical strategy of chronic Stanford A aortic dissection and aneurysmal dilation,also to summarize the early follow-up results.Methods From February 2006 to November 2011,19 patients with Stanford A aortic dissection or aortic aneurysm with extented aneurysmal dilation (megaaorta) received stented elephant trunk with femoral artery bypass grafting procedure.There were 3 acute cases and 16 chronic cases with 14 male patients and 5 female patients.Average age of this group was (42 ± 8) years and average body weight was (70 ± 15) kg.One patient was aortic aneurysm and all the other were Stanford A aortic dissection.Eight patients were Mafan's syndrome.Ascending aorta replacement or Bentall's operation was done first and total arch replacement and stented elephant trunk operation was done under deep hypothermia and circulatory arrest.After the patient was weaned from cardiopulmonary bypass,bypass from ascending aorta to femoral artery was done subcutaneously using the 10 mm graft in the same femoral incision.Results There was no operative mortality.One patient had chylothorax which recovered with medical treatment and one patient got paraplegia after surgery.The cardiopulmonary bypass time was (176 ± 42) minutes,aortic cross clamping time was (88 ± 25) minutes and deep hypothermia and low flow rate time was (23 ± 8) minutes.The blood pressure of the lower extremities were normal after operation.Follow-up time was (22 ± 19) months.All patients survived.False lumen closure rate at the stent level was 100％.CT scan at 3 to 6 months after operation showed no obvious dilation of the descending aorta.Two patient successfully received second stage operation of total (subtotal)thoracoabdominal aorta replacement.Conclusions Stented elephant trunk and aorta to femoral artery bypass is a safe procedure to treat aortic dissection or aortic aneurysm with extended aneurysmal dilation.This procedure can effectively increase the blood supply of the lower extremities due to small true lumen of the descending aorta,and may decrease the speed of dilation of the false lumen.It is also a practical procedure to lay the foundation for the second stage operation of normothemia thoracoabdominal aorta replacement.