摘要目的 探讨术中覆膜支架开窗术重建左锁骨下动脉血供在Stanford A型主动脉夹层弓部处理中的应用效果.方法 回顾性分析2008年9月至2014年12月因Stanford A型主动脉夹层而在第二军医大学长海医院胸心外科行手术治疗时采用术中覆膜支架开窗术重建左锁骨下动脉血供的67例患者的临床资料.男性54例,女性13例;年龄26 ～ 75岁,平均年龄(50±10)岁.均为急性主动脉夹层,左锁骨下动脉未累及且起源于真腔.患者行升主动脉、全主动脉弓置换联合降主动脉象鼻支架植入术.弓部处理中采用术中覆膜支架开窗术重建左锁骨下动脉血供.主动脉根部处理措施包括:主动脉瓣置换术2例、Bentall手术21例、保留瓣膜的根部重建术44例;同期行二尖瓣修复术3例,冠状动脉旁路移植术6例.结果 平均心肺转流时间(179±32) min,平均阻断时间(112±25) min,平均停循环时间(26±10)min.住院病死率7.5％ (5/67),死亡原因包括多器官功能衰竭2例、急性肾功能不全1例、感染性休克2例.术后早期并发症包括根部出血2例(3.0％)、短暂性神经功能障碍6例(9.0％)、呼吸功能不全合并感染6例(9.0％).生存患者随访1～5年,1、5年生存率分别为100％、89.8％.随访期间主动脉CT血管造影提示左锁骨下动脉血供良好,无明显夹层形成,无支架内漏发生;患者无脑卒中及左侧肢体缺血等表现.结论 对于左锁骨下动脉未受累且起源于真腔的Stanford A型主动脉夹层患者,术中覆膜支架开窗术能有效地缩短手术时间、简化手术操作方式,操作性好,安全可靠.

abstractsObjective To summarize the results and methods of left subclavian artery revascularization by stented trunk fenestration for acute Stanford type A aortic dissection.Methods Clinical data of 67 patients (54 male and 13 female,mean age of (50 ± 10) years) underwent surgical treatment of left subclavian artery fenestration for acute Stanford A aortic dissection in Department of Cardiothoracic Surgery,Changhai Hospital,Second Military Medical College between September 2008 and December 2014 were analyzed retrospectively.The origin of the left subclavian artery was in the true lumen and no dissection existed near the artery's starting.There were 18 cases of Marfan's syndrome.Preoperative echocardiography showed moderate to severe aortic regurgitation in 10 cases,and mitral regurgitation in 3 cases.Electrocardiogram showed myocardial ischemia in 5 cases.Three patients had acute impaired renal function.All the patients received total arch replacement combined with stented elephant trunk implantation.Left subclavian artery revascularization was performed by stented trunk fenestration as follows:firstly,stented elephant trunk was implanted to completely cover the left subclavian artery,then part of stented trunk's polyester lining was removed which is located at the origin of left subclavian artery.Aortic root procedures included aortic valve replacement in 2 cases,Bentall procedure in 21 cases and aortic valve sparing in 44 cases.Three patients received mitral valve repair and 6 patients received coronary artery bypass grafting.Results The cardiopulmonary bypass time,cross-clamp time,and circulatory arrest time were (179 ± 32) minutes,(112 ± 25) minutes,and (26 ± 10) minutes,respectively.The in-hospital mortality was 7.5％ (5/67):2 patients died of multiple organ failure,1 patient died of acute renal failure and another 2 patients died of severe infection shock.Two patients required reexploration for root bleeding.Transient neurology dysfunction developed in 6 patients.Six patients received tracheotomy and prolonged ventilation due to pulmonary infection.All patients discharged from the hospital were followed up for 1 to 5 years.During long-term follow-up,the survival rate was 100％ and 89.8％ at 1 and 5 years,respectively.CT angiography was performed once per year after discharged.The left subclavian artery perfusion was good.No dissection or anastomosis leakage was identified in any case.Stroke and left limb ischemia did not develope.Conclusion For acute Stanford type A aortic dissection whose origin of the left subclavian artery is in the true lumen and no dissection existed near the artery's starting,the left subclavian artery revascularization by stented trunk fenestration technique during total arch replacement combined with stented elephant trunk implantation is reliable and effective.