2023 年第 7 期 第 18 卷

直视降主动脉支架治疗主动脉弓部破口的急性B型主动脉夹层效果分析

Effect of descending aorta stent in the treatment of acute type B aortic dissection with aortic arch tear

作者：胡海瓯1郑铁1唐兵1乔志钰1里程楠1朱俊明1孙立忠1,2

英文作者：Hu Haiou1 Zheng Tie1 Tang Bing1 Qiao Zhiyu1 Li Chengnan1 Zhu Junming1 Sun Lizhong12

单位：1首都医科大学附属北京安贞医院心脏外科北京市心肺血管疾病研究所，北京100029；2上海德达医院心脏大血管外科，上海201702

英文单位：1Department of Cardiac Surgery Beijing Anzhen Hospital Capital Medical University Beijing Institute of Heart Lung and Blood Vessel Diseases Beijing 100029 China; 2Department of Cardiac and Major Vascular Surgery Shanghai Delta Health Hospital Shanghai 201702 China

关键词：急性B型主动脉夹层；直视降主动脉支架；逆行A型主动脉夹层；Ⅰa型内漏

英文关键词：AcutetypeBaorticdissection;Descendingaortastent;RetrogradetypeAaorticdissection;Type Ⅰaendoleak

• 摘要：

• 目的  探讨直视降主动脉支架治疗主动脉弓部破口的急性B型主动脉夹层（ABAD）的效果。方法  选取2021年6月至2022年9月首都医科大学附属北京安贞医院收治的18例破口位于主动脉弓部的ABAD患者，均接受直视降主动脉支架治疗。所有患者的内膜撕裂口均位于无名动脉和左锁骨下动脉之间。记录所有患者的临床表现、术中资料、术后资料和随访结果并进行分析。结果  所有患者均成功闭合了原发性弓部破口。同期心脏手术3例（16.7%），包括主动脉瓣置换术1例，冠状动脉旁路移植术2例。手术时间（325±56）min，体外循环时间、主动脉阻断时间和选择性脑灌注时间分别为（145±23）、（58±20）、（24±5）min。呼吸机使用时间（15±5）h，住监护室时间（38±24）h，术后住院天数（12±5）d。术后无死亡、脊髓损伤、Ⅰa型内漏和逆行A型主动脉夹层。1例患者术后发生非致残性脑梗死，1例术前慢性肾功能不全的患者术后接受连续性肾脏替代治疗2周。随访时间为（10±4）个月，1例患者在术后6个月接受胸腹主动脉置换术。支架周围假腔血栓化18例（100.0%），膈肌水平假腔血栓化11例（61.1%），腹腔干水平假腔血栓化6例（33.3%）。结论直视降主动脉支架治疗破口位于主动脉弓部的ABAD是安全、有效的。它保留了弓部头臂血管及升主动脉。使用该技术，没有发生Ⅰa型内漏和逆行A型主动脉夹层的风险。此外，术中支架植入也有利于二期胸腹主动脉置换手术的实施。

• Objective  To investigate the effect of descending aorta stent placement in the treatment of acute type B aortic dissection (ABAD) with aortic arch tear. Methods  From June 2021 to September 2022, 18 ABAD patients with aortic arch tear admitted to Beijing Anzhen Hospital, Capital Medical University were selected. They were treated with direct descending aorta stent. In all patients, the intimal tear was located between the innominate artery and the left subclavian artery. The clinical manifestations, intraoperative data, postoperative data and follow-up results of all patients were recorded and analyzed. Results  Primary arch lacerations were successfully closed in all patients. There were 3 patients (16.7%) with cardiac surgery, including 1 case of aortic valve replacement and 2 cases of coronary artery bypass grafting. The operation time was (325±56)min, the cardiopulmonary bypass time, aortic occlusion time and selective cerebral perfusion time were (145±23), (58±20) and (24±5)min, respectively. The ventilator use time was (15±5)h, the intensive care unit stay time was (38±24) h, and the postoperative hospital stay was (12±5) d. There was no death, spinal cord injury, type Ⅰa endoleak and retrograde type A aortic dissection. One patient developed non-disabling cerebral infarction after operation, and 1 patient with preoperative chronic renal insufficiency received continuous renal replacement therapy for 2 weeks after operation. The follow-up time was (10±4)months, and 1 patient received thoracoabdominal aortic replacement at 6 months after operation. There were 18 cases (100.0%) of false lumen thrombosis around the stent, 11 cases (61.1%) of false lumen thrombosis at the level of diaphragm, and 6 cases (33.3%) of false lumen thrombosis at the level of celiac trunk. Conclusions    Descending aortic stent placement is safe and effective in the treatment of ABAD with aortic arch tear. It preserves the brachiocephalic vessels of the arch and the ascending aorta. There is no risk of type Ⅰa endoleak and retrograde type a aortic dissection with this technique. In addition, intraoperative stent implantation is also conducive to the implementation of two-stage thoracoabdominal aortic replacement.