Stanford A型主动脉夹层的治疗进展

doi:10.3760/cma.j.issn.1007-1245.2022.16.034

摘要/Abstract

摘要： 主动脉夹层是一种常见的起病急、进展快、术后易出现并发症、并发症严重、手术病死率高的心血管外科急症。Stanford分型较常用，而其中Stanford A型主动脉夹层占所有主动脉夹层的70%～75%，主动脉夹层破口可位于升主动脉和主动脉弓，也可位于降主动脉，同时夹层也可累及主动脉弓以及降主动脉。1838年，Penneck报道了第1例主动脉夹层，至今已过了一百余年。得益于医疗技术的迅速发展，主动脉夹层的诊断、治疗水平逐渐提升，主动脉夹层的病死率在治疗后较未经治疗前有明显下降。多年来，各种治疗Stanford A型主动脉夹层的方式也层出不穷，本文对Stanford A型主动脉夹层的治疗方式的进展作一综述。

关键词: 主动脉夹层, 外科手术, 介入手术, 杂交手术

Abstract: Aortic dissection is a common cardiovascular surgical emergency with acute onset, rapid progress, easy postoperative complications, serious complications, and high operative mortality. Stanford classification is commonly used, and Stanford type A aortic dissection (TAAD) accounts for 70%-75% of all aortic dissections. The aortic dissection break can be located in the ascending aorta, aortic arch or descending aorta. At the same time, the dissection can also involve the aortic arch and descending aorta. In 1838, Penneck reported the first case of aortic dissection, which has been more than 100 years. Thanks to the rapid development of medical technology, the levels of diagnosis and treatment of aortic dissection have gradually improved, and the mortality of aortic dissection has decreased significantly after treatment compared with that before treatment. Over the years, various treatments for TAAD have emerged in endlessly. This paper reviews the progress of the treatment of Stanford TAAD.

Key words: Aortic dissection, Surgery, Interventional procedures, Hybrid surgery

李观青陈海生程可洛关晓冉朱锡梦杨霞. Stanford A型主动脉夹层的治疗进展[J]. 国际医药卫生导报, 2022, 28(16): 2362-2366.

Li Guanqing, Chen Haisheng, Cheng Keluo, Guan Xiaoran, Zhu Ximeng, Yang Xia. Advances in treatment of Stanford type A aortic dissection[J]. International Medicine and Health Guidance News, 2022, 28(16): 2362-2366.

参考文献

[1] Li M, Luo N, Bai Z, et al. A canine model of multiple organ dysfunction following acute type-A aortic dissection[J]. Surg Today, 2012, 42(9):876-883. DOI: 10.1007/s00595- 011-0073-9.
[2] Vohra HA, Modi A, Barlow CW, et al. Repair of acute type a aortic dissection: results in 100 patients[J]. Asian Cardiovasc Thorac Ann, 2012, 20(2):160-167. DOI: 10.1177/0218492311434592.
[3] 孙立忠,李建荣. 我国Stanford A型主动脉夹层诊疗进展与挑战[J]. 中华外科杂志,2017,55(4):241-244. DOI:10.3760/cma.j.issn.0529-5815.2017.04.001.
[4] Myrmel T, Larsen M, Bartnes K. The International Registry of Acute Aortic Dissections (IRAD) - experiences from the first 20 years[J]. Scand Cardiovasc J, 2016, 50(5-6):329-333. DOI: 10.1080/14017431.2016. 1240829.
[5] Criado FJ. Aortic dissection: a 250-year perspective[J]. Tex Heart Inst J, 2011, 38(6):694-700.
[6] 张培华,蒋米尔.临床血管外科学[M]. 2版.北京:科学出版社, 2007: 305.
[7] Howard DP, Banerjee A, Fairhead JF, et al. Population- based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study[J]. Circulation, 2013, 127(20):2031-2037. DOI:10.1161/CIRCULATIONAHA.112.000483.
[8] Olsson C, Thelin S, Ståhle E, et al. Thoracic aortic aneurysm and dissection: increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14,000 cases from 1987 to 2002[J]. Circulation, 2006, 114(24):2611-2618. DOI: 10.1161/CIRCULATIONAHA.106.630400.
[9] Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis[J]. Thorac Cardiovasc Surg, 1983, 31(1): 37-40. DOI: 10.1055/s-2007-1020290.
[10] Kato M, Ohnishi K, Kaneko M, et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft[J]. Circulation, 1996, 949 Suppl:Ⅱ188-Ⅱ193.
[11] Bentall H, De Bono A. A technique for complete replacement of the ascending aorta[J]. Thorax, 1968, 23(4):338-339. DOI: 10.1136/thx.23.4.338.
[12] David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta[J]. J Thorac Cardiovasc Surg, 1992, 103(4):617-621.
[13] Kirsch ME, Ooka T, Zannis K, et al. Bioprosthetic replacement of the ascending thoracic aorta: what are the options?[J]. Eur J Cardiothorac Surg, 2009, 35(1):77-82. DOI: 10.1016/j.ejcts.2008.09.011.
[14] David TE, Armstrong S, Maganti M, et al. Long-term results of aortic valve-sparing operations in patients with Marfan syndrome[J]. J Thorac Cardiovasc Surg, 2009, 138(4):859-864. DOI: 10.1016/j.jtcvs.2009.06.014.
[15] Urbanski PP, Heinz N, Zacher M, et al. Bio-Bentall procedure versus isolated biological aortic valve replacement: a case-match study[J]. Eur J Cardiothorac Surg, 2015, 47(6):1077-1082. DOI: 10.1093/ejcts/ezu316.
[16] Yacoub MH, Gehle P, Chandrasekaran V, et al. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root[J]. J Thorac Cardiovasc Surg, 1998, 115(5):1080-1090. DOI: 10.1016/S0022-5223(98)70408-8.
[17] Fann JI, Smith JA, Miller DC, et al. Surgical management of aortic dissection during a 30-year period[J]. Circulation, 1995, 929 Suppl:Ⅱ113-Ⅱ121. DOI: 10.1161/01.cir.92. 9.113.
[18] 孙立忠,刘志刚,常谦,等. 主动脉弓替换加支架"象鼻"手术治疗Stanford A型主动脉夹层[J]. 中华外科杂志,2004,42(13):812-816. DOI:10.3760/j:issn:0529-5815. 2004. 13.013.
[19] Ma WG, Zheng J, Dong SB, et al. Sun's procedure of total arch replacement using a tetrafurcated graft with stented elephant trunk implantation: analysis of early outcome in 398 patients with acute type A aortic dissection[J]. Ann Cardiothorac Surg, 2013, 2(5):621-628. DOI: 10.3978/j.issn.2225-319X.2013.09.06.
[20] Ma WG, Zheng J, Liu YM, et al. Dr. Sun's procedure for type a aortic dissection: total arch replacement using tetrafurcate graft with stented elephant trunk implantation[J]. Aorta (Stamford), 2013, 1(1):59-64. DOI: 10.12945/j.aorta.2013.13.015.
[21] Chen LW, Dai XF, Zhang GC, et al. Total aortic arch reconstruction with open placement of triple-branched stent graft for acute type A dissection[J]. J Thorac Cardiovasc Surg, 2010, 139(6):1654-1655, e1. DOI: 10.1016/j.jtcvs.2009.10.022.
[22] Hua F, Shen Z, Yu Y, et al. Application of open triple-branched aortic arch stent graft for acute Stanford type A aortic dissection[J].Vasc Endovascular Surg, 2013, 47(2):109-114. DOI: 10.1177/1538574412473184.
[23] Dai XF, Chen LW, Wu XJ, et al. Total aortic arch reconstruction with triple-branched stent graft or hemiarch replacement for acute Debakey type I aortic dissection: five-years experience with 93 patients[J]. J Card Surg, 2015, 30(10):749-755. DOI: 10.1111/jocs.12608.
[24] Crawford ES, Saleh SA. Transverse aortic arch aneurysm: improved results of treatment employing new modifications of aortic reconstruction and hypothermic cerebral circulatory arrest[J]. Ann Surg, 1981, 194(2): 180-188. DOI: 10.1097/00000658-198108000-00012.
[25] Roselli EE, Rafael A, Soltesz EG, et al. Simplified frozen elephant trunk repair for acute DeBakey type I dissection[J]. J Thorac Cardiovasc Surg, 2013, 1453 Suppl:S197-S201. DOI: 10.1016/j.jtcvs.2012.11.068.
[26] Shrestha M, Martens A, Behrendt S, et al. Is the branched graft technique better than the en bloc technique for total aortic arch replacement?[J]. Eur J Cardiothorac Surg, 2014, 45(1):181-186. DOI: 10.1093/ejcts/ezt357.
[27] DiEusanio M, Schepens MA, Morshuis WJ, et al. Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch[J]. Ann Thorac Surg, 2004, 77(6):2021-2028. DOI: 10.1016/j.athoracsur. 2003. 10.094.
[28] Matalanis G, Perera NK, Galvin SD. Aortic arch replacement without circulatory arrest or deep hypothermia: the "branch-first" technique[J]. J Thorac Cardiovasc Surg, 2015, 1492 Suppl:S76-S82. DOI: 10.1016/j.jtcvs.2014.07.100.
[29] Dorros G, Dorros AM, Planton S, et al. Transseptal guidewire stabilization facilitates stent-graft deployment for persistent proximal ascending aortic dissection[J]. J EndovascTher, 2000, 7(6):506-512. DOI: 10.1177/152660280000700612.
[30] Lu Q, Feng J, Zhou J, et al. Endovascular repair of ascending aortic dissection: a novel treatment option for patients judged unfit for direct surgical repair[J]. J Am Coll Cardiol, 2013, 61(18):1917-1924. DOI: 10.1016/j.jacc.2012.08.994.
[31] Lu Q, Liu L, Chang G, et al. Mid-term outcomes from a multicenter study: Is TEVAR safe for ascending aortic dissection?[J]. Int J Cardiol, 2018, 265:218-222. DOI: 10.1016/j.ijcard.2018.04.095.
[32] McWilliams RG, Murphy M, Hartley D, et al. In situ stent-graft fenestration to preserve the left subclavian artery[J]. J Endovasc Ther, 2004, 11(2):170-174. DOI: 10.1583/03-1180.1.
[33] Shahverdyan R, Gawenda M, Brunkwall J. Triple-barrel graft as a novel strategy to preserve supra-aortic branches in arch-TEVAR procedures: clinical study and systematic review[J]. Eur J VascEndovasc Surg, 2013, 45(1):28-35. DOI: 10.1016/j.ejvs.2012.09.023.
[34] Volodos NL. Historical perspective: the first steps in endovascular aortic repair: how it all began[J]. J EndovascTher, 2013, 20 Suppl 1: 13-23. DOI: 10.1583/1545-1550-20.sp1.I-3.
[35] 国家心血管病专家委员会血管外科专业委员会. 杂交技术治疗累及弓部主动脉病变的中国专家共识[J/CD]. 中国医学前沿杂志(电子版),2020,12(2):18-24. DOI:10.12037/YXQY.2020.02-05.