1、A型主动脉夹层外科手术体会,广东省心血管病研究所 心脏外科范瑞新,我科收治主动脉夹层情况,2009-7,年,床资料临,时间：2003年1月 至 2009年7月患者情况：285例。男性：188例，女性：97例年龄：21 68岁 （47.9 9.3 岁）,结 果,院内死亡：14例， 死亡率为4.9%(14/285)。急诊手术：9例，死亡率 10.9% （9/82）非急诊手术5例，死亡率2.4%（5/203）,主动脉夹层的危害,主动脉破裂 主动脉夹层致死的首要原因 主动脉瓣关闭不全 近端夹层主动脉瓣关闭不全的发生 率在70%90%重要脏器供血障碍 严重者可引起脏器缺血坏死，造成脏器功能衰竭,手术指征
2、,De Bakey、型主动脉夹层 Stanford A 型主动脉夹层 急性期或慢性期均采取手术为主的综合治疗,De Bakey 分型,型：原发破口位于升主动脉或主动脉弓部，夹层累及升主动脉、主动脉弓部、胸主动脉、腹主动脉大部或全部。少数可累及髂动脉。 型：原发破口位于升主动脉，夹层累及升主动脉。少数可累及部分主动脉弓。,Stanford 分型,A型：夹层累及升主动脉，无论远端范 围如何,Standford A型夹层动脉瘤，夹层撕裂由升主动脉、主动脉弓直至降主动脉。,治 疗,内科治疗外科手术 “杂交”手术,术前及术中注意,主动脉夹层的内膜破口动脉夹层累及的范围 假腔的位置Ai,手术方法,升主动脉
3、替换术;主动脉弓置换术升主动脉主瓣替换和冠状动脉移植术Bentall手术Carbrol手术David手术“杂交”手术,近心端的处理方法,夹层未累及冠状动脉开口及主动脉窦，主动脉瓣无关闭不全,近心端的处理方法,夹层累及主动脉窦和主动脉瓣环，造成主动脉瓣交界撕脱，引起轻、中度主动脉瓣关闭不全,近心端的处理方法,夹层累及无冠窦，直至瓣环、窦管交界处组织糜烂，无法缝合,近心端的处理方法,重度主动脉关闭不全者或慢性主动脉夹层，主动脉窦扩张明显或主动脉根部瘤继发夹层,弓部处理,破口位于升主动脉，弓部夹层位于小弯侧，头臂干血管未受累及 升主动脉置换或右半弓置换,0区升主动脉置换或加右半弓1. 升主动脉加无名
4、动脉或加右颈总动脉2. 升主动脉加无名动脉、左颈总动脉3. 升主动脉、全弓加支架 3以下、右半弓或全弓，术后经股动脉放支架,弓部处理,破口位于升主动脉或主动脉弓，头臂干血管有夹层 主动脉弓置换,弓部处理,破口位于降主动脉，逆行剥离至升主动脉 主动脉弓置换或术中支架 如果破口远离左锁骨下动脉，可术后经股动脉放支架,Thank you!,英文版,Surgical Treatment of Aortic Dissection Stanford type A,Ruixin Fan Guangdong provincial Cardiac-vascular Institute,Type A aortic
5、 dissection annual admission rate,Year,No. of Cases,Patients,From Jan. 2003 to Jul. 2009Patients:285 cases. Male: 188(66%) Female: 97(34%)Mean age 47.99.3 yr.(Rage21-68),Results,Over-all hospital mortality 4.9%(14/285)。 Emergency mortality 10.9% （9/82）Non-Emergency mortality2.4%(5/203),Complications
6、 of aortic dissection,Aortic rupture primary cause of deathAortic regurgitation accurs in 70 90% Blood flow impairment to important organs causing organ ischemic, necrosis and permanent failure,Surgical indications,De Bakey type 、 Stanford type A aortic dissection Both acute and chronic,De Bakey Cla
7、ssification,Type I Intimal tear: asc. aorta and aortic arch Dissection: asc. & desc. aorta Type Intimal tear: only asc. Aortic Dissection: limited to asc. aorta, and aortic arch,Stanford classification,Type A Dissection: asc. aorta desc aorta,Dissection extending from asc. aorta, aortic arch and des
8、c. aorta.,Standford type A aortic aneurysm,Treatment,Medical treatmentSurgical treatment “Hybrid” surgery,Attentions pre & during operation,Location of intimal tear Extent of dissection Position of false lumen Presence of Ai,Surgical Technique,Replacement of asc. aorta Replacement of aortic arch Rep
9、lacement of asc. aorta, aortic valve and coronary artery re-implantationBentall operationCarbrol operationDavid operation “Hybrid ” operation,Management of the proximal dissection,Dissection not involving coronary arteries and aortic sinus No aortic valve regurgitation,Situation 1,Dissection involvi
10、ng aortic sinuses and aortic annulus, with tear at the junction of aortic valve and mild to moderate aortic regurgitation.,Situation 2,Management of the proximal dissection,Dissection involving the sinuses and aortic annulus. With erosion of the sinuses and can not be repaired,Situation 3,Management
11、 of the proximal dissection,Sever aortic regurgitation Chronic aortic dissection, marked aortic sinus expansion or aortic aneurysm complicated with dissection,Situation 4,Management of the proximal dissection,Management of the arch,Intimal tear in asc. aortic. And at the small curvature of the arch.
12、 Asc. aortic and hemi-arch replacement,0. Replace asc.aorta hemi-arch1. asc. aortic plus innominate and left carotid artery2. asc. aorta and innominate and left common carotid artery3. asc. Aortic, aortic arch and stent placement4. Half or full arch and stent placement,Intimal tear in asc. aorta and
13、 aortic arch ，dissection in brachiocephalic artery replacement of aortic arch,Management of the arch,Intimal tear in desc. aorta ,with retrograde dissection tear to arch and asc. aorta Replacement of aortic arch or place stent If tear occurs distal to subclavian artery, stent may be placed from femoral artery after operation,Management of the arch,Thank you!,
