| Research BackgroundAortic dissection(AD)means that blood enters the mid-layer aortic wall due to tearing of aortic inner membrane and mid-layer elastic membrane,and then an inter-wall false lumen is formed through forward and/or reverse peeling,which communicates with the aortic true lumen through one or several crevices.[1]Featuring "high acuteness and severity,fast progression and high mortality",this disease is called a catastrophic aortic disease.With the improvement of living standard and environmental changes,incidence rate of this disease is presenting a year-by-year rising trend.The number of AD patients in China is growing at about 30,000/year at present and incidence rate is 0.5-2.95/100,000 people per year or so[3]Therefore,a retrospective analysis of clinical cases in our department is carried out and experience and lessons are summed up so that this type of diseases can be treated with high proficiency.Research ObjectiveBased on patient data,the influence of island vascular patches anastomosis at three branches of aortic arch on treatment and prognosis of Stanford A acute AD patients was explored and discussed,thus providing a powerful experience and basis for accuracy and suitability of surgical method selection in the follow-up clinical work.Research MethodsA retrospective analysis of 17 Stanford A acute AD patients(12 males and 5 females,aging from 26 to 67 years old(52.04±9.86 years old))hospitalized in our department from October,2016 to February,2018 was carried out.Intensive care,strict confinement to bed and urinary catheterization were given to patients after hospitalization,and when necessary,sedation and analgesia were given.For patients with sustained hypertension,medicines like sodium nitroprusside and urapidil were combined to control aortic systolic pressure below 120mmHg.For patients with high heart rates,esmolol was used to maintain their heart rates at 80 beats/min.Onset time of patients in this group lasted from 7h to 4 days with chest pain being the initial symptom,manifested by tearing-type acute pain,where 3 patients suffered from chest distress,syncope and vomiting;1 patient had toothache and headache;5 ones had radiating pain at shoulders and back;2 ones were concurrent with loss of consciousness;others experienced pure acute chest pain without obvious concomitant symptoms.Most patients in this group had hypertension history,year span of their medical history ranged from 2 to 33 years,the highest blood pressure was 180-240mmHg and 1 patient denied hypertension history.Aortic CTA examination was carried out to clarify crevice location,cervical and brachiocephalic vascular involvement and AD extent;Echocardiography was performed beside the bed to clarify necessary parameters such as conditions of cardiac valves,AD crevice location,aortic diameter,size of cardiac atrium,ejection fraction and pericardial effusion.Primary crevices of 17 Stanford A acute AD patients were all located at ascending aorta,where 2 patients experienced brachiocephalic blood vessel dissociation,1 experienced hematoma at the root of the left subclavian artery with intact brachiocephalic trunk inner membrane without no crevice,brachiocephalic blood vessels of 14 patients were not involved,and 13 patients suffered from thrombosis in the AD.According to their clinical manifestations,absolute surgical contraindications like severe cerebral complications,mesenteric artery ischemia and arterial ischemic necrosis of the lower extremity were excluded,and emergent surgical treatment was conducted.Postoperative positive support and symptomatic treatment were given to patients in this group to protect their organ functions like lung,kidney and bran,prevent infection,control blood pressure and realize cardiac and diuretic effects.According to their state of illness,blood products like plasma,red blood cells,blood platelets and albumin were given as the supportive treatment,and blood filtering and like was adopted when necessary.Follow-up visit was paid before discharge and 3 months,6 months and 12 months after the operation for aortic CTA and echocardiography examinations to observe and evaluate their cardiac functions,blood supply at three branches-aortic valve,aortic root and aortic arch-as well as false lumen occlusion at distant descending aortic side.Research ResultsAortic arches of 17 patients were put under three-branch island vascular patches anastomosis,where 2 ones accepted Bentall operation+ aortic arch three-branch island vascular patches anastomosis + elephant trunk stent implantation;4 ones accepted aortic sinus forming + aortic arch three-branch island vascular patches anastomosis +elephant trunk stent implantation.Extracorporeal circulation time was 219.69±43.80min.aortic occlusion time was 123.46±39.26min,minimum-flow perfusion cerebral protection time after deep hypothermic circulatory arrest was 32.85±15.90min,length of stay in the cardiac intensive care unit was 10.56±5.06 d and respirator-assisted ventilation time was 4.53±2.34d.All patients smoothly stopped extracorporeal circulation machine,no one died in the middle of operation,and 2 patients were concurrent with transient neurological symptoms after the operation,which were mainly intermittent mania,delirium and obnubilation and were recovered smoothly after symptomatic treatment;1 patient experienced difficult hemostasis in the middle of operation,sterile gauze was used for packing and hemostasis by compression and taken out through secondary chest opening 48h after the operation,and the patient was smoothly recovered then;1 patient experienced acute renal insufficient 21d after the operation,intermittent CRRT treatment was given,and the patient was automatically discharged due to capillary leakage syndrome;1 patient died of stress ulcer-induced gastrointestinal hemorrhage 10d after the operation.15 patients accepted aortic CTA re-examination before being discharged,showing unobstructed blood vessels in three branches.Elephant trunk stent fitted in well with descending aorta,false lumen was gradually shrunk with thrombosis,the recovery was satisfying and they were smoothly discharged.Postoperative follow-up visit lasted 12-24 months,and all 15 patients returned to normal life and work.Research Conclusion1.Aortic arch three-branch island vascular patches anastomosis is safe and effective for treating Stanford A AD,so it is worthy of clinical application and promotion.2.The precondition for choosing aortic arch three-branch island vascular patches anastomosis is that inner membrane at the arch brachiocephalic three-branch vascular root should be intact without any crevice.3.Aortic arch three-branch island vascular patches anastomosis can simplify the operation,reduce related postoperative complications and prevent deadly hemorrhage at the anastomotic stoma,etc.4.Aortic arch three-branch island vascular patches anastomosis can lower incidence rate of long-term stricture of brachiocephalic blood vessels. |
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