A型主動脈夾層外科手術體會,廣東省心血管病研究所 心臟外科 范瑞新,我科收治主動脈夾層情況,2009-7,年,床資料臨,時間：2003年1月 至 2009年7月 患者情況： 285例。男性：188例，女性：97例 年齡：21 68歲 （47.9 9.3 歲）,結 果,院內死亡：14例， 死亡率為4.9%(14/285)。 急診手術：9例，死亡率 10.9% （9/82） 非急診手術5例，死亡率2.4%（5/203）,主動脈夾層的危害,主動脈破裂 主動脈夾層致死的首要原因 主動脈瓣關閉不全 近端夾層主動脈瓣關閉不全的發生 率在70%90% 重要臟器供血障礙 嚴重者可引起臟器缺血壞死，造成臟器功能衰竭,手術指征,De Bakey、型主動脈夾層 Stanford A 型主動脈夾層 急性期或慢性期均采取手術為主的綜合治療,De Bakey 分型,型：原發破口位于升主動脈或主動脈弓部，夾層累及升主動脈、主動脈弓部、胸主動脈、腹主動脈大部或全部。少數可累及髂動脈。 型：原發破口位于升主動脈，夾層累及升主動脈。少數可累及部分主動脈弓。,Stanford 分型,A型：夾層累及升主動脈，無論遠端范 圍如何,Standford A型夾層動脈瘤，夾層撕裂由升主動脈、主動脈弓直至降主動脈。,治 療,內科治療 外科手術 “雜交”手術,術前及術中注意,主動脈夾層的內膜破口 動脈夾層累及的范圍 假腔的位置 Ai,手術方法,升主動脈替換術;主動脈弓置換術 升主動脈主瓣替換和冠狀動脈移植術 Bentall手術 Carbrol手術 David手術 “雜交”手術,近心端的處理方法,夾層未累及冠狀動脈開口及主動脈竇，主動脈瓣無關閉不全,近心端的處理方法,夾層累及主動脈竇和主動脈瓣環，造成主動脈瓣交界撕脫，引起輕、中度主動脈瓣關閉不全,近心端的處理方法,夾層累及無冠竇，直至瓣環、竇管交界處組織糜爛，無法縫合,近心端的處理方法,重度主動脈關閉不全者或慢性主動脈夾層，主動脈竇擴張明顯或主動脈根部瘤繼發夾層,弓部處理,破口位于升主動脈，弓部夾層位于小彎側，頭臂干血管未受累及 升主動脈置換或右半弓置換,0區升主動脈置換或加右半弓 1. 升主動脈加無名動脈或加右頸總動脈 2. 升主動脈加無名動脈、左頸總動脈 3. 升主動脈、全弓加支架 3以下、右半弓或全弓，術后經股動脈放支架,弓部處理,破口位于升主動脈或主動脈弓，頭臂干血管有夾層 主動脈弓置換,弓部處理,破口位于降主動脈，逆行剝離至升主動脈 主動脈弓置換或術中支架 如果破口遠離左鎖骨下動脈，可術后經股動脈放支架,Thank you!,英文版,Surgical Treatment of Aortic Dissection Stanford type A,Ruixin Fan Guangdong provincial Cardiac-vascular Institute,Type A aortic dissection annual admission rate,Year,No. of Cases,Patients,From Jan. 2003 to Jul. 2009 Patients: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 of aortic dissection,Aortic rupture primary cause of death Aortic 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 Classification,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 desc. aorta.,Standford type A aortic aneurysm,Treatment,Medical treatment Surgical 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 Replacement of asc. aorta, aortic valve and coronary artery re-implantation Bentall operation Carbrol operation David operation “Hybrid ” operation,Management of the proximal dissection,Dissection not involving coronary arteries and aortic sinus No aortic valve regurgitation,Situation 1,Dissection involving 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 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. Asc. aortic and hemi-arch replacement,0. Replace asc.aorta hemi-arch 1. asc. aortic plus innominate and left carotid artery 2. asc. aorta and innominate and left common carotid artery 3. asc. Aortic, aortic arch and stent placement 4. Half or full arch and stent placement,Intimal tear in asc. aorta and aortic arch ，dissection in brachiocephalic artery replacement of aortic arch,Management of the arch,Intimal tear in desc. aorta ,with retrograde dissection tear