Distal Extent of Surgery for Acute Type A Aortic Dissection.
Distal Extent of Surgery for Acute Type A Aortic Dissection.
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DOI：
10.1053/j.optechstcvs.2019.06.002
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发表时间：
2019-01-01
期刊：
影响因子：
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通讯作者：
Gleason, Thomas G
中科院分区：
文献类型：
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作者：
Dufendach, Keith A;Sultan, Ibrahim;Gleason, Thomas G
急性 A 型主动脉夹层 (TAAD) 是一种复杂的疾病，发病率和死亡率极高，我们提倡采用协调一致的、以方案为驱动的护理服务系统，该系统从患者诊断开始，一直持续到主动脉重建期间和之后。 TAAD 修复的基本组成部分包括迅速恢复真腔血流并消除假腔血流、切除主要撕裂部位、恢复瓣膜功能以及消除任何器官灌注不良。本文特别关注主动脉弓的修复范围，并解释了我们关于插管位置和技术、大脑和远端器官保护策略、头臂血管的管理以及远端主动脉重建范围的方案。我们描述了 TAAD 修复的手术策略，包括（1）在所有病例中进行连续的神经脑监测，（2）在开弓重建过程中不间断的顺行和/或逆行脑灌注（取决于弓修复的程度），（3）主动脉弓置换技术，使用或不使用定制的三叉移植物进行头臂血管置换，以及（4）使用或不使用大象或冷冻象鼻（远端支架移植物）进行降主动脉稳定。我们的主动脉弓和头臂重建范围的方案已经标准化，并且基于概述的不同病理解剖学发现和/或脑灌注不良。
Acute type A aortic dissection (TAAD) is a complex disease associated with extremely high morbidity and mortality for which we advocate a coordinated, protocol-driven system of care delivery that begins at patient diagnosis and continues throughout and beyond aortic reconstruction. Essential components of TAAD repair include prompt restoration of true lumen blood flow with obliteration of the false lumen flow, resection of the primary tear sites, restoration of valvular competency, and elimination of any organ malperfusion. This article focuses specifically on extent of repair of the aortic arch and explains our protocols regarding cannulation location and technique, cerebral and distal organ protection strategy, management of the brachiocephalic vessels, and extent of distal aortic reconstruction. We describe an operative strategy for TAAD repair that includes (1) continuous neurocerebral monitoring in all cases, (2) uninterrupted antegrade and/or retrograde cerebral perfusion (depending upon extent of arch repair) during open arch reconstruction, (3) aortic arch replacement technique with or without brachiocephalic vessel replacement using a custom trifurcate graft, and (4) descending aortic stabilization with or without the use of an elephant or frozen elephant trunk (distal stent graft). Our protocol for extent of aortic arch and brachiocephalic reconstruction has been standardized and is predicated on distinct pathoanatomic findings and/or cerebral malperfusion that are outlined.