No aortic valve regurgitation
Management of the proximal dissection
Situation 2
Dissection involving aortic sinuses and aortic annulus, with tear at the junction of aortic valve and mild to moderate aortic regurgitation.
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
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
1. 升主动脉加无名动脉 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
Management of the proximal dissection
Situation 4
Sever aortic regurgitation
Chronic aortic dissection, marked aortic sinus expansion or aortic aneurysm complicated with dissection
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
4. Half or full arch and stent placement
Management of the arch
Intimal tear in asc. aorta and aortic arch ，dissection in brachiocephalic artery
replacement of aortic arch
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
60
53
55
50
48
40
39
41
30
31
20
18
10
0
2003 2004 2005 2006 2007 2008 2009-7 年
患者总数
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）
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
手术方法
升主动脉替换术;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
Results
Over-all hospital mortality 4.9%(14/285)。
– Emergency mortality 10.9% （9/82） – Non-Emergency mortalof aortic dissection
严重者可引起脏器缺血坏死，造成脏 器功能衰竭
手术指征
De BakeyⅠ、Ⅱ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
Ⅰ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。
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
No. of Cases
60
53
55
50
48
39
41
40
31 30
20
18
10
0 2003 2004 2005 2006 2007 2008 2009.7
Year
Patients
From Jan. 2003 to Jul. 2009 Patients:285 cases. Male: 188(66%) Female: 97(34%) Mean age 47.9±9.3 yr.(Rage21-68)
Ⅱ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
Standford type A aortic aneurysm
Dissection extending from asc. aorta, aortic arch and desc. aorta.
Treatment
• Medical treatment • Surgical treatment • “Hybrid” surgery
Surgical indications
De Bakey type Ⅰ、Ⅱ 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
Bentall operation Carbrol operation David operation “Hybrid ” operation
Management of the proximal dissection
Situation 1
Dissection not involving coronary arteries and aortic sinus
Management of the proximal dissection
Situation 3
Dissection involving the sinuses and aortic annulus. With erosion of the sinuses and can not be repaired
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
Type Ⅱ Intimal tear: only asc. Aortic Dissection: limited to asc. aorta, and
aortic arch
Stanford classification
Type A Dissection: asc. aorta ± desc
aorta
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