| ObjectiveTo analyze the efficacy of debranching technique combined with thoracic aortic endovascular repair and Sun’s operation in the treatment of Stanford type A aortic dissection(AD),summarize relevant experience,and provide a basis for clinicians to choose more appropriate surgical options.At the same time,through the analysis of post-operative complications,to provide a basis for clinicians to better prevent and deal with post-operative complications.MethodsFrom January 2015 to December 2018,95 patients with acute Stanford type A aortic dissection who had undergone thoracic endovascular aortic repair(TEVAR)or Sun’s operation in Cardiovascular Surgery of the First Affiliated Hospital of Zhengzhou University were included in the study.All patients met the criteria for admission.All patients were diagnosed as type A aortic dissection because of the involvement of ascending aorta and its distal vessels.The diagnostic methods were aortic CTA and echocardiography.In the de-branching hybridization group,the arch was debranched under moderate hypothermia and thoracic aorta was repaired at the same time.In the Sun’s operation group,the ascending aorta was replaced under deep hypothermic circulatory arrest(DHCA),the whole arch was replaced with elephant trunk(ET),and all patients had signed the preoperative informed consent.Then according to the different surgical methods,they were divided into 45 cases in the debranching technique combined with endovascular repair group and 50 cases in the Sun’s operation group,including 53 males and 42 females.The age ranged from 30 to 70 years.The time of cardiopulmonary bypass(CPB),the operation time,the total amount of platelets,red blood cells and plasma transfused during the operation were compared between the two groups.The intraoperative urine volume,the incidence of complications and the improvement of cardiac function were compared.After discharge,patients were followed up for 1 year by CTA and echocardiography to understand the prognosis of different operations.ResultsBoth the de-branching hybridization group and Sun’s operation group successfully completed the operation process.Among them,the average age of the de-branching hybrid group was older than that of Sun’s operation group,and there was statistical difference(P < 0.05);the number of de-branching hybrid group with Marfan syndrome was lower than that of Sun’s operation group,and there was statistical difference(P < 0.05);other indicators such as sex ratio,the proportion of diabetes mellitus,the proportion of hypertension,left heart.There was no significant difference in indoor diameter and LVEF(P > 0.05).CBP time and operation time in the de-branching hybridization group were 110.25±20.77 minutes and 5.58±1.45 hours,respectively.CBP time and operation time in Sun’s operation group were 240.56±50.77 minutes and 8.61±1.84 hours,respectively.The results showed that CBP time and operation time in the de-branching hybridization group were significantly lower than those in Sun’s operation group,and there were statistical differences(p values were 0.024 and 0.037,respectively,P < 0.05).The total amount of platelet,erythrocyte and plasma transfusion and urine volume during operation in the de-branching hybridization group were 0 U,1.25(±1.26U),502.75(±312.46 ml)and 1305.94(±984.35 ml),respectively,while those in the Sun’s operation group were 3.08(±1.54 U),4.06(±2.32 U),1004.18(±502.43 ml)and 703.78(±612.45 ml),which indicated that the blood loss and blood volume during operation in the de-branching hybridization group were less than those in the Sun’s operation group,and the renal function was infused.The injection was good and had statistical difference(p values were 0.012,0.041,0.026 and 0.039,respectively,P < 0.05).The number of secondary intubation due to acute respiratory insufficiency,dialysis due to acute renal failure and neurological complications after operation in the de-branching hybridization group were 2,1 and 1 cases respectively.The corresponding proportion in the Sun’s operation group was 5,3 and 5 cases respectively.It showed that the overall incidence of complications in the de-branching hybridization group was less than that in Sun’s hand.The difference was statistically significant(p values were 0.031,0.047,0.049,all P < 0.05).In the improvement of left ventricular ejection fraction(LVEF)1 week after operation,the de-branching hybridization group increased from 50.17(±7.51%)to 56.62(±8.74%)and the Sun’s operation group increased from 48.24(±9.14)to 52.45(±6.41).This indicated that the improvement of cardiac function after de-branching operation was more obvious than that of Sun’s operation group,but there was no significant difference(p value was 0.142,P < 0.05).During hospitalization,2 patients in the de-branching hybridization group developed acute respiratory insufficiency after operation.One patient improved after secondary intubation,and eventually recovered and discharged.Another patient died due to ineffective treatment of secondary severe pulmonary infection.In Sun’s operation group,3 cases were cured and discharged after dialysis for acute renal failure,and 2 cases were cured and discharged.Another case died of multiple organ dysfunction after rescue.Among the 5 cases of neurological complications,3 cases were cured and discharged after active treatment,and 2 cases died of progressive aggravation of neurological symptoms.There was a significant difference in the number of deaths in the first week after operation between the two groups(p value was 0.034,P < 0.05).Follow-up was conducted for 1 year after discharge.The follow-up methods were telephone follow-up or in-hospital review.One patient died of severe pulmonary infection one year after discharge,one died of severe cerebral infarction and the rest had no obvious abnormalities.Two patients in the debranched hybridization group had endoleaks during echocardiography and aortic CTA reexamination three months after discharge.The endoleaks disappeared after reexamination one month later,and one died of heart failure.There was no statistical difference in follow-up results(p > 0.05).ConclusionBoth Sun’s operation and de-branching hybridization are effective treatments,and the two different surgical methods have different indications and advantages and disadvantages.Therefore,different surgical methods can be selected for Stanford A aortic dissection according to different conditions.The main advantage of debranching combined surgery is that it can reduce the surgical trauma without deep hypothermia hemiplegia.Therefore,for patients with severe complications,poor physical condition and older age,patients who can not tolerate long-term deep hypothermia circulatory arrest surgery are better choices.The main advantage of Sun’s operation is that it can completely relieve the vascular lesion by artificial blood vessel replacement.Therefore,Sun’s operation is preferred for young patients with longer life expectancy and better physical condition.In terms of postoperative complications,the incidence of complications of debranching combined surgery was lower than that of Sun’s operation.Possible post-operative complications should be comprehensively analyzed in clinical work in order to reduce the incidence of post-operative complications and improve the cure rate. |
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