Stanford A型急性大動脈解離手術成績向上に向けて―臓器灌流障害に対する戦略

To Improve the Results of Surgery for Stanford Type A Acute Aortic Dissection：Strategy for Organ Malperfusion

Stanford A型急性大動脈解離の手術成績は，術式の改良，周術期管理の進歩により，年々改善してきているが，術後在院死亡率17～25％といまだに良好とはいいがたい1，2）．一方，本邦における手術成績は術後在院死亡率9.1～11.8％と，優れたものとなっている3～6）．しかし，術前臓器灌流障害を伴った症例の術後成績は不良であり3，7），特に中枢神経系の障害をいかに軽減させるかが，さらなる成績向上の鍵である．われわれは，当施設でのStanford A型急性大動脈解離手術成績を提示するとともに，脳合併症軽減を中心とした臓器灌流障害に対する戦略を述べる．

Objectives：We presented the results of surgery for Stanford type A acute aortic dissection at our hospital and described strategies for organ malperfusion （especially brain malperfusion）.

Results：From January 2012 to December 2019, we underwent 174 patients of Stanford type A acute aortic dissection at our hospital. There were 47 patients （27.0％） with postoperative cerebral infarction （stroke group）. Compared to the non-stroke group, the stroke group had significantly more cases of persistent central nervous system malperfusion before surgery and had more intraoperative bleeding and blood transfusion. The hospital mortality was 23.4％ in the stroke group and 3.9％ in the non-stroke group （p＜0.001）. As a result of multivariate analysis, risk factors for hospital mortality were preoperative endotracheal intubation, long-term cardiopulmonary bypass time and postoperative stroke. The risk factor for postoperative stroke was preoperative central nervous system malperfusion.

Conclusions：As a strategy for cerebral malperfusion, it is useful to use the right axillary artery blood supply and the isolated cerebral perfusion method.