1．Stanford A型急性大動脈解離

Up to Date for Treatment of Stanford Type A Acute Aortic Dissection

Stanford A型急性大動脈解離の手術成績は向上しつつあるが，今日においても院内死亡率は依然として高いままである．薬物加療に比して手術加療の成績が良好であるため，原則として手術加療が選択される．2000年に2,000件/年であった手術件数は2020年に6,000件/年へ増加し，20％であった院内死亡率は2010年には10％程度まで大きく改善した．しかしながら日本心臓血管外科手術データベース（Japan Cardiovascular Surgery Database：JCVSD）をもとにした本邦からの報告によると，2010年以降はほぼ横ばいで推移している1，2）．Japan Registry of Aortic Dissection（JRAD）からの報告では，術前心停止，術前意識障害，80歳以上が有意な院内死亡のリスク因子であると示されている3）．

Surgical outcomes for acute type A aortic dissection （ATAAD） have been improving, but mortality rate remains about 10％ in the last decade. Based on the current literatures including American Association for Thoracic Surgery （AATS） expert consensus, we presented the latest treatments and our surgical strategies for ATAAD. This section states about cannulation strategies for cardio-pulmonary bypass, aortic root managements, aggressive arch strategies, distal anastomosis strategies and the managements of malperfusion syndrome. We recommended the ascending aorta using the Seldinger technique as the cannulation site. As the aortic root management, valve resuspension is effective, but valve-sparing aortic root repair may be an option for young patients with annulo-aortic ectasia, intimal tear located in Valsalva sinus or Valsalva sinus rupture. The tear-oriented surgery is the standard for the range of the graft replacement, however, aggressive arch repair is also good indication for young patients. Distal anastomoses are felt sandwich technique for hemi-arch replacement or partial arch replacement and frozen elephant trunk is useful to total arch replacement. Early reperfusion strategies were important to the malperfusion syndrome of coronary arteries, supra-aortic vessels and superior mesenteric artery. To the dissected common carotid arteries （CCAs）, early reperfusion and direct reconstruction of CCAs were effective.