Late at night, the phone in the emergency department of Xijing Hospital rang one after another. Among them, there was a phone call from a hospital in another province that said: "The patient is aortic dissection + mediastinal hematoma." The other party hurriedly told about his condition and asked if he could be transferred to the hospital. After 2 minutes of detailed questioning and careful judgment, the on-duty doctor of the surgical cardiac surgery department gave a positive answer and told him that "there is still a glimmer of life in the transfer hospital!"
At 1 a.m., the ambulance carrying the patient and his family rushed all the way to Xi'an, after 10 hours and 800 kilometers to Xijing Hospital.
An all-out and concerted effort to save lives began......
The night on duty is very long, and there are many stories of life and death rescue, and Lao Gu's story starts from three days before the onset of the illness.
Lao Gu, who suddenly had severe pain in his chest and back, thought it was angina pectoris at first, but after a complete examination, he didn't expect it to be an aortic dissection that was ten thousand times more dangerous. "If you don't get treated, your life will be in danger at any time, and you may not be able to survive to Xi'an. "The emergency doctor of the hospital in other provinces told the family that it could not be treated locally, so they should be transferred to the hospital immediately, and there may be a glimmer of life. 800 kilometers, 10 hours, the family did not dare to delay for a moment, and set off for Xi'an overnight.
Preoperative CTA
Preoperative CT
After arriving at Xijing Hospital, he was quickly admitted through the "green channel of aortic dissection". The results showed that there was a localized dissection of the aortic arch, which was close to the important branch blood vessels of the head and neck, the size of the break was 3.7cm, the pseudoaneurysm of the descending transition part of the aortic arch, mediastinal effusion, hematoma, pericardial effusion, and bilateral pleural effusion.
"It hurt so badly, my chest and back felt like it was torn, and my chest was so blocked that I couldn't breathe. It's like suddenly someone is cutting your back with a knife. Recalling the situation at that time, Lao Gu still had palpitations.
The aorta, as the "river of life" of the human body, is responsible for transporting the blood pumped by the heart to all parts of the body. When the high-speed flow of blood in the cavity continues to wash away the weak point of the aortic inner wall day after day, the less strong inner wall of the blood vessel will be torn apart, and a large amount of blood flow will continue to pour into the aortic wall from the gap, and the more it is filled, at this time, the effective aortic lumen will continue to be flattened, the ineffective false lumen will continue to be congested, and the part torn by the dissection will become more and more fragile, and finally only a thin layer of membrane will be left.
Aortic dissection is extremely dangerous, if the treatment of acute aortic dissection is not timely, the mortality rate is as high as 50% within 48 hours, and sudden death can occur instantaneously when the whole thickness is ruptured.
Professor Yi Dinghua, Professor Yu Shiqiang, Director Liu Jincheng, Deputy Director Yi Wei, Deputy Chief Physician Zuo Jian and other experts of the Department of Cardiovascular Surgery quickly conducted consultations and discussions.
Preoperative discussion
Option 1: Conventional total arch replacement surgery.
"Thoracotomy, cardiac arrest, cardiopulmonary bypass instead of cardiopulmonary work, nearly 10 hours of surgery, large trauma, and high perioperative risk, it is a veritable bloody battle, a night battle, and a battle to the death. ”
"Lao Gu has suffered from cerebral infarction and ischemic hypoxic encephalopathy, and the implementation of full arch replacement surgery under deep and low temperature circulation arrest is more dangerous, and neurological complications will follow. ”
Option 2: Aortic endovascular intervention.
Because of the proximity of the aortic arch dissection to the important branch vessels of the head and neck, this option is less invasive, but experts have raised many concerns.
"With the current clinical application of in vivo fenestration technology, after the release of the main stent, there is a period of blockage of blood flow in the arch branches, which increases the neurological complications of patients. ”
"Parallel stent technique and extracorporeal fenestration technique increase the incidence of endoleakage and affect the surgical effect. ”
"The existing endovascular arch techniques mostly require incision of the common carotid artery or incision of the neck artery bypass surgery, which has a high incidence of adverse events such as trauma and cerebral infarction. ”
Open the chest, or intervene? is always a difficult question for experts. After full discussion and comprehensive evaluation, the team finally decided to adopt a new and pioneering technology - aortic arch dissection aneurysm full luminal transfemoral artery three-branch interventional surgery, to strive for the "optimal solution" for Lao Gu.
Intraoperatively
On the day of the operation, more than 30 medical staff from 6 discipline units, including cardiovascular surgery, interventional surgery center, anesthesiology, radiology, ultrasound, and extracardiac intensive care unit, jointly "escorted" the old Gu.
During the operation, the team of deputy chief physician Zuo Jian found through angiography that Lao Gu's aortic dissection had further deteriorated, the aortic adventitia was on the verge of rupture, and blood was oozing. It is necessary not only to ensure that the tumor is well isolated, but also to ensure that the opening of the main stent is accurately aligned with the branch blood vessels, so as to provide continuous blood flow supply for the blood vessels of the head and neck, and also to create good conditions for the next step of branch stent placement. The team skillfully sent the main stent, accurately positioned it according to the location of the lesion, and released it accurately step by step, so as to ensure the smooth blood flow of the three branch arteries in the arch before the branch stent was introduced. Next, the team accurately overselected the three branches of the arch through the femoral artery approach, and used adaptive branch scaffolds to skillfully cope with the complex anatomical differences of the three branches of the arch, as if carved by a craftsman, to achieve anatomical reconstruction of the three branches of the arch.
Contrast before stent placement
Post-stent imaging
Postoperative CTA
The operation took 2 hours and 20 minutes, only the unilateral femoral artery at the root of the thigh was punctured during the operation, the wound was about 1cm, a band-aid could be covered, the bleeding was only 100ml, the main stent and branch stent were introduced through the femoral artery, and there was no incision in the neck.
Postoperative ward rounds
After the operation, Lao Gu's vital signs were stable, and he was able to move on the ground the next day, and he was discharged from the hospital on the 4th day. Follow-up CTA showed that the dissection of the aortic arch and the descending aortic arch was well isolated, no endoleakage was found, the main body and branch stents were in good position, and the blood flow in the stent was smooth.
After new searches, there were no similar reports at home and abroad on the full-cavity transfemoral artery three-branch interventional treatment technology for aortic arch dissection aneurysm. According to Zuo Jian, deputy chief physician, this technology breaks through the bottleneck problem of endovascular arch technology in clinical practice, and realizes the anatomical reconstruction of the endovascular aortic arch and its branches without thoracotomy, which has the advantages of small trauma, fast recovery, high safety and easy promotion, and provides the "optimal solution" for the treatment of such diseases. Since the beginning of this year, the department has successfully performed 7 similar surgeries, and all patients have recovered well.