常温非体外循环胸腹主动脉置换术治疗广泛主动脉瘤

摘要

目的 比较常温非体外条件行胸腹主动脉瘤置换术与传统低温停循环手术方式的治疗效果.方法 回顾性分析2004年1月至2013年12月阜外心血管病医院连续收治的128例广泛主动脉瘤患者(CrawfordⅡ型)的临床资料.男性97例,女性31例;年龄15～ 71岁,平均年龄(37±11)岁;慢性Stanford A夹层74例,慢性Stanford B型夹层34例,胸腹主动脉真性动脉瘤20例.71例在低温心肺转流下(转流组)、57例在常温非体外循环下(常温组)行胸腹主动脉置换术.采用配对t检验或x2分析比较两组临床资料,采用Kaplan-Meier曲线计算术后生存时间.结果 转流组平均转流时间(251±87)min,停循环时间(45±24) min.两组的脊髓缺血时间相似.常温组手术时间、呼吸机辅助时间、ICU停留时间和住院时间均低于转流组[(408±114) min比(630±156) min,t=-7.67,P=0.05;(18±13)h比(113±89)h,t=-3.86,P=0.00;(4±2)d比(10±9)d,t=-4.19,P=0.00;(15±7)d比(25±14)d,t=4.47,P=0.00].常温组术中出血量低于转流组[(900±750) ml比(1 400±400) ml,t=-2.23,P=0.04],血液制品用量亦低于转流组.常温组术后病死率和神经系统并发症发生率低于转流组(1.7％比9.8％,x2=3.544,P=0.05;1.7％比22.6％,x2=9.35,P=0.00),术后截瘫或轻瘫发生率两组无差异.平均随访时间(78±54)个月,随访率88.2％.随访期间5例死亡,2例死于脑卒中,3例截瘫患者死于感染.8例患者平均术后6个月行二期全主动脉弓置换.全组术后3、5、7年生存率分别为97％、93％、87％.结论 常温非体外循环技术较低温心肺转流明显降低了胸腹主动脉动脉置换术早期病死率和术后神经系统并发症发生率,降低了术中出血量,减少了血液制品用量,改善了早期外科手术效果.%Objective To assess the safety and efficacy of off-pump technique with normothemia to extend thoracoabdominal aortic aneurysm replacement compared with traditional hypothermic circulatory arrest.Methods From January 2004 to December 2013, 128 consecutive patients underwent surgical repair of thoracoabdominal aortic aneurysm (type Crawford Ⅱ) in Fuwai Hospital.The mean age was (37 ± 11) years.The patients included 74 cases (57.8％) with chronic Stanford A dissection, 34 cases (26.6％) with chronic Stanford B dissection, 20 cases (15.6％) with thoracoabdominal aortic true aneurysm.There were 71 patients who underwent hypothermic circulatory arrest surgery (cardiopulmonary bypass (CPB) group) and 57 patients who underwent off-pump surgery with normothermia (off-pump group).The clinic data was compared between the 2 groups using paired t tests and x2 test.Kaplan-Meier survival analysis was used for postoperative survival stays.Results The mean CPB time in CPB group was (251 ± 87) minuets and the circulatory arrest time was (45 ± 24) minuets.Spinal cord ischemia time in the two groups was (21 ± 12) minuets and (18 ± 10) minuets (t =5.68, P =0.51).The operation time, ventilator time, length of ICU stay and length of hospital stay of off-pump group were shorter than CPB group ((408 ± 114) minuets vs.(630 ± 156) minuets, t =-7.67, P =0.05;(18 ± 13) hours vs.(113 ± 89)hours, t=-3.86, P=0.00;(4±2) days vs.(10±9) days, t =-4.19, P=0.00;(15 ±7) days vs.(25 ± 14) days, t =-4.47, P =0.00).The intraoperative blood loss in off-pump group and CPB group was (900±750) ml and (1 400±400) ml (t=-2.23, P=0.04).The mortality was 1.7％ and 9.8％ in the off-pump group and CPB groups (x2 =3.544, P =0.05).The cerebral complication rate in the normal temperature group was 1.7％ vs.22.6％ in extracorporeal group (x2 =9.35, P ＜ 0.05).A total of 113 patients were followed up, with a follow-up rate of 88.2％.Duration of follow-up was (78 ± 54) months.Five patients died during the follow-up period, including 2 who died of cerebral infarction and 3 paraplegia patients who died of infection.Eight patients had phase Ⅱ aortic arch replacement after a mean time of 6 months.The overall postoperative survival rate was 97％, 93％ and 87％ at 3 years, 5 years and 7 years, respectively.Conclusion Off-pump technique with normothemia was associated with a lower risk of a composite outcome of mortality and major adverse cardiac and cerebrovascular events during repair of extensive thoracoabdominal aortic aneurysm.