常温非体外循环进行弓部优先重建在A型夹层全弓置换中的应用

摘要

Objective To assess the effect of normothermic arch-first technique without extracorporeal circulation in total aortic arch replacement for management of acute Stanford type A dissection. Methods The surgical data were reviewed for 23 patients (age range 32-58 years) with Stanford type A dissection undergoing total aortic arch replacement with the arch-first technique in our department between January, 2006 and November, 2011. During the surgery, a 4-branched prosthetic graft was connected with the inflow tube and femoral artery using the Y-type tube. The 3 aortic branches were disconnected and anastomosed to the respective branches of the graft, with continuous perfusion of the brain by femoral arterial return. After clamping of the ascending aorta, the graft was connected to the remaining arch before the common stem of the graft was anastomosed with the aortic root. Results The operations were successfully completed in all the 23 cases with a mean total bypass time of 187±60 min (117-254 min), mean ascending aorta clamping time of 35 ± 8 min, and mean nasopharyngeal temperature of 22±2 ℃. Death occurred in one case (4.3%) after the operation, and 2 (8.7%) patients experienced temporary neurological dysfunctions. The postoperative consciousness recovery time was 6-8 h in these cases. The shortest postoperative mechanical ventilation time was 18 h, and 11 (48%) patients were weaned from mechanical ventilation within 48 h postoperatively. The ICU stay ranged from 3 to 7 days in these cases. Conclusion Normothermic arch-first technique without extracorporeal circulation can provide better brain protection and reduced the incidence of postoperative complications by shortening the time of circulation bypass and aortic clamping.%目的 探讨在常温非体外循环情况下优先完成主动脉弓部分支重建在全弓置换术中的应用效果.方法 回顾性分析2006年1月～2011年11月期间,使用常温非体外循环进行弓部优先重建术式治疗的A型夹层患者23例.建立体外管道:将四分叉人工血管单分支侧与体外循环动脉管连接,并通过Y型管连接股动脉插管.重建弓部血管:依次行弓上三血管与人工血管三分支吻合,并由股动脉供血.完成分支重建后,插二级管,开始体外循环.阻闭升主动脉后,完成人工血管与主动脉弓部吻合,最后完成人工血管近心端与升主动脉根部吻合.结果 23例患者手术均获成功.总循环时间187±60 min,升主动脉阻断时间35±8 min,平均鼻咽温22±2℃.死亡1例(43％),术后暂时性神经系统并发症2例(8.7％),术后意识恢复时间6～48h,呼吸机辅助通气时间最短18h,11(48％)名患者在48 h内脱离呼吸机,ICU停留时间3～7 d.结论 常温非体外循环进行弓部优先重建术式可明显缩短复杂弓部手术体外循环时间及主动脉阻闭时间,具有较好的脑保护作用,降低术后并发症率.