全身麻醉深低温停循环选择性脑灌注技术在主动脉弓替换和支架“象鼻”手术中的应用

General Anesthesia and Selected Cerebral Perfusion Technique Used in Total Arch Replacement Combined with Stented Elephant Trunk Implantation for Stanford Type A Aortic Dissection

目的回顾性总结StanfordA型主动脉夹层动脉瘤病人行升主动脉及全弓替换+支架“象鼻”手术的麻醉、体外循环及脏器保护方法。方法2003年4月至2004年1月,本院连续在全麻深低温停循环选择性脑灌注下对StanfordA型主动脉夹层动脉瘤病人实施升主动脉及全弓替换+支架“象鼻”手术40例。其中男35例,女5例,年龄28～78(53)岁。急诊手术23例,择期手术17例。结果全组平均体外循环时间(166±38)min,心肌血运阻断时间(107±28)min,选择性脑灌注时间(30±15)min。死亡率:住院死亡2例(5%,2/40),其中1例术后2周死于多器官功能衰竭,另1例术后2个月死于多发脑梗塞。并发症:术后突发截瘫1例(2.5%,1/40);血管吻合口出血二次开胸止血3例;乳糜胸3例,经治疗后治愈。全组38例出院病人随访4～36周,无晚期死亡或需要再次手术病例。结论升主动脉及全弓替换+支架"象鼻"手术中应用全身麻醉、深低温停循环、选择性脑灌注及多种脑保护、血液保护措施可成功保障手术安全,有效减少术后并发症。

OBJECTIVE To review the anesthetic management including the cerebral and other organs protection methods during ascending aorta and total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta for acute and chronic type A aortic dissection.METHODS From April 2003 to January 2004, 40 consecutive patients with acute or chronic Stanford type A aortic dissection underwent the procedure of total aortic arch replacement combined with stented elephant trunk implantation. The left radial and femoral artery were used for blood pressure monitoring. Propofol, midazolam, fentanyl, isoflurane and pipecuronium were used to induce and maintain anesthesia. Right auxiliary artery cannulation was routinely used for cardiopulmonary bypass and selected cerebral perfusion. The stented elephant trunk was implanted through the aortic arch under profound hypothermic(18℃) circulatory arrest. The stented elephant trunk was a 10cm long self-expandable graft. Thiopental (5mg/kg) or propofol (3mg/kg) was given 3 minutes prior to HCA. Mannitol (0.5g/kg) was infused during rewarming period. Large dose of steroid was also used.RESULTS Cardiopulmonary bypass time was (166±38)minutes, and average selective cerebral perfusion and lower body arrest time was (30±15)minutes. The in-hospital mortality was 5% (2/40). One patient died of multi-organ failure postoperatively and another died of cerebral infarction 2 month after surgery. One suffered from spinal cord injury perioperatively. There was no late death during follow up.CONCLUSION It is safe to apply the selected cerebral perfusion during ascending aorta and total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta and contribute to the better long term outcomes of type A aortic dissection. Adjuncts for cerebral protection are also useful to decrease the complications.