胸腹主动脉瘤手术中重建肋间动脉的简易方法

A simple surgery technique for intercostals artery preservation in thoracic and thoracoabdominal aortic aneurysm repair

目的:脊髓缺血性损伤是胸腹主动脉瘤手术后一种严重并发症,改进重建肋间动脉的外科技巧可减少这一风险的发生。方法:自2003年8月至2005年1月,行全胸腹主动脉替换术41例(男性30例,女性11例),年龄22～58岁,平均(40.3±9.1)岁。Crawford Ⅱ型38例,Crawford Ⅲ型3例,其中马方综合征合并胸腹主动脉瘤19例。采用深低温、分段停循环技术应用四分叉人工血管行全胸腹主动脉替换,其中自T6-L2肋间和腰动脉开口动脉壁修剪重建成新肋间血管管道,再与四分叉血管之8mm分支吻合,恢复脊髓血供。结果:术后早期死亡3例(病死率7.3%),脑部系统并发症3例(7.9%),脊髓损伤并发症2例(5.3%),均经脱水及神经营养治疗后痊愈。随访除3例死亡(病死率7.9%)外均生存良好,CT检查显示"新肋间动脉"血流通畅。结论:在胸腹主动脉瘤四分叉人工血管置换术中,采用修剪重建新肋间血管管道的方法,能简化手术方式,明显缩短脊髓和重要腹腔脏器的缺血时间,减少脊髓并发症发生,效果良好。

Objective： Ischemic spinal cord injury remains a major complication after thoracic and thoracoabdominal aortic operation. Several approaches, including reimplantation of the intercostals arteries have been used to try and lessen the risk of spinal cord ischemia. We present a technique to simplify this approach. Method： Between August 2003 and January 2005, 41 patients with extensive thoracoabdominal aortic disease, including Crawford Ⅱ type （ n = 38 ）, Crawford Ⅱ type （ n = 3 ）, and Marfan＇ s syndrome with chronic thoracoabdominal aneurysm （n = 19） underwent resection and multiple branched graft replacement of the diseased aortic segments. After completing the proximal anastomosis, the all intercostal arteries（T6-L2）were sewn into an arterial tube and then anastomosed to a side limb of the graft, allowing spinal cord perfusion to be resumed early. Result：Hospital mortality was 7.3 %. Cerebral complications occurred in 3 （7.9 % ） patients. 2 patients （5.3 % ） showed spinal cord ischemia complications and were cured after hydration therapy. After treatment, postoperative spiral CT showed that ＂new intercostal arteries＂ were patent. During the follow-up of 14 to 50 months （37.2 ± 8.9）months, 3 patients died and the survivors all were well. Concluslon：using this method, we can lessen the risk of paraplegia associated with aortic surgery. This technique significandy shortened ischemic time of spinal cord and other major organs, and restored almost all perfusion to spinal cord.