非体外循环下全主动脉弓替换术治疗主动脉弓降部动脉瘤的早、中期结果

The early and midterm results of total aortic arch replacement for aortic aneurysm without cardiopulmonary bypass

目的评价采用常温、非体外循环下全主动脉弓替换手术治疗主动脉弓、降部动脉瘤的术后早、中期结果。方法2004年4月至11月，对连续7例主动脉弓降部动脉瘤病人实施常温、非体外循环下全主动脉弓替换手术。术后对所有病人进行长期随访，随访截止日期为2011年3月。7例均为男性，年龄23—75岁，中位年龄57岁。真性动脉瘤3例，假性动脉瘤4例，其中1例为弓降部巨大假性动脉瘤覆膜支架置入术失败者。采用胸部正中与左胸前外侧联合切口，全身肝素化后，依次在升主动脉前外侧壁安放主动脉侧壁钳，降主动脉与头臂动脉分别放置主动脉阻断钳，将带四分支人工血管依次与升主动脉行端-侧吻合、与降主动脉及3支头臂动脉行端-端吻合，最后闭合升主动脉残端，切除弓降部主动脉瘤壁。结果平均胸降主动脉阻断（13．6±5．6）min，左颈总动脉阻断（5．7±0．8）min，无名动脉阻断（7．8±2．5）min，左锁骨下动脉阻断（11．2±1．5）min。术后使用呼吸机平均（12．3±4．1）h。病人全部生存。与同期常温体外循环下主动脉弓替换手术组相比，本组机械通气时间显著减少。无神经系统并发症。术后CT扫描结果显示，主动脉弓降部人工血管形态佳，吻合口周围无渗漏或假性动脉瘤形成。全组平均随访（79．7±2．1）个月，病人生活质量良好，复查CT结果均未见异常。无远期死亡。结论在常温、非体外循环状态下实施全主动脉弓替换手术，是一种治疗主动脉弓、降部真性或假性动脉瘤的安全、有效的方法，严格把握手术适应证是手术成功的关键。

Objective Study the early and midterm results of a technique-total aortic arch replacement without using extracorporeal circulation or aortic bypass for the treatment of aortic aneurismal disease involving the transverse aortic arch and proximal descending aorta. Methods Between April and November 2004, 7 consecutive patients with true （ n = 3 ） or false （n =4） aortic aneurysm underwent this procedure. The mean follow-up was 6.6 years. The median age at operation was 57 years （range 23 to 75 years）. Normothermia general anesthesia and median sternotomy combined with left anterior thoracotomy were administered. A partially occluding clamp was placed on ascending aorta and a longitude aortic incision was made. Anastomosis of a branched graft to ascending aorta in an end-to-side fashion was commenced. The descending aorta distal to the aneurysm was occluded and transected, and anastomosed to the distal end of the branched graft in an end-to-end fashion. Finally, the arch vessels were divided and anastomosed to the branches of the graft and the aneurysm excised. Results The average cross-clamp time of descending aorta, left common carotid artery, and innominate artery was （ 13.6 ± 5.6） min, （5.7 ± 0.8 ） rain, and （7.8± 2.5 ） min respectively. The mean intubation time was （ 12.3 ± 4.1 ） hours. There were no adverse outcomes or neurologic complications in this series. All patients survived and recovered completely. The mean follow-up time was （79.7 ± 2.1 ） months. All patients lead a normal life. There was no late death. CT follow-up study 6 years after surgery reveals no abnormal inlage. Conclusion Total aortic arch replacement without cardiopulmonary and aortic bypass is a feasible and effective method for the aortic aneurismal disease involving the transverse aortic arch and proximal descending aorta in selected patients.