经右侧腋动脉插管选择性单侧脑灌注在主动脉瘤手术中的应用

The use of selective cerebral perfusion through right axillary artery cannulation in aortic aneurysm surgery

目的总结经右侧腋动脉插管选择性脑灌注(SCP)在主动脉瘤手术中应用的经验。方法回顾性分析我院2009年5月至2011年5月期间采用深低温停循环(DHCA)SCP的手术方式治疗的105例主动脉瘤患者。男78例,女27例。行Bentall+次全弓置换6例,行升主动脉置换+次全弓置换5例,行Bentall+全弓置换+降主动脉支架植入手术61例,行升主动脉置换+全弓置换+降主动脉支架植入手术33例,同期行冠状动脉旁路移植(CABG)术10例,行二尖瓣成形(MVP)或二尖瓣置换(MVR)24例,三尖瓣成形(TVP)11例。结果体外循环(CPB)时间81～374(178.6±41.5)min;心肌血运阻断时间为79～235(132.6±33.5)min;DHCA时间8～36(23.2±10.1)min,经右腋动脉SCP时间为8～46(30.4±12.4)min,流量8～10 ml/(kg.min);停循环时最低鼻咽温度15.5～23.5(19.5±1.7)℃;最低肛温18.0～25.6(20.6±1.6)℃。升主动脉开放后,心脏自动复跳89例,16例电击除颤复跳;术后2～72 h内神志清醒。术后死亡5例,其中3例死于多脏器衰竭,1例死于恶性心律失常,1例死于吻合口破裂,死亡原因与腋动脉插管无关。术后并发症包括:吻合口出血再次开胸止血4例,脑梗塞1例,截瘫1例,肾脏衰竭1例,一过性意识障碍6例;余患者经治疗后均顺利痊愈出院。结论在主动脉瘤手术中采用右侧腋动脉插管行SCP,可以提供有效的脑保护,减少神经系统并发症的发生,操作方法简单,临床效果满意。

Objective To summarize the experiences of selective cerebral perfusion through right axillary artery cannulation in aortic aneurysm surgery. Methods Methods Retrospectively analyzed 105 cases （from May 2009 to May 2011 ） of aortic aneurysm surgery with deep hypothermic circulatory arrest （DHCA）. 78 cases were male and 27 cases were female. The operation procedure included Bentall procedure and semi arch replacement in 6 cases, ascending aorta replacement and semi arch replacement in 5 cases, Bentall procedure and elephant trunk technique in 61 cases, ascending aorta replacement and elephant trunk technique in 33 cases. Combined operations included coronery artery bypass grafting （10 cases）, mitral valve replacement or mitral valve repair （24 cases） and tricuspid valve repair （ 11 cases）. Results Average cardiopulmonary bypass time was 81 - 374 （ 178.6± 41.5 ） min, average DHCA time was 8 - 36 （23.2 ± 10.1 ） min, average selective cerebral perfusion time was 8 - 46 （ 30.4 ± 12.4 ） rain, nasopharynx temperature during DHCA was 15.5 -23.5 （ 19.5± 1.7） ℃, rectal temperature during DHCA was 18.0 -25.6 （20.6± 1.6） ℃. 89 patients＇hearts automaticly rebeated and 16 rebeated after defibrillation. 5 cases died postoperatively. The complications included multiorgan failure for 3 cases, malignant arrhythmia for 1 case and sudden bleeding for 1 case. Conclusion The use of selective cerebral perfusion through right axillary artery cannulation in aortic aneurysm surgery can get effective brain protection and reduce the postoperative nervous system complications with acceptable results.