经升主动脉插管在急性Stanford A型主动脉夹层手术中的应用

Application of Ascending Aortic Cannulation in the Operation on Acute Stanford Type A Aortic Dissection

目的:总结急性Stanford A型主动脉夹层手术中经升主动脉插动脉灌注管的临床经验。方法:45例急性Stanford A型主动脉夹层患者,在深低温停循环下手术,根据术前CTA、MRI及术中探查情况,在食道超声引导下,选取升主动脉夹层累及轻或没有夹层的区域作为插管位置,控制有创动脉压在90mmHg左右,用尖端较长的直型主动脉灌注管插管,4-0prolene线做双荷包缝合固定,右心房插右心引流管,右上肺静脉插左心引流管建立体外循环。深低温停循环时,直视下经头臂动脉及左颈总动脉分别插双侧脑灌注管行脑保护。结果:所有升主动脉插管成功,没有发生夹层破裂及灌注不足病例。住院死亡3例(6.7%),1例死于术后早期失血性休克,1例死于术后多器官功能衰竭,1例死于感染性心内膜炎。一过性脑功能紊乱6例(13.3%);脑血管意外2例(4.4%),其中脑栓塞1例,脑出血1例,出院时均处于恢复期。血管吻合口出血开胸止血3例;声音嘶哑1例;肾功能衰竭1例。1例于术后4月因院外抗凝不当突发脑出血死亡。结论:急性Stanford A型主动脉夹层手术,在准备充分的条件下,经升主动脉插管能快速建立体外循环,提供顺行灌注,辅以双侧顺行脑灌注,能取得满意的机体保护效果,具有快速、简单、安全、创伤小的特点。经升主动脉灌注仍是较好的选择之一。

Objective： To summarize the clinical experience of ascending aortic cannulation in acute Stan- ford type A aortic dissection. Methods： From Jan 2005 to July 2009, 45 patients with acute Stan ford type A aortic dissection underwent operation with ascending aortic cannulation. According to CTA, MRI, and the operative exploration, under the guidance of esophageal echocardiography, the aortic cannula with a straight long top was located in the site of the minimal distances of the dissected layers and was supported by double purse-string sutures （4-0 prolene） when arterial blood pressure was controlled on about 90 mmHg. Cardiopulmonary bypass was installed through ascending aortic cannula and the right artrium with a two-stage cannula. Under deep hypothermic circulatory arrest, the brain was continuously perfused in an anterograde manner through innomi- hate and left common carotid artery under direct vision. Results： No malperfusion and aortic rup-ture occurred. The in-hospital mortality was 6.7% （3/45）. of the three cases, the first patient died of the hemorrhage shock, the second died of multi-organ failure postoperatively, and the last died of infective endocarditis. The complications included transient neurologic deficit in 6 （13.3%）, cerebrovascular accidence in 2 （4.4%, one cerebral embolism and one cerebral hemor- rhage）, hemorrhage of anastomose in 3 who were treated by reoperation, hoarseness in 1, and re nal failure in 1. One case died of the cerebral hemorrhage after 4 months due to inappropriate an- ticoagulation during following up. Conclusion： Cardiopulmonary bypass is established quickly via ascending aortic cannulation in acute Stanford type A aortic dissection, which can provide ante grade perfusion and attain satisfactory organism protection with the help of bilateral antegrade cerebral perfusion. It is a fast, easy, safe, and minimally invasive technique for the operation on acute Stanford type A aortic dissection.