深低温停循环技术在胸腹主动脉瘤外科手术中的应用

The application of deep hypothermic circulatory arrest in the surgical treatment of complex thoracoabdominal aortic aneurysm

目的探讨深低温停循环在复杂胸腹主动脉瘤外科治疗中的应用及近中期效果。方法回顾性分析2009年8月至2018年6月本中心34例胸腹主动脉瘤近端无法常规阻断的临床资料,全组均在深低温停循环下行外科手术。男23例,女11例;年龄23~67岁,平均(42.26±10.96)岁。Crawford分型Ⅰ型12例,Ⅱ型22例;动脉瘤最大直径50~120mm,平均(65.26±16.09)mm;马方综合征15例,动脉粥样硬化14例,主动脉缩窄5例;合并高血压病22例;首次主动脉手术28例,再次主动脉手术6例。手术经胸腹联合切口,覆膜外入路,采用股动脉及下腔静脉插管,使用深低温停循环技术完成近端吻合口,动脉管法重建肋间动脉,腹腔脏器供血动脉与四分支血管分支进行吻合,四分支血管与"Y"形人工血管主干进行端端吻合,双侧髂动脉分别于"Y"形人工血管的10mm人工血管进行端端吻合。结果全组无颅脑神经系统并发症。深低温停循环(17.68±4.88)min,呼吸机辅助(34.88±16.04)h,术后肾功能衰竭5例,经CRRT治疗后均恢复,术后截瘫1例,经脑脊液引流减压等治疗后肌力恢复,全组死亡1例,系多脏器功能衰竭死亡,术后随访3个月~5年,效果满意,随访期间无因主动脉问题死亡者,5例因远端血管扩张再次手术,4例重建的肋间动脉闭塞但未发生截瘫。结论对于胸腹主动脉瘤近端无法直接进行阻断患者,采用深低温停循环下进行近端吻合口吻合是安全的。

Objective To discuss the application of deep hypothermic circulatory arrest in surgical treatment of complex thoracoabdominal aortic aneurysms and its near-midterm effect. Methods The clinical data of 34 cases of thoracoabdominal aortic aneurysm in the center from August 2009 to June 2018 were analyzed retrospectively. All the patients underwent surgery under deep hypothermic circulatory arrest.There were 23 males and 11 females;aged 23-67 years, mean(42.26±10.96) years old;Crawford type Ⅰ in 12 cases and Crawford type Ⅱ in 22 cases;aneurysms with a maximum diameter of 50-120 mm, mean(65.26±16.09) mm;Marfan syndrome 15 cases, atherosclerosis 14 cases, aortic coarctation in 5 cases;22 cases of hypertension;28 cases of first aortic surgery, 6 cases of re-aortic surgery.Surgical transthoracic and abdominal incision, extracapsular approach, femoral artery and inferior vena cava intubation, deep hypothermic circulatory arrest technique to complete proximal anastomosis, arterial tube reconstruction of intercostal artery, abdominal organ blood supply artery and four The bifurcated vessels were anastomosed, and the bifurcated vessels were anastomosed with the " Y" type artificial blood vessel trunk. The bilateral radial arteries were end-to-end anastomosis in the 10 mm artificial blood vessels of the " Y" type artificial blood vessels. Results There were no complications of cranial nerve system in the whole group, deep hypothermic circulatory arrest(17.68±4.88) min, ventilator assist time(34.88±16.04) hours, postoperative renal failure in 5 cases, after CRRT treatment After recovery, 1 case of paraplegia after operation, muscle strength recovered after cerebrospinal fluid drainage and decompression, and 1 case died in the whole group, and died of multiple organ failure. The patients were followed up for 3 months to 5 years, and the results were satisfactory. The survivors did not die. The survivors did not die.However, 5 patients underwent thoracic aortic replacement under deep hypothermic circulatory arrest for the first time, and 4 patients underwent reoperation because of distal vasodilation. The reconstructed intercostal artery occlusion occurred in 4 patients, but no paraplegia occurred. Conclusion When cross clamping the aorta is not feasible, it is safe to perform proximal anastomosis with deep hypothermic circulatory arrest.