70岁以上急性A型主动脉夹层患者弓部重建的体外循环管理

Management of cardiopulmonary bypass in elderly patients with acute type A aortic dissection of aortic arch reconstruction

目的回顾性总结35例70岁以上累及弓部的急性A型主动脉夹层患者的体外循环管理经验.方法 2013年4月至2017年12月,35例70岁以上均累及主动脉弓部、头臂干、左颈总动脉及左锁骨下动脉且弓部病变严重,假腔大,有较大的破裂风险的急性A型主动脉夹层患者,在急诊体外循环下应用三分支支架重建主动脉弓部.体外循环期间采用中度低温(25℃)下选择性脑灌注及间断停循环,减少脑缺血缺氧时间,并加强重要脏器保护的管理方法.结果体外循环(144.85±32.98)min,主动脉阻断(51.82±17.59)min,选择性脑灌注(12.17±4.70)min,间断停循环(4.50±3.54)min,下半身停循环(16.6±7.49)min,全部患者顺利脱离体外循环机.所有患者48 h内清醒,其中3例早期出现短暂性精神障碍,出院前恢复正常;2例出现脑梗死.院内死亡6例(17.1%).结论高龄并非急性A型主动脉夹层手术重建弓部的禁忌证.合理的体外循环管理可以为70岁以上急性A型主动脉夹层患者弓部重建手术提供重要保障.

Objective To summarize the clinical experience of cardiopulmonary bypass(CPB) in acute type A aortic dissection received aortic arch reconstruction on age over 70 years patients. Methods From April 2013 to December 2017, 35 elderly patients aged over 70 who were involved the aortic arch, brachiocephalic trunk, left common carotid artery and left subclavian artery and severe arch lesions, large false lumen and large rupture risk of acute A aortic dissection were reconstructed by triple-branched stent graft in emergency extracorporeal circulation. During the period of cardiopulmonary bypass, selective cerebral perfusion and discontinuous arrest under moderate hypothermia(25 degrees C) were used to reduce the time of cerebral ischemia and hypoxia, and to strengthen the management of the protection of important organs. Results Cardiopulmonary bypass time was(144.85±32.98)minutes, and aortic cross clap time was(51.82±17.59)minutes, and selective cerebral perfusion time was(12.17±4.70)minutes, discontinuous arrest time was(4.50±3.54) minutes, the lower body arrest time was(16.6±7.49)minutes. All patients were smoothly weaned from cardiopulmonary bypass.35 patients resuscitated within 48 hours, of which 3 patients had transient mental disorders in the early stage and recovered before hospital discharge;2 patients had cerebral infarction. Hospital mortality in this group was 17.1%(6/35). Conclusion Advanced age is not a contraindication to the reconstruction of the arch of the aortic dissection. Reasonable management of cardiopulmonary bypass can provide an important guarantee for the reconstruction of the elderly patients with acute type A aortic dissection.