无名或左颈总动脉横断插管结合弓部优先吻合技术在Stanford A型主动脉夹层手术中的应用

Clinical experience of innominate artery or left common carotid artery cannulation combined with arch-first technique in Stanford type A aortic dissection surgery

目的探讨无名或左颈总动脉横断插管结合弓部优先吻合技术在Stanford A型主动脉夹层手术中的应用。方法2018年1月至2020年1月,本中心通过无名动脉或左颈总动脉横断,并将动脉管逆插入主动脉弓部真腔灌注结合弓部优先的吻合技术,完成Stanford A型主动脉夹层手术6例。弓部优先吻合技术:在横断无名动脉或左颈总动脉插管成功后,优先把横断后的血管吻合至四分支人造血管上,吻合过程中根据脑氧饱和度决定是否利用逆灌管保证双侧脑灌注,通过监测左右上肢血压控制灌注流量,避免奢灌,降温过程中完成另一分支动脉吻合,通过单泵双管连接四分支血管形成双侧脑灌注,左锁骨下动脉的吻合根据难易程度决定是否在停循环过程中完成。术式包括:2例胸骨上段小切口主动脉瓣成形+升主、全弓置换+降主动脉支架植入术;1例Bentall+二尖瓣置换+升主、全弓置换+降主动脉支架植入术;1例David+三尖瓣成形+升主、全弓置换+降主动脉支架植入术;1例升主、全弓置换+降主动脉支架植入术;1例升主、全弓置换+降主动脉支架植入+冠状动脉旁路移植术。结果所有6例手术动脉插管成功,手术过程顺利,所有患者术后10 h内清醒,1例拔管后出现谵妄症状,转出监护室后恢复;1例术前因“胸痛、下肢无力”发病,术后拔管后下地困难,经康复锻炼1周左右能借助器械下地活动。所有患者均痊愈出院。结论无名或左颈总动脉横断插管结合弓部优先吻合技术安全有效,可优化体外循环建立,优先保证脑部供血,减少神经系统并发症。

Objective To review the experience of innominate or left common carotid artery cannulation combined with archfirst technique in Stanford type A aortic dissection surgery.Methods From January 2018 to January 2020,in our center,6 cases of Stanford type A aortic dissection surgery were completed by transection of the innominate artery or the left common carotid artery,asso⁃ciated with reverse insertion of the arterial cannula into the true lumen,combined with the arch-first anastomosis technique.The arch-first anastomosis technique means:after successful transaction of innominate or left common carotid artery,the anastomosis of the transected blood vessel to the four branch artificial blood vessels is preferentially performed.During the anastomosis,whether to use the retrograde irrigation to ensure bilateral cerebral perfusion is determined by cerebral oxygen saturation.The perfusion flow is controlled by monitoring the blood pressure of the left and right upper limbs to avoid excessive perfusion.Another branch arterial anastomosis is completed during the hypothermic period.Bilateral cerebral perfusion is achieved by double arterial lines with a single pump head per⁃fusion through the artificial four branch vessel.The anastomosis of the left subclavian artery during deep hypothermic circulatory arrest is determined according by the degree of operating difficulty.The surgical procedures included 2 cases of AVP+ascending aorta and to⁃tal arch replacement combined with stent implantation in descending aorta,1 case of Bentall+MVR+total arch replacement combined stent implantation in descending aorta,1 case of David+TVP+ascending aorta and total arch replacement combined with stent im⁃plantation in descending aorta,1 case of ascending aorta and total arch replacement combined with stent implantation in descending a⁃orta and 1 case of CABG+ascending aorta and total arch replacement combined with stent implantation in descending aorta.Results Arterial intubation was successfully performed in all 6 cases,and the operation was finished smoothly.All patients were a⁃wake within 10 hours after surgery.One case appeared delirium after extubation and recovered after out of ICU.One patient had"chest pain and weakness of lower extremity"before surgery,and he was immobile after extubation.After rehabilitation exercise for 1 week,he could walk with the aid of equipment.All patients were cured and discharged form the hospital.Conclusion Innominate left com⁃mon carotid artery cannulation combined with arch-first technique in Stanford type A aortic dissection was safe and effective.It could optimize the establishment of cardiopulmonary bypass,prioritize brain blood supply,and reduce neurological complications.