升主动脉瘤累及右半弓的外科治疗及体外循环探讨  

The different methods of surgery and cardiopulmonary bypass for ascending aorta and partial aortic arch aneurysm replacement

作　　者：于坤[1] 孙桂民[1] 冯钧[1] 孙立忠[1] 常谦[1] 高国栋[1] 龙村[1] 

机构地区：[1]北京阜外心血管病医院体外循环科,100037

出　　处：《心肺血管病杂志》2009年第3期148-150,188,共4页Journal of Cardiovascular and Pulmonary Diseases

摘　　要：目的:总结升主动脉及右半弓置换术的外科治疗经验,探讨不同体外循环(CPB)方式在术中的应用。方法:28例升主动脉瘤伴右半弓受累的患者行升主动脉及右半弓置换术,其中8例单纯经股动脉与右心房插管建立CPB,在深低温停循环(DHCA)下开放吻合主动脉弓和人工血管远端;15例经右腋动脉或无名动脉及股动脉与右心房插管建立CPB,在中深低温选择性脑灌注(ACP)加全身停循环下开放吻合主动脉弓和人工血管远端;5例经股动脉右心房插管的同时,经腋动脉或无名动脉插管浅低温全流量下行ACP加下半身股动脉逆行灌注,在无名动脉和左颈总动脉之间阻断主动脉弓后吻合主动脉弓和人工血管远端。结果:术后突发大面积心肌梗死造成心源性休克死亡1例。术后偏瘫经CT确诊为脑梗死2例。呼吸功能不全需2次气管插管1例,机械通气辅助24h病情改善后脱离呼吸机。术后出现严重高钠血症需进行血滤1例。2次开胸止血1例。结论:在主动脉右半弓置换术CPB方法的选择上,外科医生和灌注师需根据患者病情、手术熟练程度正确掌握DHCA和ACP技术,选择最佳的灌注方式。Objective： To summarize cardiopulmonary bypass of ascending aorta and partial aortic arch aneurysm replacement. Method： All surgeries were performed through a median stemotomy. Arterial perfusion was done via the femoral artery, axillary artery, innominate artery or a combination of both. Only deep hypothermic circulatory arrest （DHCA） was induced in 8 cases; it was associated with .antegrade selective cerebral perfusion （ACP） in 15 patients, antegrade selective cerebral perfusion associated with continuous perfusion of the lower body by means of cross-clamp the aorta between left common carotid artery and innominate artery in 5 cases. Result： One patient died from cardiogenic shock due to acute myocardium infarction on postoperative day 1. Postoperative complications included cerebral infarction in 2 patients, reoperation to control hemorrhage in 1 patient, respiratory insufficiency in 1 patient, and hypernatremia in 1 patient need continuous renal replacement therapy. Conclusion： DHCA and ACP are all safe and effective methods for the surgery of hemiarch rreplacement. Surgical and perfusion types depend on the nature of aneurysm, acute or chronic dissection, location of intimal tear, and the skill of the surgeon.

关 键 词：升主动脉瘤 深低温停循环 选择性脑灌注 体外循环 

分 类 号：R543.16[医药卫生—心血管疾病]