104例胸主动脉瘤手术的体外循环转流经验

目的总结不同胸主动脉瘤手术所采用的体外循环（ECC）策略，探讨深低温停循环（DHCA）期间的重要器官保护方法。方法2005年7月-2011年7月共完成胸主动脉瘤手术共104例，其中，采用中低温ECC完成10例，采用DHCA双侧选择性顺行脑灌注（SACP）技术完成92例，采用常温半身ECC完成手术2例。疾病种类包括DeBakey（Ⅰ、Ⅱ、Ⅲ）型夹层、真性胸主动脉瘤和假性胸主动脉瘤。结果ECC时间75-371（198±51．25）min，升主动脉阻断时间35-299（125．87±67．88）min，停循环时间29-136（54．87±22．51）min，DHCA时最低鼻咽温度11．6-20（17．08±0．73）℃，常规超滤81例，超滤液量1000-4500ml，常规超滤＋平衡超滤11例，超滤液量5000-7200ml，术中出现“假腔灌注”一例。104例患者手术顺利，安返监护室，术后12-72h清醒，术后早期清醒前出现躁动9例，早期低氧血症18例，肾功能不全13例。99例治愈出院，死亡5例。1例术后死于肾功能衰竭，1例死于肾功能衰竭和脑出血，1例死于术后上消化道出血及肾功能衰竭，1例死于术后多发性腔隙性脑梗、脑出血及气管食管瘘，1例死于吻合口大出血床旁开胸止血后感染。结论根据胸主动脉瘤发病部位和手术方法不同，应采用不同的ECC方法。灌注师与术者的紧密配合和高水平的ECC管理是手术成功的基础。加强术中重要器官的保护是减少术后并发症和死亡率的关键。

Clinical experiences of cardiopulmonary bypass management in 104 cases of thoracic aortic aneurysm surgery

Objective To summarize the clinical experiences of cardiopulmonary bypass(CPB) management in different type of thoracic aortic aneurysm surgery and methods of vitals protection during deep hypothermic circulatory arrest(DHCA). Methods From July 2005 to July 2011,total 104 patients with thoracic aortic aneurysm cases were performed with different ways of CPB.The moderate hypothermia CPB was used in 10 ascending aortic aneurysm cases,DHCA combined with bilateral selective antegrade cerebral perfusion(SACP) was used in 92 thoracic aortic cases,and femoral A-V bypass with normothermia in the lower half of the body was used in 2 descending aortic aneurysm cases.The variety of disease included DeBakey type(Ⅰ,Ⅱ,Ⅲ) aortic dissecting aneurysm,true thoracic aortic aneurysm and false thoracic aortic aneurysm. Results The CPB time was 75-371(189.76±51.33) min,the aortic cross-clamp time was 35-299(116.69±60.38) min,DHCA time was 29-136(51.68±20.44) min,the lowest nasopharynx temperature was 11.6-23.9(17.73±1.91)℃ during the DHCA.The volume of 81 cases of conventional ultrafiltration(CUF) was 1000-4500 ml;the volume of 11 cases of CUF combined with balance ultrafiltration(BUF) was 5000-7200 ml.1 case of false lumen perfusion was detected during CPB.104 patients returned to ICU safely and recovering consciousness in 12-72 hours;9 cases appeared dysphoria before recovering consciousness;18 cases occurred postoperative hypoxemia and 13 cases occurred renal insufficiency.99 cases charmed away and discharged from the hospital,5 patients died.1 patient died from the renal failure,1 patient died from the renal failure and the brain hemorrhage,1 patient died from the renal failure and the upper digestive duct bleeding,1 patient died from the multiple lacunar cerebral infarction,the brain hemorrhage and the tracheoesophageal fistula,1 patient died from the bleeding of anastomotic stoma and the infection after bedside chest open. Conclusion According to the diseased segment of thoracic aortic aneurysm and the different method of surgical operation,the suitable method of CPB should be applied.The close cooperation of surgeon and perfusionist and the high level of CPB management are the base of successful operation.Strengthening the protection of vitals during DHCA is the key of decreasing the postoperative complications and mortality.