股动脉和腋动脉插管应用于主动脉弓部手术的结果比较

目的 比较股动脉和腋动脉插管在成人主动脉弓部手术中的应用及结果比较。 方法 选取行主动脉弓部手术患者58例，根据术中采用的插管方式分为股腋动脉两组，分别记录两组患者一般情况、手术方式、体外循环转流时间、主动脉阻断时间、脑灌注时间、术后清醒时间、气管插管时间、重症监护室（intensive care unit,ICU）住院时间、术后心功能恢复、插管相关并发症和术后出现认知功能障碍等情况。 结果 两组共计3例患者死亡,其余患者均痊愈出院，两组患者一般情况及主动脉阻断时间股动脉组（113±18）min、腋动脉组（117±16）min；脑灌注时间股动脉组（25±6）min、腋动脉组（25±6）min、两组体外循环转流时间股动脉组（266±24）min、腋动脉组（267±24）min患者术后清醒时间股动脉组（37±26）h、腋动脉组(38±26)h；气管插管时间股动脉组（64±6）h、腋动脉组（63±7）h；重症监护室住院时间股动脉组（8.5±2.1）d、腋动脉组（8.1±2.2）d、休克的发生率、插管相关并发症发生率及术后出现认知功能障碍的差异均无统计学意义。 结论 股动脉和腋动脉插管对行主动脉弓部手术患者术后脑部并发症及插管相关并发症的发生无显著差异。     

双侧颈动脉前向灌注在急性A型主动脉夹层合并单侧颈总动脉闭塞外科治疗中的应用△

目的在急性Stanford A型(A型)主动脉夹层合并单侧颈动脉闭塞患者手术治疗中,通过改进传统手术、体外循环插管等方式,实施患者术中双侧颈动脉前向血流灌注、行闭塞侧颈动脉人工血管置换,以探索减少此类高危患者神经系统并发症的有效措施。方法本队列回顾性分析2017年9月至2019年2月,于广东省人民医院同期行主动脉夹层矫治以及颈动脉人工血管置换的5例急性A型主动脉夹层合并单侧颈动脉闭塞患者的临床资料。本组患者均行Bentall或Wheat合并主动脉弓部血管岛状吻合、术中降主动脉直接植入、患侧颈总动脉灌注及人工血管置换术(两例为右、三例为左侧颈总动脉闭塞),体外循环均行右腋动脉、股动脉、病变闭塞侧颈总动脉远端(近端颈总动脉结扎、远端颈总动脉与人工血管端-端吻合后直接与体外循环一分支动脉灌注)插管,后行患侧颈总动脉人工血管近端与升主动脉人工血管吻合完成主动脉-患侧颈总动脉血运重建;术中持续行双侧脑灌注,降主动脉支架植入过程暂停经股动脉血流灌注,待支架释放、固定后于人工支架内植入隔离球囊恢复全身循环。分析此5例A型主动脉夹层合并单侧颈动脉闭塞的患者基本资料及临床数据。结果 5例患者中4例为男性,年龄(52±12.4)岁,体质量(65.9±11.9)kg,发病至手术时间(9.6±7.1)d,体外循环时间(262.6±37.3)min,主动脉阻断时间(148.2±27.1)min,下半身停循环时间(19.2±10.2)min,术后呼吸机使用时间(82±56.1)h,术后重症监护病房停留时间(8.4±4.0)d,术后住院时间(不包括重症监护病房停留时间)(22.6±10.3)d;术后随访时间(17.6±7.4)个月。患者经计算机断层扫描复查显示血运重建良好,无神经系统及其他主要并发症发生。结论急性A型夹层合并单侧颈动脉闭塞患者外科治疗风险、神经系统并发症发生率高,经过早期针对闭塞颈总动脉行双侧脑灌注的体外循环和手术策略的改进,可以使神经系统并发症发生率降低,手术效果得到提高,是针对此类患者安全有效的外科干预策略。     

改良支架“象鼻”手术在B型夹层中的应用

目的:探讨改良支架"象鼻"手术在B型夹层中的应用。方法:纳入2019年1月至2019年9月,在北京安贞医院行改良支架"象鼻"手术的7例复杂型Stanford B型主动脉夹层患者,男性6例、女性1例,年龄29~50岁,平均(40.29±7.52)岁;所有患者均合并高血压,体质量60~110 kg,平均(91.43±17.73)kg,其中≥90 kg 5例。患者均在低温体外循环下,经主动脉弓切口置入支架型人工血管。术后出院前均复查主动脉CTA。结果:手术时间4.5~5.5 h,平均(4.86±0.38)h,体外循环时间129~163 min,平均(145±12.94)min,主动脉阻断时间32~59 min,平均(44.43±7.93)min,选择性脑灌注时间17~32 min,平均(24.29±4.50)min,脑灌注流量5~8 mL·min^-1·kg^-1,平均(6.71±1.38)mL·min^-1·kg^-1,深低温停循环鼻咽温23.5~26.8℃,平均(25.21±1.16)℃,深低温停循环左上肢血压20~31 mmHg,平均(25.58±4.65)mmHg,术中动脉插管位置:无名动脉人工血管+左锁骨下动脉人工血管插管4例,无名动脉人工血管+右股动脉+左锁骨下动脉人工血管插管3例,术后呼吸机辅助时间8~15 h,平均(10±2.65)h,监护室滞留时间1 d,术后住院时间6~8 d,平均(7.14±0.69)d,无手术死亡,支架周围假腔闭合率100%,股动脉切口延迟愈合1例,无吻合口漏,无神经系统并发症。结论:改良支架"象鼻"手术治疗复杂型Stanford B型主动脉夹层安全有效。     

Stanford A型主动脉夹层手术中的体外循环管理

目的:总结我院165例Stanford A型主动脉夹层手术体外循环管理经验。方法:收集165例Stan-ford A型主动脉夹层患者,实施Wheat、David、Bentall及全弓置换和支架象鼻术等术式。根据术式分别采用常规中低温体外循环,深低温停循环(DHCA)加选择性顺行性脑灌注(SACP)等体外循环灌注方法。其中,主动脉全弓置换术均行右锁骨下动脉与右心房插管建立体外循环,在DHCA加SACP下完成主动脉远端支架植入及弓部血管吻合,期间脑灌注流量5～10ml.kg-1.min-1。术中采用单泵双管及单侧选择性脑灌注、α+pH稳态和高氧血气管理及超滤等技术。结果:体外循环转流时间(197.3±28.3)min、深低温停循环时间(25.3±3.8)min、SACP时间(45.2±7.7)min、心肌阻断时间(86.1±10.8)min。重症监护室时间72～516(181.31)h。院内死亡17例(死亡率11.25%),余134例均痊愈出院,出院时心功能NYHAⅠ～Ⅱ级。结论:正确选择体外循环方法及良好的体外循环管理是Stanford A型主动脉夹层手术成功的保障。主动脉全弓替换术中采用单泵双管及单侧选择性脑灌注、α+pH稳态和高氧血气管理及超滤等技术切实可行,临床预后满意。     

Stanford A型主动脉夹层手术中股动脉插管的应用

目的 :探讨经股动脉插管行主动脉夹层动脉瘤手术的应用。方法 :88例StanfordA型主动脉夹层动脉瘤经股动脉插管建立体外循环进行手术 ,其中 2 6例深低温停循环。结果 :8例 (9. 1% )在术中出现假腔灌注 ;4例 (4. 5 % )脑部并发症 (2例广泛脑缺氧 ,2例脑栓塞 ) ,2例死亡 ,1例不清醒 ,1例偏瘫 ;6例 (8. 0 % )皮肤切口延迟愈合 ,局部感染 1例 (1.3% )。术后插管侧无下肢缺血或股动脉血栓形成。结论 :经股动脉插管行体外循环或左心转流手术治疗主动脉夹层动脉瘤的方法是有效的。采用经人工血管行股动脉插管可有效的降低了股动脉狭窄、血栓形成和下肢缺血的并发症发生率 ;股动脉插管主动脉逆行灌注造成的假腔灌注和脑部并发症在本组发生率虽较低 ,但后果严重。     

深低温停循环三分支主动脉弓覆膜支架植入治疗老年急性A型主动脉夹层的疗效

目的探讨深低温停循环三分支主动脉弓覆膜支架植入治疗老年急性A型主动脉夹层的临床效果。方法 2010年2月至2011年12月,16例老年Stanford A型主动脉夹层患者,〔平均(64.25±4.49)〕岁;男性12例,女性4例在全身麻醉体外循环下先进行近心端操作,降温至20℃时,停体外循环,选择性脑灌注,术中直视植入三分支主动脉弓覆膜支架重建主动脉弓,主干支架血管近端与替换近端升主动脉的人造血管端吻合。结果全组无手术死亡,所有患者术中都顺利植入三分支主动脉弓覆膜支架。本组体外循环时间(181.88±26.51)min,心肌阻断时间(81.69±14.58)min,停循环时间(8.75±7.04)min,选择性脑灌注时间(35.19±5.89)min。术后胸腔及心包积液引流量(812.19±357.29)ml。住院期间死亡1例,死因为术后急性肾衰竭。15例患者定期门诊随访,无死亡和需要再次手术病例,无与覆膜支架相关的并发症发生。复查主动脉增强血管CT(CTA)提示:主干支架血管及分支血管通畅,无扭曲,主动脉弓和胸降主动脉假腔部分血栓形成。结论老年主动脉夹层病情凶险,深低温停循环三分支主动脉弓覆膜支架植入治疗Stanford A型主动脉夹层可简化主动脉弓部手术,降低手术风险,适合老年Stanford A型主动脉夹层患者的治疗,效果满意。但手术例数尚少,长期效果尚需进一步观察。     

急性Stanford A型主动脉夹层术中渗血防治-单中心经验总结

目的 通过分析近年来收治的急性Stanford A型主动脉夹层病例,总结关于防治术中渗血的经验,为手术方案的改进提供临床依据。 方法 选取罹患急性Stanford A型主动脉夹层并接受升主动脉+主动脉弓修复手术的患者纳入本回顾性研究。主动脉根部处理采用内衬片法;弓部处理应用三分支支架血管或单分支支架血管联合头壁血管内小支架;体外循环则运用中低温停循环技术联合右腋动脉加股动脉双通道灌注法;内瘘技术采用改良包裹法。临床数据采集包括一般临床资料、病因、主动脉夹层破口位置和累及范围、术前合并症、心功能、手术情况及预后。 结果 共计178例患者纳入本研究,手术时间308±49.8 min,体外循环时间131±23.9 min,升主动脉阻断时间88.2±12.1 min,中低温停循环加选择性脑灌注时间21.5±6.7 min,术后心包腔引流液300±90 ml,住院死亡率5.6%,术后神经系统并发症发生率8.6%,出院后死亡率为0。术后3个月发现内瘘1例（0.5%）,胸主动脉夹层愈合率79.8%;术后1年,未发现内瘘发生,胸主动脉夹层愈合率达82.7%;所有患者均未发现人造血管周围造影剂外渗。 结论 渗血仍是急性Stanford A型主动脉夹层常见的并发症。“新内膜技术”、中低温停循环联合双侧头臂干动脉灌注以及改良包裹内瘘法等多种技术的应用,有助于减少术中渗血,缩短手术时间,减少内瘘发生,提高胸主动脉夹层愈合率和患者总体生存率,改善预后。     

主动脉导尿管球囊阻断在急性A型夹层手术治疗中的应用

目的 对比分析急性A型主动脉夹层患者术中常规体外循环方式和采用单泵三管联合降主动脉阻断中低温短暂停循环方式。方法 143例A型主动脉夹层手术患者，根据体外循环方式方法不同分为观察组(n=69)和对照组(n=74),观察组术中行单泵三管(右侧腋动脉、左侧颈总动脉、右侧股动脉插管),降主动脉导尿管球囊注水阻断，中低温短暂停循环[25～28℃,(5±1)min];对照组术中行右侧腋动脉插管，深低温停循环[18～22℃,(43±6)min]。对比两组术中体外循环时间、降温时间、最低肛门温度、最低鼻咽温度、复温时间、手术全程时间、输注库存血红细胞、血浆量及术后急性生理与慢性健康状况评估(APACHE)-Ⅱ评分、Glasgow评分、术后清醒时间、术后死亡率、并发症发生率、脑血管不良事件发生例数、平均ICU住院天数、总住院天数。结果 观察组术中停循环时间、降温时间、复温时间均较短；观察组术中最低肛门温度(28℃左右)、最低鼻咽温度(25℃左右)均较高，输入库存红细胞量、输入血浆量均较少；观察组术后APACHE-Ⅱ评分、术后清醒时间、术后死亡率、并发症发生率、脑血管不良事件发生例数、平均ICU住院天数...     

分支优先联合阻断弓部术中支架血管避免深低温停循环的全弓置换手术

目的:通过对全弓置换手术(孙氏手术)的改良,避免深低温停循环,以获得更好的早期临床效果。方法:2017年1月至2017年11月连续13例患者采用阻断弓部术中支架血管联合分支优先技术行全弓置换手术。右腋动脉和股动脉插供血管,单泵双管建立体外循环,首先以2分支人工血管先后吻合无名动脉和左颈总动脉建立持续双侧脑灌注,然后处理主动脉根部病变,在短暂停循环(1min左右)、中浅低温(鼻咽温28~30℃)下剖开主动脉弓部至无名动脉根部,置入术中支架血管,术中支架血管连同弓部血管一并阻断,恢复体外循环,继续完成重建手术。结果:13例患者均手术成功,全组平均下半身停循环时间(76±32)s,平均体外循环时间(213±28)min,平均主动脉阻断时间(105±22)min,手术后清醒时间(220±43)min,全组患者很快脱离呼吸机(25±17)h,无神经系统并发症发生,无肝肾功能损伤。结论:此改良全弓置换术式避免了深低温停循环,提供充分的大脑和内脏灌注,有效降低了神经系统并发症和内脏器官损伤。     

孙氏手术治疗急性Stanford A型主动脉夹层的临床疗效及安全性分析

目的评价孙氏手术治疗急性Stanford A型主动脉夹层的临床疗效及安全性。方法选择2013年7月至2017年7月梅州市人民医院39例急性Stanford A型主动脉夹层患者,均在深低温停循环、低流量选择性脑灌注下行孙氏手术治疗。记录患者ICU停留时间、住院时间,近期和远期并发症发生率和死亡率,比较术前与术后12个月随访时左心室舒张末期内径(LVEDd)、左心室射血分数(LVEF)和升主动脉最大内径变化。结果 39例患者术中平均体外循环时间(223.52±51.72)min、平均主动脉阻断时间(143.71±34.81)min、平均脑灌注时间(33.72±7.53)min。围术期死亡2例(5.1%,2/39),1例为肾衰竭,1例为多脏器功能衰竭;围术期并发症发生率为23.1%(9/39)。37例存活患者ICU停留时间为(6.2±1.7)d,住院时间为(26.9±6.2)d。术后随访12个月,2例患者主动脉再次破裂死亡,死亡率为5.4%(2/37)。35例存活患者术后12个月时LVEDd和升主动脉最大内径为(50.87±4.27)mm和(28.19±3.61)mm,均明显小于术前的(55.02±6.81)mm和(48.85±7.93)mm,而LVEF为61%±9%,明显大于术前的47%±12%,差异均有统计学意义(t=13.726、52.417和24.208,均为P<0.001)。结论孙氏手术治疗急性Stanford A型主动脉夹层可显著降低围术期死亡率,改善远期心功能,同时降低并发症发生率。     

Innominate artery cannulation for aortic surgery

When disease involving the ascending aorta or aortic arch precludes ascending aortic cannulation, axillary artery cannulation is used for cardiopulmonary bypass. An additional incision and the relatively small caliber of the axillary artery are the drawbacks of this approach. Innominate artery cannulation using the same sternotomy wound is a simple and effective alternative.     

Axillary artery cannulation provides balanced cerebral oxygenation

Deterioration of cerebral performance remains a major problem after cardiac surgery. Axillary artery cannulation can improve clinical outcome, but some experimental series show a malperfusion of the right hemisphere. The aim of our clinical study was to analyze the intraoperative investigation of cerebral oxygenation in two different arterial cannulation sites by use of near-infrared spectroscopic oximetry (NIRO). We compared retrospectively the cerebral saturation of 20 patients with aortic cannulation (group AoC) and 20 patients with right axillary artery cannulation (group AxC) during either valve, coronary artery bypass graft (CABG), combined procedures, or aortic surgery. Patients were monitored with bihemispheric NIRO (NIRO-200, Hamamatsu, Herrsching, Germany). The oxygenation data were calculated as tissue oxygenation index (TOI). And the cardiopulmonary bypass time was considered with special regard to potentially dangerous phases for cerebral desaturation like the starting of the extracorporeal circulation (ECC), cross-clamping, rewarming phase, aortic declamping, and stopping of ECC. Patients were then postoperatively evaluated by a standardized neurological examination. During the entire CPB time and the specific phases potentially at risk for cerebral desaturation, no statistically significant drop of cerebral oxygenation (>20 % for >60 s) was detected after aortic and right axillary artery cannulation, respectively. Furthermore, no significant difference in TOI was found comparing the left and right hemisphere in each group. Postoperatively 2 transient confusional syndromes (CS) were observed after aortic and 3 CS after axillary artery cannulation. Right axillary artery cannulation provides balanced cerebral oxygenation in both hemispheres during extracorporeal circulation and its specific phases potentially at risk for cerebral malperfusion. It might therefore reduce the risk of neurological injury by reduction of solid embolization and maintenance of balanced cerebral oxygenation.     

Femoral artery cannulation as a safe alternative for aortic dissection arch repair in the era of axillary artery cannulation

BackgroundTo evaluate the safety and efficacy of femoral artery cannulation as an alternative to axillary artery cannulation, we retrospectively compared outcomes between patients with axillary or femoral artery cannulation during open aortic arch repair for type A aortic dissection (TAAD).MethodsBetween January 2014 and January 2019, 646 patients underwent open aortic arch repair with circulatory arrest for TAAD using antegrade selective cerebral perfusion (SACP) and were divided into two groups according to the site of arterial cannulation: an axillary artery group (axillary group, n=558) or a femoral artery group (femoral group, n=88). The axillary artery was considered as the primary cannulation site, and the femoral artery was used as an alternative when axillary artery cannulation was deemed unsuitable or had failed. Propensity score matching was performed to correct baseline differences.ResultsAfter propensity score matching, the patients’ characteristics were comparable between groups (n=85 in each). The incidence of in-hospital mortality (10.6% vs. 14.1%; P=0.642) and stroke (3.5% vs. 5.9%; P=0.720) were comparable between the axillary and femoral groups. The incidence of newly required dialysis was lower in the femoral group, but the difference was not statistically significant (34.1% vs. 20.0%; P=0.050). Other outcomes and major adverse events were comparable.ConclusionsFemoral artery cannulation produced similar perioperative outcomes to axillary cannulation after open arch repair for TAAD. The femoral artery can be used as a safe and effective alternative to the axillary artery for arterial cannulation in TAAD patients undergoing open arch repair.     

Percutaneous closure after inadvertent subclavian artery cannulation.

Accidental insertion of an arterial sheath is an uncommon but potentially serious complication of jugular venous catheterization. When the subclavian artery is inadvertently cannulated, sheath removal can be complicated by significant hemorrhage due to its incompressible location. We report a case of inadvertent insertion of an 8 French sheath into the subclavian artery, which was successfully removed and the puncture site sealed with a collagen-based vascular closure device (Angio-Seal STS Plus). This averted an otherwise emergent open surgical procedure to remove the sheath and repair the subclavian artery in a high-risk patient.     

A late complication of percutaneous radial artery cannulation

Radial artery pseudoaneurysms occurring as a late complication of percutaneous radial artery cannulation are rare, while those which are infected are exceptional. Known risk factors are age-related with patients being in their seventies and onwards, the duration of the radial artery catheter and staphylococcal catheter-related infections. We report the case of an 82-year-old patient who developed a mycotic radial artery pseudoaneurysm as a late complication of arterial catheterization.     

Safe innominate artery cannulation for cardiopulmonary bypass in neonates

To reduce the neurological complications of deep hypothermic circulatory arrest, continuous cerebral perfusion was introduced, either by direct innominate artery cannulation or by a tubular prosthesis. This second option, used in our clinical experience, has been extended to applications other than aortic arch reconstruction, to facilitate cardiopulmonary bypass in small neonates (< 3.0 kg) with complex congenital heart defects, and to facilitate postoperative extracorporeal membrane oxygenation.     

Cannulation of the axillary artery: the decision between direct cannulation and cannulation via side graft

BACKGROUND: The axillary artery has emerged as promising alternative cannulation site when the ascending aorta is unsuitable for cannulation. However, in order to minimize vascular injury, the decision to cannulate the artery directly or via graft has to be considered carefully. METHODS: Seventy patients underwent axillary artery cannulation during a two-year period. Indications for operation were acute aortic dissection type A in 25(36 %), ascending aortic or arch aneurysm in 32 (46 %), redo surgery in 6 (9 %), and severely atherosclerotic aorta in 3 (4.3 %) patients. Depending on the diameter of the vessel and the rigidity of the wall, the artery was either cannulated directly or via an 8-mm prosthetic Dacron graft. RESULTS: Direct cannulation was performed in 46 patients (66 %) and cannulation via graft in the remaining 24 patients (34 %). The complication rate associated with axillary artery cannulation was 3.8 %. These two patients developed retrograde type A dissection and further dissection into the descending aorta caused by forceful insertion of a 20-French cannula in a very elastic and small artery. CONCLUSIONS: Cannulation of the axillary artery is an attractive approach with a wide indication spectrum. However, the decision to cannulate directly or via graft should be based on the diameter and elasticity of the vessel, to minimize the complications of vascular injury and subsequent dissection.