主动脉弓部手术75例

目的 总结主动脉弓部手术的方法和临床经验。方法75例弓部手术中74例采用深低温停循环（DHcA）技术，其中54例脑保护采用上腔静脉逆灌（RCP），20例采用右腋动脉顺灌（SCP）；仅1例在中度低温体外循环下行局部切除吻合。升主动脉和半弓置换53例，其中同期行降主动脉腔内支架植入术11例，弓部内膜破口修补6例，降主动脉近端内膜破口修补3例；升主动脉和全弓置换20例，其中同期行传统象鼻手术12例，降主动脉腔内支架植入4例；单纯弓部瘤切除缝合及弓部置换各1例。同期手术包括17例Bentall手术，12例AVR，3例Cabrol手术，5例二尖瓣成形术，9例主动脉瓣悬吊成形术等。DHCA9～120min，平均42．3min。结果手术死亡5例，死亡率6．7％。主要并发症为呼吸功能不全11例，肾功能不全7例，一过性精神异常9例。结论DHCA＋RCP及DHCA＋SCP技术均是主动脉弓部手术的有效方法，但后者更适用于复杂的弓部手术；手术范围和方式取决于病变性质和范围，术前状况和手术技术是影响手术效果的决定因素。     

再次及多次主动脉瘤手术的临床分析

目的：总结13例共27次主动脉瘤手术的经验。方法：全组13例中男8例,女5例,2次手术者12例,3次手术1例,再次手术距前次手术平均50个月（22d-233个月）,首次手术分别是：主动脉根部置换7例,慢性B型夹层行胸降主动脉人工血管置换3例,肾动脉下方腹主动脉瘤切除人工血管置换1例,急性A型夹层行主动脉瓣及升主动脉成形,川崎病行升主动脉人工血管置换和左冠状动脉前降支成形各1例,再次手术分别是因残余夹层扩大行全弓置换加ElephantTrunk1例,胸降主动脉置换2例,2例再发弓部夹层,1例行根部置换＋部分弓部置换,1例行升弓部置换;2例胸降主动脉瘤,1例胸腹主动脉瘤,1例B型夹层,常温阻断下行人工血管置换术,1例根部瘤在中低温体外循环下行根部置换术,川崎病再发无名动脉和弓部动脉瘤行无名动脉及部分弓置换1例,1例A型夹层升主动脉及主动脉瓣成形术后感染性假性动脉瘤形成,1例再发升主动脉瘤行升主动脉置换;1例根部置换再行弓降部置换术后,再发弓部动脉瘤,第3次手术行全弓置换,再手术时采用深低温停循环8例,常温阻断4例,中低温体外循环2例。结果：术后4例出现脑部并发症,1例肝功能异常,均治愈,无住院死亡。随访远期死亡3例,另有2例随访6个月和70个月,现待手术。结论：再次手术以再发或多发动脉瘤（包括主动脉夹层）为最常见原因,其次是残余夹层进一步发展,再次手术一定要积极,以免延误手术时机导致死亡。应根据再次手术的部位选择基本方法,累及弓部需深低温停循环并选择性脑灌注,远弓部和胸,腹主动脉可用常温阻断或股一股转流,如无法游离阻断则需要深低温停循环,累及根部则只需要一般体外循环,大出血和昏迷是再次手术最危险的并发症,尽早建立体外循环,低温和停循环期间的脑灌注可有效预防这类并发症。     

Stanford A型主动脉夹层的外科治疗

目的总结A型主动脉夹层的外科治疗经验。方法回顾分析手术治疗68例StanfordA型主动脉夹层患者的临床资料。其中急性主动脉夹层45例,慢性主动脉夹层23例。采用中低温体外循环53例,深低温停循环(DHCA)和上腔静脉逆行灌注脑保护11例,DHCA加选择性脑灌注4例。急诊手术39例(其中紧急手术19例),择期手术29例。术式为升主动脉置换术7例,升主动脉加右半弓置换术6例,升主动脉加全弓置换术3例,升主动脉加全弓置换加术中支架置入术4例,Bentall手术34例,改良的Wheat术12例,同时行主动脉瓣成形术2例、二尖瓣成形1例。结果全组死亡5例(7%),其中急诊手术3例,急诊手术病死率8%(3/39);择期手术2例,择期手术病死率7%(2/29)。共随访58例,随访率92%(58/63),随访时间(37±22)个月(5~77个月),死亡4例,累积1,3和5年的生存率分别是100%,95%和86%。结论StanfordA型夹层的手术方式应根据内膜破口位置决定,正确的手术指征、技巧和脑保护是手术成功的关键。     

Stanford A型主动脉夹层外科手术方法和疗效

目的探讨Stanfond A型主动脉夹层的手术方法，评价其疗效。方法回顾分析手术治疗108例Stanford A型主动脉夹层的临床资料，其中急诊手术53例，择期手术55例；深低温停循环（DHCA）下手术85例。手术包括升主动脉和半弓部置换或全弓置换（附加降主动脉支架人工血管置入术）以及“象鼻”手术；同期行弓部或降主动脉近端破口修补术、Bentall手术、主动脉瓣置换手术、Cabrol或改良Cabrol手术、主动脉瓣悬吊成形术、二尖瓣成形或二尖瓣置换术、三尖瓣环缩成形术和冠状动脉旁路移植术。结果住院死亡7例（6．5％），其中急诊手术死亡4例（7．5％），择期手术死亡3例（5．4％）。101例出院，96例随访1个月-13．3年，平均（3．2±1．3）年，晚期死亡2例，再次手术3例。结论Stanford A型的手术方法依病变部位不同而不同，准确掌握手术适应证，完善手术技术，加强术后处理，可以取得更好的手术效果。     

主动脉夹层的外科治疗

目的总结84例主动脉夹层患者的外科治疗经验,探讨手术技巧和围术期处理,以提高手术疗效。方法50例Stanford A型主动脉夹层患者在体外循环下（11例采用深低温停循环技术）行Bentall手术或Cabrol手术24例,升主动脉人工血管置换术8例,Trusler手术5例,Wheat手术5例,升主动脉＋主动脉全弓或半弓人工血管置换术8例;34例Stanford B型主动脉夹层采用带膜支架主动脉腔内修复术治疗。结果住院死亡11例,死亡率13．1％。术中死亡3例,其中1例升主动脉＋次全弓人工血管置换患者因术中主动脉开放后主动脉根部大出血无法止血;1例升主动脉部分切除＋人工血管置换患者心脏无法复跳;1例升主动脉＋半弓血管置换患者因降主动脉夹层破裂死亡。术后早期死亡8例,其中死于低心排血量综合征2例,肺部感染2例,肾功能衰竭2例,呼吸衰竭1例,永久性神经系统损害1例。术后发生并发症16例。随访62例（84．9％,62／73）,随访时间3个月～10年。随访期间死亡2例,其中1例死于心内膜炎,1例猝死（原因不明）。结论快速准确地诊断、个体化的手术方案和精确的手术技术是主动脉夹层手术成功的关键。     

35例DebakeyⅠ型主动脉夹层外科治疗体会

目的 总结Debakey Ⅰ型主动脉夹层外科治疗经验.方法 回顾分析手术治疗35例DebakeyⅠ型主动脉夹层患者的临床资料.均采用深低温停循环(DHCA)和有选择性的进行脑保护,急诊手术28例,择期手术7例.Bentall术加全弓置换加术中硬支架置入术23例,其中2例加行二尖瓣置换术,改良的Wheat术加全弓置换加术中硬支架置入术6例,升主动脉加全弓置换术加术中硬支架置入术6例.结果 全组患者手术死亡4例(11.4%),均为急诊手术死亡(14.3%).术后近期死亡1例(2.9%),术后CT随访9～33个月,夹层闭合良好,移植物通畅,无扭曲及移位.结论 对于Debakey Ⅰ型夹层患者应积极果断予以手术治疗,个体化的手术方法、操作技巧和脑保护措施是手术成功的关键.     

深低温停循环逆行脑灌注行胸主动脉瘤手术体会

20 0 1年 7月至 2 0 0 2年 4月 ,我们采用用深低温停循环(DHCA)辅以上腔静脉持续逆行脑灌注 (CRCP)方法 ,手术治疗 2例急性DeBakeyI型夹层动脉瘤 (DAA)和 1例急性钝性创伤性主动脉峡部破裂伴假性动脉瘤 (FA)病人 ,效果满意。现报道如下。临床资料　 2例DAA均为男性 ;年龄 32、4 4岁。急性胸痛入院 ;经CT、MRI确诊 ;单个内膜裂口 ,分别位于导管韧带旁、左锁骨下动脉旁 ;升主动脉直径 5 4cm、4 6cm ;超声心动图示主动脉瓣微量反流。 1例行升主动脉加半弓置换术 ,1例行升主动脉、全弓置换加“象鼻”术。1例FA为女性 ,38岁。车祸…     

胸主动脉夹层的外科治疗

目的总结胸主动脉夹层(AD)的外科治疗经验。方法1993年至2003年4月手术治疗A型AD40例，B型20例，其中急性夹层16例。A型采用中度低温体外循环13例，深低温停循环(DHCA)和上腔静脉逆灌(RCP)27例；行升主动脉置换24例，升主动脉和半弓置换11例，升主动脉、全弓和象鼻手术5例；同期行Bentall手术18例，主动脉瓣置换8例，冠状动脉旁路移植术1例。B型采用左心转流7例，股一股转流2例，DHCA 11例；行近端降主动脉置换14例，全胸降主动脉置换或伴肋间动脉移植6例。结果全组术后死亡率10％(急性夹层18．8％，慢性夹层6．8％)，近3年降至4．4％。术后并发呼吸功能不全8例，二次开胸止血3例，延迟性心包压塞和腹腔内出血各2例，声音嘶哑3例。结论正确掌握手术指征、手术技巧和术中脑保护是手术治疗AD的关键。A型夹层的手术范围应依据内膜破裂口位置决定。     

四分支人工血管置换术治疗主动脉弓部疾病

目的总结应用深低温停循环(DHCA)、顺行选择性脑灌注(ASCP)四分支人工血管置换术治疗主动脉弓部疾病的方法和经验。方法2004年9~12月,日本群马心血管病中心心血管外科应用四分支人工血管置换治疗主动脉弓部疾病12例,其中主动脉瘤7例(4例为升主动脉瘤累及主动脉弓部、3例为主动脉峡部瘤),主动脉夹层动脉瘤5例(DeBakey型1例、DeBakey型3例、DeBakey型1例)。在深低温停循环下应用球囊灌注管对3个头臂动脉行选择性脑灌注,用四分支人工血管行主动脉弓置换;其中Bentall手术加主动脉弓部/右半弓置换各1例,全弓部置换3例,右半弓置换3例,弓降部置换4例;12例手术中2例行象鼻手术。结果全组12例患者恢复良好,无脑部及其它系统并发症发生。手术时间5.5±1.7h,术中深低温停循环时间42.2±12.9min;术中4例未输血;术后住院时间22.3±7.2d。结论顺行选择性脑灌注对脑保护安全可靠,应用四分支人工血管置换术治疗主动脉弓部疾病可缩短深低温停循环的时间,降低弓部置换手术的复杂程度。     

A型主动脉夹层动脉瘤的外科治疗

目的　总结 1996年 1月至 2 0 0 2年 8月收治的 34例 A型主动脉夹层动脉瘤的外科治疗经验。　方法　应用 Bentall手术 19例 ,升主动脉人工血管置换术 7例 ,升主动脉人工血管置换加主动脉瓣成形术 (Trusler's法 )5例 ,分别行升主动脉人工血管置换及主动脉瓣置换术 (Wheat术 ) 2例 ,升主动脉、主动脉弓人工血管置换术 1例。结果　手术死亡 6例 ,死亡率 17.6 %。其中慢性主动脉夹层动脉瘤死亡 3例 ,急性夹层动脉瘤死亡 3例。随访 2 0例 ,随访率 71.4 %。随访时间 2～ 4 6个月 ,平均 2 4 .7个月 ,1例术后 3个月猝死 (原因不明 ) ,1例术后 6个月死于心内膜炎。18例存活患者情况良好。　结论　应根据夹层动脉瘤的部位及范围采用不同的手术方式 ,保留主动脉瓣的升主动脉人工血管置换术治疗该病效果较好 ,准确可靠的吻合技术、保留瘤壁的完整性 ,将使手术更为安全。     

经上腔静脉逆行灌注脑保护在主动脉瘤手术中的应用

目的　探讨在主动脉瘤手术中应用经上腔静脉逆行灌注的脑保护效果。　方法　 65例主动脉瘤患者分 2组 ,15例采用深低温停循环 (DHCA) ,5 0例经上腔静脉逆行灌注 (RCP)进行脑保护。术中比较 2组患者不同时间颈内静脉的血乳酸含量 ,对部分RCP患者测定了灌注血和回流血的流量分布 ,以及灌注血和回流血的氧含量。　结果　DHCA组停循环时间为 10 0～ 63 0min ,平均(3 5 9± 18 8)min ;RCP组为 16 0～ 81 0min ,平均 (45 5± 17 2 )min。术后至清醒时间DHCA组为4 4～ 9 4h ,平均 (7 1± 1 6)h ;RCP组 2 0～ 9 0h ,平均 (5 4± 2 2 )h。DHCA组手术死亡 3例 ,RCP组死亡 1例 ;术后神经系统并发症DHCA组 3例 (死亡 2例 ,成活 1例 ) ,RCP组 1例 (存活 )。手术总成功率和神经系统并发症发生率RCP组分别为 96%和 2 % ,DHCA组为 67%和 2 0 % (P <0 0 5 )。RCP组再灌注期间颈内静脉血乳酸含量增高幅度低于DHCA组 [(4 4± 0 6)mmol/Lvs (6 2± 0 9)mmol/L ,P <0 0 1],经头臂和下腔静脉血流量测定显示约 2 0 %血液经头臂动脉回流 ,灌注血和回流血氧差9 0 0～ 13 67ml/L ,证实RCP期间脑组织有氧利用。　结论　在主动脉瘤手术中 ,应用RCP可以延长停循环的安全时限 ,是可行的脑保护方法     

Clinical application of retrograde cerebral perfusion for brain protection during surgery of ascending aortic aneurysm--a report of 50 cases

This study was designed to discuss the effects on the brain by different protective methods in ascending aortic aneurysm surgery retrospectively. Two hundred seventy-one surgeries of ascending aortic aneurysm have been done in the past 15 years. There were 65 patients with a dissecting aneurysm of the aortic arch or right arch. To protect the brain, deep hypothermic circulatory arrest (DHCA) combined with retrograde cerebral perfusion (RCP) through superior vena cava (N = 50) and simple DHCA (N = 15) were used during the procedure. Blood samples for lactic acid level from the jugular vein were compared in both groups. Perfusion blood distribution and oxygen content difference between the perfused blood and returned blood were measured in 5 and 10 of RCP patients, respectively. The DHCA time was 35.86 +/- 18.81 min (10 approximately 63 min) and DHCA + RCP time was 45.5 +/- 17.21 min (16 approximately 81 min). The resuscitation time was 7.11 +/- 1.59 h (4.4 - 9.4 h) in DHCA versus 5.43 +/- 2.15 h (2 approximately 9 h) in RCP patients. The operation death rate was 3/15 in DHCA group and 1/50 in RCP patients. Central nervous complication occurred in 3/12 of DHCA patients and 1/49 of RCP patients (p < .01). The overall survival rate was 96% (RCP) versus 67% (DHCA); the central nervous system dysfunction was 20% in DHCA versus 2% in RCP (p < .001). The blood lactic acid level increased significantly after reperfusion in DHCA than that in RCP. The measurement of blood distribution indicated that approximately 2Q% of the perfused blood returned from arch vessels. The difference of oxygen content between perfused and returned blood showed that the oxygen uptake was adequate in RCP group. The application of RCP can prolong the safety duration of circulation arrest. Continuous cerebral perfusion may maintain the brain at a cooler temperature and flush out particulate and air emboli while open anastomosis of the aortic arch to the prosthesis can be safely performed. Therefore, RCP is a preferable method for brain protection in our clinical practices.     

升主动脉瘤的外科治疗

目的探讨升主动脉瘤治疗经验。方法Marfan’s综合征12例，其中6例合并二尖瓣关闭不全。升主动脉夹层动脉瘤伴主动脉瓣关闭不全6例，升主动脉瘤合并主动脉瓣、二尖瓣关闭不全2例，单纯升主动脉瘤5例，行Bentall手术12例，Cabrol手术3例，Wheat手术5例；单纯升主动脉替换术5例。结果全组无手术死亡。结论Bentall手术是外科治疗升主动脉瘤的主要术式。早期诊断、早期手术是改善升主动脉瘤患者疗效的关键。     

胸主动脉瘤合并冠心病同期外科治疗(附15例报告)

目的 总结胸主动脉手术同期行冠状动脉旁路移植术的经验。方法1999年6月至2002年7月，胸主动脉瘤手术同期行冠状动脉旁路移植术15例，均为男性；年龄40～66岁，平均57．2岁；体重60～89kg，平均70．2kg。病种包括主动脉根部瘤5例、升主动脉瘤2例、弓部瘤3例、主动脉夹层5例。经胸骨正中切口在全麻低温体外循环下手术14例；左外侧切口非体外循环下冠状动脉旁路移植同期股股转流降主动脉置换术1例。结果术后早期30d内死亡1例，随访1～36个月，无远期死亡，无再次手术及冠心病相关事件发生。结论胸主动脉置换术与冠状动脉旁路移植术能够安全同期进行，同期冠心病的再血管化对预防冠心病相关事件的发生有积极作用。     

Hypothermic circulatory arrest does not increase the risk of ascending thoracic aortic aneurysm resection.

OBJECTIVE: The purpose of this study was to investigate the safety and efficacy of a period of deep hypothermic circulatory arrest (DHCA) during elective replacement of the ascending thoracic aorta. SUMMARY BACKGROUND DATA: DHCA has been implemented in ascending thoracic aortic aneurysm resection whenever the anatomy or pathology of the aorta or arch vessels prevents safe or adequate cross-clamping. Profound hypothermia and retrograde cerebral perfusion have been shown to be neurologically protective during ascending aortic replacement under circulatory arrest. METHODS: The authors conducted a retrospective analysis of 91 consecutive patients who underwent repair of chronic ascending thoracic aortic aneurysms from 1986 to present. The authors hypothesized that patients undergoing DHCA with or without retrograde cerebral perfusion during aneurysm repair were at no greater operative risk than patients who received aneurysm resection while on standard cardiopulmonary bypass. RESULTS: There were no significant differences in hospital mortality, stroke rate, or operative morbidity between patients repaired on DHCA when compared to those repaired on cardiopulmonary bypass. CONCLUSIONS: DHCA with or without retrograde cerebral perfusion does not result in increased morbidity or mortality during the resection of ascending thoracic aortic aneurysms. In fact, this technique may prevent damage to the arch vessels in select cases and avoid the possible complications associated with cross-clamping a friable or atherosclerotic aorta.     

Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch

Sixty-seven operations were performed in 59 patients for aneurysmal disease occurring after previous operations involving the ascending aorta and transverse aortic arch. The initial aortic pathological condition included the following: fusiform aneurysm due to medial degenerative disease in 34 patients, 12 of whom had Marfan's syndrome; aortic dissection in a previously undilated aorta in 23; and aneurysm persisting or occurring after brachiocephalic bypass in 2. One of the latter had an aneurysm because of aortitis. Various operations initially performed did not completely treat the disease, and certain complications occurred spontaneously, including infection and dissection. The residual pathological condition led to the development of aortic insufficiency, aortic dissection, coronary artery insufficiency, and progressive aneurysmal dilatation. These complications were treated by composite valve graft replacement of the aortic valve and ascending aorta or the transverse aortic arch or both, simple aortic valve replacement, graft replacement of the ascending aorta or arch or both, and suture of false aneurysm with viable tissue wrap. Twenty patients (34%) had an aneurysm of the distal aorta. The entire aorta was replaced in 3, thoracoabdominal segments in 9, and the abdominal aorta in 1. Of the 59 patients, 49 (83%) were early survivors and 40 (68%) were alive on January 1, 1985. Principles of therapy that may have prevented the complications leading to reoperation include aneurysm replacement at the time of aortic valve replacement and coronary artery bypass; total replacement of the ascending aorta and aortic valve in patients with Marfan's syndrome; the same procedure or aortic valve replacement and separate graft replacement in patients with non-Marfan's medial degenerative disease; ascending aortic replacement in all patients with dissection combined with valve resuspension, aortic valve replacement, or composite valve graft depending on the involvement of the aortic sinuses and the presence of aortic insufficiency.