深低温停循环主动脉弓手术术后急性肾损伤的危险因素

目的 目的分析深低温停循环主动脉弓手术术后急性肾损伤(acute kidney injury,AKI)的危险因素.方法 回顾2005年1月至2011年6月549例行深低温停循环主动脉弓部手术患者的资料,按照术后是否发生AKI分为两组进行单因素分析,单因素分析差异有统计学意义的logistic回归多因素分析.结果 术后102例(18.6％)患者发生AKI,27例(4.9％)行透析治疗.Logistic回归多因素分析显示,体质量指数(BMI)(OR=1.072,95％ CI:1.006 ～1.141,P=0.031)、术前血清肌酐(OR=1.011,95％ CI:1.006 ～1.017,P=0.000)、体外循环(CPB)时间(OR=1.006,95％ CI:1.002 ～1.009,P=0.005)和术中血糖峰值(OR=1.007,95％CI:1.002 ～ 1.011,P=0.003)是AKI发生的独立危险因素.结论 患者术前BMI、血清肌酐高预示术后较高的AKI发生率,术中减少CPB时间和积极控制血糖水平可降低AKI的发生.     

深低温停循环主动脉夹层手术后高胆红素血症的危险因素分析

目的研究深低温停循环(deep hypothermic circulatory arrest,DHCA)主动脉夹层手术后高胆红素血症的危险因素。方法回顾性分析青岛大学附属医院177例DHCA下Stanford A型夹层手术患者资料,男126例,女51例,年龄≥18岁,ASA均为Ⅳ级。将患者分为两组:高胆红素血症组(HB组,n=96),血浆总胆红素(total bilirubin,TBIL)51.3μmol/L;正常组(N组,n=81),TBIL≤51.3μmol/L。采用Logistic回归分析高胆红素血症的危险因素。结果术后高胆红素血症发生率为54.2%。阻断时间(OR=1.026,95%CI 1.005～1.048,P=0.017),术中输红细胞(OR=1.192,95%CI 1.032～1.378,P=0.017),术前TBIL(OR=1.098,95%CI 1.038～1.161,P=0.001)是DHCA主动脉夹层手术后高胆红素血症的独立危险因素。采用ROC曲线分析显示,阻断时间、术中输红细胞、术前TBIL的临界值分别为93.5min、3.0U、21.3μmol/L。HB组术后输注血浆量明显多于N组(P0.05)。HB组存活率明显低于N组(81.3%vs 92.6%,P=0.03)。结论DHCA主动脉夹层手术后高胆红素血症的发生率较高,预后较差。阻断时间93.5min、术中输注红细胞3.0U、术前TBIL21.3μmol/L是高胆红素血症发生的危险因素。     

Aortic balloon occlusion technique versus moderate hypothermic circulatory arrest with antegrade cerebral perfusion in total arch replacement and frozen elephant trunk for acute type A aortic dissection

BackgroundModerate hypothermic circulatory arrest (MHCA) with antegrade cerebral perfusion (ACP) is safe and efficient in total arch replacement (TAR) and frozen elephant trunk (FET) for acute type A aortic dissection (ATAAD). Complications related to hypothermia and ischemia are inevitable, however. The aortic balloon occlusion (ABO) technique is performed to elevate the lowest nasopharyngeal temperature to 28°C and shorten the circulatory arrest time. In this study, we aimed to evaluate the efficacy of this new technique.MethodsWe reviewed the clinical data of patients with ATAAD who underwent TAR and FET, including 79 who underwent ABO and 109 who underwent MHCA/ACP.ResultsCirculatory arrest time was significantly lower in the ABO group compared with the MHCA/ACP group (mean, 4.8 ± 1.2 minutes vs 18.4 ± 3.1 minutes; P < .001). The composite endpoint was comparable in the 2 groups (11.4% for ABO vs 13.8% for MHCA/ACP; P = .631). Fewer patients in the ABO group developed high-grade acute kidney injury (AKI) according to a modified RIFLE criterion (22.8% vs 36.7%; P = .041), and the rate of hepatic dysfunction was lower in the ABO group (11.4% vs 28.4%; P = .005). Multivariable logistic analysis showed that the ABO technique is protective against duration of ventilation >24 hours (odds ratio [OR], 0.455; 95% confidence interval [CI], 0.234-0.887; P = .021), hepatic dysfunction (OR, 0.218; 95% CI, 0.084-0.561; P = .002), and grade II-III AKI (OR, 0.432; 95% CI, 0.204-0.915; P = .028).ConclusionsThe ABO technique significantly shortens the circulatory arrest time in TAR and FET. Available clinical data suggest that it has a certain protective effect on the liver and kidney. Future large-sample studies are warranted to thoroughly evaluate this new technique.     

Crawford type II thoracoabdominal aortic aneurysm repair using deep hypothermic circulatory arrest and continuous proximal aortic perfusion

We successfully operated a patient with Crawford type II dissecting thoracoabdominal aortic aneurysm using deep hypothermic circulatory arrest and continuous proximal aortic perfusion. A 70-year-old male who had a history of chronic Stanford type B aortic dissection treated by Y-graft replacement of the abdominal aorta 2 years ago underwent dissecting thoracoabdominal aotic aneurysm repair due to expansion of the aneurysm. A preoperative examination revealed 90% stenosis in his coronary system. We used deep hypothermic circulatory arrest (bladder temperature: 22 degrees C) and continuous proximal aortic perfusion as adjuncts to prevent organ malperfusion (including the coronary arteries) or embolism because sequential aortic clamping seemed impossible and the true lumen became narrowed. To minimize the duration of the extracorporeal circulation (ECC), visceral branches were reattached using a selective shunt after conclusion of ECC. The duration of aortic cross-clamping, ECC, and operation was 170, 302, and 1,020 minutes, respectively. The patient required mechanical ventilation for 12 days but survived the operation and was discharged after 42 days hospitalization without any neurologic sequela. A perioperative intensive treatment must be required to prevent morbidities related to extensive thoracoabdominal aortic aneurysm repair.     

Short-term outcomes of a simple and effective approach to aortic root and arch repair in acute type A aortic dissection

Objective

To evaluate short-term outcomes following direct aortic root and arch repair in patients with acute type A aortic dissection (ATAAD) without technical adjuncts.

Normothermic total arch replacement without hypothermic circulatory arrest to treat aortic distal arch aneurysm in a patient with cold agglutinin disease

Cold agglutinin disease although rare, can lead to serious complications for patients undergoing cardio-thoracic surgery, especially when cardiopulmonary bypass is applied under hypothermic circulatory arrest. We describe normothermic total arch replacement without hypothermic circulatory arrest in a patient with cold agglutinin disease. The patient tolerated all procedures well and did not develop cerebral ischemia due to surgical maneuvers or thrombotic or haemolytic complications due to cold agglutinin disease. Although endovascular aortic repair is the first choice under such complex conditions, this method could also serve as an alternative strategy when endovascular aortic repair is precluded.     

改良全主动脉弓置换治疗老年Stanford A型主动脉夹层

目的总结改良全主动脉弓置换治疗老年Stanford A型主动脉夹层的临床经验,并探讨其疗效。方法 39例老年Stanford A型主动脉夹层患者在深低温停循环、双侧顺行脑灌注下行外科手术。根部处理根据不同病变情况,选择不同术式,包括单纯升主动脉置换、Bentall、Wheat手术。主动脉弓部采用四分支血管行全主动脉弓置换,降主动脉内置入硬象鼻支架,并行支架开窗,完成左锁骨下动脉重建。结果全组平均体外循环时间为(180.49±30.46)min,平均停循环时间(27.22±10.58)min,平均脑灌注时间(32.42±12.36)min,平均心肌阻断时间(94.84±24.83)min。升主动脉置换17例,Wheat手术10例,Bentall手术12例。全组无术中死亡,术后住院死亡2例,脑梗塞1例,短暂性神经功能障碍3例,行肾脏透析治疗3例。全组无出血再次开胸、声音嘶哑、左上肢感觉运动功能障碍等情况。术后复查主动脉CTA弓部分支血管血流通畅,象鼻支架无内漏。无术后死亡及二次手术者。结论选择合适的手术时机及手术方式,老年Stanford A型主动脉夹层患者仍能获得满意的外科手术效果。     

深低温停循环主动脉弓部手术后苏醒延迟危险因素分析

目的 探讨在深低温停循环(deep hypothermic circulatory arrest,DHCA)选择性脑灌注(antegrade selective cerebral perfusion,ASCP)下行主动脉弓部手术后发生苏醒延迟的危险因素. 方法 回顾性分析2006年10月至2013年6月期间南京市鼓楼医院97例行主动脉弓部手术患者的临床资料.97例患者分为两组:正常组(46例),男37例,女9例,平均年龄(48±11)岁;苏醒延迟组(51例),男40例,女11例,平均年龄(52±11)岁.观察两组患者的临床资料,采用单因素方差分析和Logistic多因素回归分析导致患者术后发生苏醒延迟的危险因素. 结果 97例患者中术后发生苏醒延迟51例(52.58％),其中11例患者(11.34％)术后一直未醒,住院死亡20例(20.62％).单因素分析结果显示:年龄(P=0.047)、高血压病史(P=0.005)、急诊手术(P=0.031)、体外循环(cardiopulmonary bypass,CPB)时间(P=0.017)、心肌阻断时间(P=0.021)、输血(P=0.001)是DHCAASCP术后发生苏醒延迟的危险因素.Logistic回归分析结果显示:急诊手术(P=0.005)、CPB时间＞240 min(P＜0.001)是导致DHCA ASCP术后发生苏醒延迟的独立危险因素. 结论 主动脉弓部手术后发生苏醒延迟是多因素共同作用的结果.     

Atrial fibrillation after aortic arch repair requiring deep hypothermic circulatory arrest: incidence, clinical outcome, and clinical predictors

OBJECTIVE: To delineate the incidence, outcome impact, and clinical predictors of atrial fibrillation (AF) after adult aortic arch repair requiring deep hypothermic circulatory arrest (AAR-DHCA) AIMS: To determine the incidence of AF after AAR-DHCA, to determine whether AF after AAR-DHCA affects mortality or stay in the intensive care unit (ICU), to determine multivariate predictors for AF after AAR-DHCA, and to determine whether aprotinin protects against AF after AAR-DHCA. STUDY DESIGN: Retrospective and observational. STUDY SETTING: Single large university hospital. PARTICIPANTS: All adults undergoing AAR-DHCA in 2000 and 2001. MAIN RESULTS: The cohort size was 144. Antifibrinolytic exposure was 100%, aprotinin 66% and aminocaproic acid 34%. The incidence of AF was 34.0%. AF was not significantly associated with increased mortality or prolonged ICU stay. Advanced age was a multivariate risk factor for AF. Lower temperature nadir during DHCA was protective against postoperative AF. Aprotinin had no demonstrable effect on AF after AAR-DHCA. CONCLUSIONS: AF after AAR-DHCA is common but does not independently increase mortality or ICU stay. The risk of AF after AAR-DHCA increases with age but decreases with the degree of hypothermia during DHCA. Aprotinin does not appear to affect the risk of AF after AAR-DHCA.     

深低温停循环下升主动脉全弓置换联合降主动脉远端支架“象鼻”植入术的护理配合

目的提供深低温停循环下升主动脉全弓置换联合降主动脉远端支架"象鼻"植术的护理配合程序和护理经验。方法选择我院2013年5月至2016年12月收治Stanford A型主动脉夹层患者38例,均成功实施深低温停循环下升主动脉全弓置换联合降主动脉远端支架象鼻手术,对其手术的护理配合进行总结分析。结果全组38例患者均手术成功,出院后随访2~27个月,患者生存良好。结论加强Stanford A型主动脉夹层的手术配合有利于减少手术风险。     

Long-term results of aortic arch replacement using combination of deep hypothermic circulatory arrest and retrograde cerebral perfusion; comparison of result for atherosclerotic aneurysm and aortic dissection

Between 1992 and 2001, 73 patients with aortic arch lesion underwent surgical treatment. The aneurysm was characterized by atherosclerosis in 54 patients (TAA) and by aortic dissection in 19 patients (DAA). All patients received graft replacement under combination of deep hypothermic circulatory arrest and retrograde cerebral perfusion. The hospital mortality rate for all patients was 15.6%. The follow-up period of 61 survival patients ranged from 2 to 90 months (mean 33.2 months). The actuarial survival rate was 93.2%, 83.5%, and 79.7% at 1, 3, and 5 years, respectively. No significant difference was noted between TAA and DAA in the actuarial survival rate. The freedom from vascular complication was 97.9%, 95.8%, and 95.8% at 1, 3, and 5 years, respectively. The rate was significant higher in the patients of DAA than in those of TAA (TAA: 100%, 100%, and 100%, DAA: 90.9%, 81.8%, and 81.8%). The freedom from cardiac complication was 96.4%, 89.7%, and 84.1% at 1, 3, and 5 years, respectively. There was no significant difference between TAA and DAA. The freedom from cerebrovascular complication was 100%, 97.6%, and 83.4% at 1, 3, and 5 years, respectively. No significant difference was noted between TAA and DAA. The late result of surgical treatment for the aortic arch using combination of deep hypothermic circulatory arrest and retrograde cerebral perfusion was satisfied. The long-term survival rate was higher in TAA patient than in DAA one. The possibility remained that fatal vascular complication affected the long-term survival rate.     

急性Stanford A型主动脉夹层弓部病变处理决策

目的 总结急性Stanford A型主动脉夹层弓部处理的临床经验,探讨选择手术时机、确定治疗方案和手术方式的重要性.方法 2005年8月至2010年8月对210例急性Stanford A型主动脉夹层行弓部替换手术治疗.手术方式采用深低温停循环及顺行性脑灌注,半弓替换+支架象鼻手术92例;次全弓替换+支架象鼻手术50例;全弓替换+支架象鼻手术68例.术后随访,胸腹主动脉CT观察降主动脉假腔闭合情况.结果 全组体外循环(146±52)min,主动脉阻断(93±25)min,深低温停循环(35±14)min.主动脉弓部手术围手术期死亡10例(4.8%).术后18例(8.6%)发生并发症,主要包括急性肾功能不全、神经系统并发症、纵隔感染及急性呼吸功能衰竭.术后随访2～60个月,平均(27±18)个月.随访过程中无死亡,再次入院行降主动脉替换术1例.增强CT检查结果显示支架远端胸降主动脉假腔闭合率为74%.结论 主动脉弓部处理是急性Stanford A型主动脉夹层治疗的重要手段.正确的决策对于提高手术的疗效有重要意义.

Abstract：

Objective Stanford type A acute aortic dissection is a life-threatening medical condition with high rates of morbidity and mortality that requires surgical repair, on an emergency basis. The extent of aortic arch repair that should be carried out during emergency surgery of this type is controversial. This study was conducted to report clinical experience on aortic arch repair and determine surgical indication, optimal operative procedures and strategy for Stanford type A acute aortic dissection. Methods 210 consecutive patients with acute Stanford A aortic dissection who underwent aortic arch replacement combined with implantation of stented elephant trunk into the descending aorta between August 2005 and August 2010. Surgical procedures included hemi-aortic arch replacement in 92 patients, subtotal aortic arch replacement in 50 patients and total aortic arch replacement in 68 patients. All operations were performed with the aid of deep hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP). Enhanced computed tomography scanning was performed to evaluate the postoperative outcomes, particularly the fate of the false lumen remaining in the descending thoracic aorta by aortic arch replacement combined with implantation of stented elephant trunk during follow up. Results Average cardiopulmonary bypass time was (146 ±52) min. The average cross clamp time was(93 ±25)min and average selective cerebral perfusion and circulatory arrest time was(35 ±14)min. The overall in-hospital mortality was 4. 8% (10/210) and morbidity was 8. 6% ( 18/210). Postoperative complications included acute renal failure, stroke, mediastinitis and respiratory insufficiency. During the follow-up period [mean (27 ± 18) months, ranged 2 to 60 months], 1 patient underwent reoperation due to the descending thoracic and abdominal aortic aneurysm. There was no late death. Follow-up enhanced CT scanning showed about 74% false lumens obliterated at the level of the distal border of the stent graft post operation. Conclusion Open aortic arch replacement is an effective approach and provides acceptable outcomes for type A acute aortic dissection. Optimal treatment strategy is the key factor to success in emergency surgical intervention.