经人工血管右腋动脉插管在升主动脉和弓部手术中的应用

目的介绍经人工血管右侧腋动脉插管进行体外循环和选择性顺行性脑灌注的方法。方法共30例患者经右侧腋动脉体外循环，其中累及主动脉弓部的急性StanfordA型夹层动脉瘤23例，合并弓部扩张的升主动脉瘤7例。在右侧锁骨中点下方做长约4～5cm切口，游离腋动脉而不游离臂丛神经和腋静脉，将直径8ram的人工血管与之端侧吻合并与动脉管连接。腋动脉插管用于体外循环，也用于选择性顺行性脑灌注。涉及主动脉弓部手术30例，其中采用经腋动脉顺行性脑灌注行全主动脉弓置换15例，深低温停循环下置换右半弓15例。体外循环结束时直接将人工血管结扎即可。结果患者全部康复出院，经腋动脉插管灌注流量和压力与经升主动脉插管无差异。术后无神经系统并发症发生，右上肢血压正常，未发生动脉损伤、栓塞以及上肢感觉、运动障碍等。结论经人工血管右侧腋动脉插管进行体外循环和选择性脑灌注，操作简单，安全可靠。     

右锁骨下动脉插管体外循环技术的临床应用

目的　探讨右锁骨下动脉插管体外循环技术在临床应用的价值。方法　在深低温、停循环时应用右锁骨下动脉插管的选择性脑灌注技术 ,手术治疗 70例累及主动脉弓的心血管疾病病人。结果　全组体外循环时间 5 2～ 32 8min ,平均 (12 9 18± 46 78)min ,脑部低流量灌注时间最长达 81min ,平均(2 8 0 6± 2 1 0 7)min ,术后病人 6h内全部清醒 ,无神经系统并发症。结论　停循环期间 ,采用右锁骨下动脉插管的选择性脑灌注方法进行脑保护简便、安全、有效。     

经右锁骨下动脉顺行选择性脑灌注技术的临床应用

我们采用经右锁骨下动脉插管深低温停循环(DHCA)行持续选择性脑灌注技术，手术治疗累及主动脉弓的胸主动脉瘤或主动脉夹层病人19例，均获得良好的临床效果。现总结报道如下。     

改良右腋动脉插管脑灌注在弓部主动脉夹层手术中的应用经验

顺行选择性脑灌注下行Standford A主动脉夹层手术已得到了广泛的应用.一般采用的方式是从右锁骨下作切口,分离右锁骨下动脉(有学者称为右腋动脉)进行插管,由于位置深,暴露不易,常需吻合一段人造血管再灌注,增加了操作的难度.我们采用经右腋下小切口穿刺插管进行灌注,方法简便,暴露好,节省了一部分手术时间.2002年11月至2007年6月我们采取右腋下小切口腋动脉插管对104例5tandford A主动脉夹层患者实施了主动脉弓部手术,现将经验总结报告如下.     

经右锁骨下动脉、右房插管兔体外循环及选择性脑灌注模型的建立

目的 建立体外循环及深低温停循环时选择性脑灌注兔模型。方法 选用大耳白兔２９只,经右锁骨下动脉及右房插管建立ＣＰＢ,鼻温２０℃时停循环或ＳＣＰ８０ｍｉｎ,监测血流动力学指标及血气变化。结果 在ＣＰＢ中动物血流动力学稳定,心脏自动复跳率较高,为７５．９％。自制微型氧合器氧合完全符合满意ＣＰＢ标准。结论 经右锁骨下动脉、右 插管兔体外循环及选择性脑灌注建立的模型安全、稳定、简单、实用,是进行深低温停循     

选择性脑灌注对深低温停循环下的脑保护作用

目的总结并分析39例急性DeBakey Ⅰ型主动脉夹层患者在深低温停循环期间选择性脑灌注对脑保护的效果。方法经右锁骨下动脉或升主动脉插灌注管,右心房插引流管建立体外循环。全身降温至鼻咽温28℃时阻断并切开升主动脉,左、右冠状动脉开口灌注冷血心脏停跳液15—20ml／kg,完成近心端处理。鼻咽温18℃,肛温20℃时停体外循环,头部戴冰帽,取20°-30°头低位,阻断主动脉弓三大分支,右锁骨下动脉脑灌注5例,无名动脉和左颈总动脉插管脑灌注34例,灌注流量5—8ml／（kg·min）。结果体外循环转流时间206～256min,平均（230±30）min;主动脉阻断时间95—155min,平均（118±23）min;选择性脑保护灌注时间39—59min,平均（53±14）min。手术死亡3例（7．69％）。一过性精神障碍2例（5．13％）。结论选择性脑灌注能显著降低深低温停循环手术的脑部并发症,有助于改善DeBakey Ⅰ型主动脉夹层患者的手术预后。     

腋动脉侧接人工血管插管法在深低温停循环手术中的应用

目的介绍腋动脉侧接人工血管插管法在深低温停循环手术中的应用,总结其经验。方法2006年1月至2008年12月,我们在36例A型主动脉夹层的患者中应用腋动脉侧接人工血管插管法建立体外循环中的动脉灌注;将右侧腋动脉游离,全身肝素化,前后阻断腋动脉,于腋动脉前壁作一长约8～10mm切口,用一直径8～10mm、长约6～8cm的人工血管与腋动脉行端侧吻合,侧接人工血管与普通升主动脉插管连接。结果施行腋动脉侧接人工血管顺利,成功率为100%,体外循环及选择性脑灌注满意。无腋动脉插管的相关并发症发生,除2例苏醒延迟外,其余均无神经系统并发症。手术死亡3例,死亡原因与腋动脉侧接人工血管插管无关。结论腋动脉侧接人工血管插管法作为心脏大血管深低温停循环手术中建立体外循环的动脉灌注及选择性脑灌注,其方法简单、疗效可靠、无插管相关并发症,值得临床应用。     

急性复杂型Stanford A型主动脉夹层的外科治疗

目的：评价急性复杂型Stanford A 型主动脉夹层手术中改良双侧选择性顺行脑保护的效果及升主动脉插管、左锁骨下动脉（LSA）“开窗”技术对手术风险的影响。方法122例急性复杂型Stanford A 型主动脉夹层患者行改良全主动脉弓置换加降主动脉内支架象鼻植入术,按照脑保护及动脉供血管插管方式分为单侧脑保护组与改良双侧脑保护组及右锁骨下动脉（RSA）插管组与主动脉插管组,比较各组的手术方式、死亡率及并发症率。部分患者采用左锁骨下动脉“开窗”技术重建血运。结果单侧脑保护组与改良双侧脑保护组总的院内死亡率分别为5．77％、2．86％,差异无统计学意义（P值为0．650）;神经系统总并发症率分别为26．92％、10．00％,差异有统计学意义（P值为0．014）。右锁骨下动脉插管组与升主动脉插管组总的院内死亡率均为4．55％,总并发症率分别为15．9％、15．2％,差异均无统计学意义（P值分别为1、0．914）。左锁骨下动脉“开窗”者术后多次复查CTA左锁骨下动脉均通畅,无左锁骨下盗血综合征发生,1例出现无需处理的少量内漏。结论改良双侧选择性顺行脑保护安全、可行、可靠;选择升主动脉插管符合生理、操作简捷,不增加手术风险;左锁骨下动脉“开窗术”简化了手术,缩短了深低温停循环时间,增加了手术安全性。     

主动脉弓部动脉瘤术中灌注效果的监测与评估

目的研究主动脉弓部动脉瘤术中单泵双管灌注期间的血液灌注状况。方法回顾性分析2012年9月至2014年4月我院实施主动脉弓全弓置换手术37例患者的临床资料,其中女9例、男28例,年龄19.0~72.0(48.1±10.8)岁。患者术中体外循环均采用单泵双管灌注,采用血流检测仪进行上、下半身灌注管路流量监测,经颅多普勒超声和脑血氧饱和度(rSO_2)监测装置实时监测脑组织内的灌注状况。结果 37例患者总体体外循环(CPB)时间为136.0~277.0(195.8±40.5)min,停循环选择性脑灌注时间为5.0~35.0(21.6±5.6)min。降、复温阶段腋动脉插管流量约占全身灌注管路灌注流量的31.5%~40.8%。2例患者停循环期间rSO_2监测和大脑中动脉血流显著低于术前,提高灌注流量至15.0 ml/(kg·min)后监测指标恢复,患者顺利康复;2例类似病例未处理,术后1例死亡,1例有脊髓并发症。结论主动脉弓部动脉瘤术中体外循环单泵双管灌注技术合理有效,脑灌注监测有助于发现术中灌注异常。     

不同腋动脉插管方法在StanfordA型主动脉夹层手术中的应用

目的比较两种不同右侧腋动脉插管方法对Stanford A型主动脉夹层患者行主动脉弓置换术的安全性和临床效果。方法 2008年7月至2010年7月北京安贞医院对280例Stanford A型主动脉夹层患者采用右侧腋动脉插管建立体外循环(CPB),行全弓置换+降主动脉支架人工血管植入术。根据术中腋动脉插管方式将280例患者分为两组,直接插管组(n=215),年龄(43.1±9.5)岁,行直接腋动脉插管;间接插管组(n=65),年龄(44.7±8.3)岁,腋动脉连接人工血管行间接插管。观察两组患者的安全性,比较相关手术参数、临床结果和术后恢复情况。结果住院死亡10例,其中直接插管组7例(7/215,3.3%),间接插管组3例(3/65,4.6%);所有患者均成功行腋动脉插管;术后25例(25/280,8.9%)出现暂时性神经系统功能障碍,其中直接插管组19例(8.8%),间接插管组6例(9.2%),均经治疗痊愈。间接插管组患者术后腋动脉插管并发症明显少于直接插管组,差异有统计学意义((1例vs.19例,P=0.045)。两组患者体外循环期间最高流量、最高泵压,深低温停循环时间、顺行性脑灌注时间和CPB时间差异均无统计学意义(P0.05)。结论经人工血管右侧腋动脉插管可以降低腋动脉插管相关并发症,安全用于Stanford A型主动脉夹层患者的外科手术治疗。     

Extrathoracic cannulation of the left common carotid artery in thoracic aorta operations through a left thoracotomy: preliminary experience in 26 patients

BACKGROUND: In aortic operations performed through a left thoracotomy, which require total bypass and deep hypothermic circulatory arrest, femoral artery cannulation is commonly used for arterial perfusion. This route limits the time of safe circulatory arrest and is associated with the risks of retrograde embolization or, in the case of aortic dissection, malperfusion of the vital organs. To overcome these problems, we have used cannulation of the extrathoracic left common carotid artery to ensure a central a route of arterial perfusion in these operations. The preliminary results are presented. METHODS: Between December 1999 and April 2001, we used left common carotid artery cannulation in 26 operations on the thoracic aorta performed through a posterolateral thoracotomy with an open technique during deep hypothermic circulatory arrest. Institutional review board approval and informed consent were obtained. The indications included perforating atherosclerotic ulcer (n = 5), chronic aortic aneurysm (n = 9), acute type B aortic dissection (n = 3), and chronic dissection of the thoracic aorta (n = 9). Transcranial Doppler ultrasonographic monitoring of both the right and left middle cerebral arteries was used to assess the adequacy of cerebral bihemispheric perfusion and to determine the differences in blood flow velocities throughout the procedure. RESULTS: Left common carotid artery cannulation was successful in all patients. All patients awoke from the operation, and none had cerebrovascular accidents. None died in the hospital, and complications related to carotid artery cannulation were not observed. None of the patients experienced postoperative paraplegia. In all patients transcranial Doppler monitoring indicated the absence of cerebral embolic phenomena throughout the entire procedure. Significant differences in middle cerebral artery flow velocities were observed at different phases of the procedures and between the right and left middle cerebral arteries during carotid cannulation and during selective cerebral perfusion. Nevertheless, the maximal drop of right middle cerebral artery blood velocity during selective perfusion through the left common carotid artery was within 50% of the left middle cerebral artery velocity, indicating adequate bihemispheric perfusion. CONCLUSIONS: In patients undergoing aortic operations through a left thoracotomy, extrathoracic left common carotid artery cannulation was a safe and effective means of providing proximal arterial inflow during cardiopulmonary bypass, which can be used to selectively perfuse the brain, as well as to prevent embolic phenomena in the arch vessels.     

Advantages of subclavian artery perfusion for repair of acute type A dissection.

OBJECTIVE: Arterial perfusion through the right subclavian artery is proposed to avoid intraoperative malperfusion during repair of acute type A dissection. This study evaluated the clinical and neurological outcome of patients undergoing surgery of acute aortic type A dissection following subclavian arterial cannulation compared to femoral artery approach. METHODS: From 1/97 to 1/03, 122 consecutive patients underwent surgery for acute type A aortic dissection. Subclavian cannulation was performed in 62 versus femoral cannulation in 60 patients. Clinical characteristics in both groups were similar. Mean age was 61 years (SD+/-14 years, 72% male) and mean follow-up was 3 years (+/-2 years). Patient outcome was assessed as the prevalence of clinical complications, especially neurological deficits, mortality at 30 days, perioperative morbidity and time of body temperature cooling and analyzed by nominal logistic regression analysis for odds ratio calculation. RESULTS: Arterial subclavian cannulation was successfully performed without any occurrence of malperfusion in all cases. Patients undergoing subclavian cannulation showed an odds ratio of 1.98 (95% CI 1.15-3.51; P=0.0057) for an improved neurological outcome compared to patients undergoing femoral cannulation. Re-exploration rate for postoperative bleeding was significantly reduced in the subclavian group (P<0.0001), as well as occurrence of myocardial infarction (P<0.0001) and duration for body temperature cooling (P=0.004). The 30-day mortality of patients with femoral cannulation was significantly higher compared to patients with subclavian artery cannulation (24 versus 8%; P=0.0179). CONCLUSIONS: Arterial perfusion through the right subclavian artery provides an excellent approach for repair of acute type A dissection with optimized arterial perfusion body perfusion and allows for antegrade cerebral perfusion during circulatory arrest. The technique is safe and results in a significantly improved clinical and especially neurological outcome.     

人工四分支血管在主动脉外科的应用

目的总结应用人工四分支血管行不同部位主动脉替换术的经验。方法自2003年8月至2005年5月,我中心采用人工四分支血管行不同部位的主动脉替换术142例。男118例、女24例,年龄(44±12)岁(22~78岁),体重(72±20)kg(49~130kg)。其中:StanfordA型主动脉夹层94例(18例为马凡综合征);StanfordB型主动脉夹层34例(6例为马凡综合征),真性动脉瘤11例,假性动脉瘤3例。在深低温停循环选择性脑灌注下,行升主动脉及全弓替换85例(83例远端加带膜支架);分段停循环下,行全胸腹主动脉替换术38例;深低温选择性脑灌注分段停循环下,行全或次全主动脉替换8例;常温非体外循环下,行全主动脉弓替换11例(3例远端加带膜支架)。结果术后早期死亡6例,病死率4·2%。术后神经并发症,较严重,严重脑功能障碍(昏迷超过3d)16例(11·3%);永久性脊髓损伤2例(1·4%);一过性脊髓损伤4例(2·8%)。结论人工四分支血管可应用于主动脉外科,能达到尽可能的缩短主动脉阻断时间和快速重建血管的目的。     

Acute type A aortic dissection and coarctation of aortic isthmus

Acute type A aortic dissection and coarctation of the aorta is a rare associated disease. A case of two-stage repair is presented. Firstly the ascending aorta and the right hemi-arch was replaced using deep hypo-thermic circulatory arrest. Cardiopulmonary bypass was proximally instituted, in a patient with total aortic isthmus occlusion, using right axillary artery cannulation. Distally arterial perfusion was obtained cannulating the bilateral hypoplasic femoral arteries. Ten months later a left subclavian artery-descending thoracic aorta bypass was performed.     

Limiting circulatory arrest using regional low flow perfusion

Deep hypothermic circulatory arrest (DHCA) is commonly used for neonatal cardiac surgery. However, prolonged exposure to DHCA is associated with neurologic morbidity. The Norwood operation and aortic arch advancement are procedures that typically require DHCA during surgical correction. Regional low flow perfusion (RLFP) can be used to limit or exclude the use of circulatory arrest. This technique involves cannulation of the innominate or subclavian artery using a Gore-Tex graft, allowing isolated cerebral perfusion. Data was collected in 34 patients undergoing either neonatal aortic arch reconstruction or the Norwood procedure using RLFP. All patients had two arterial pressure monitors using either the umbilical or femoral artery catheters and radial or brachial catheters. Adequacy of perfusion was determined using cerebral saturation, blood flow velocity, mean arterial pressures, and arterial blood gas results. Cerebral saturation and blood flow velocity were monitored using the near-infrared spectroscopy (NIRS) (INVOS 5100, Somanetics Corp, Troy, MI) and a transcranial Doppler pulse-wave ultrasound (TCD) (EME Companion, Nicolet Biomedical, Madison, WI), respectively throughout the entire bypass period. Blood gases were monitored using a point of care blood gas analyzer (Gem Premier, Mallinckrodt Sensor System, Inc., Ann Arbor, MI). Data collected revealed total bypass times for repair between 69-348 min, with a mean of 180 min. Regional low flow perfusion times lasted between 6-158 min, with an average of 50 min., and DHCA times ranged from 0-66 min, with a mean of 19 min. The perfusion techniques used allowed patient clinical data to remain consistent throughout the cardiopulmonary bypass period, regardless of lower flows (Figure 1) The 30-day postoperative mortality rate was 2.9 %, with no evidence of neurologic injury during follow up. In conclusion, regional low flow cerebral perfusion might benefit patients by limiting the use of circulatory arrest during cardiac surgery. Further study is necessary to evaluate patient outcomes, comparing regional cerebral perfusion and circulatory arrest techniques.     

Postoperative peri-axillary seroma following axillary artery cannulation for surgical treatment of acute type A aortic dissection

The arterial cannulation site for optimal tissue perfusion and cerebral protection during cardiopulmonary bypass (CPB) for surgical treatment of acute type A aortic dissection remains controversial. Right axillary artery cannulation confers significant advantages, because it provides antegrade arterial perfusion during cardiopulmonary bypass, and allows continuous antegrade cerebral perfusion during hypothermic circulatory arrest, thereby minimizing global cerebral ischemia. However, right axillary artery cannulation has been associated with serious complications, including problems with systemic perfusion during cardiopulmonary bypass, problems with postoperative patency of the artery due to stenosis, thrombosis or dissection, and brachial plexus injury. We herein present the case of a 36-year-old Caucasian man with known Marfan syndrome and acute type A aortic dissection, who had direct right axillary artery cannulation for surgery of the ascending aorta. Postoperatively, the patient developed an axillary perigraft seroma. As this complication has, not, to our knowledge, been reported before in cardiothoracic surgery, we describe this unusual complication and discuss conservative and surgical treatment options.     

Experience with the Norwood procedure without circulatory arrest.

OBJECTIVE: We evaluated a new cardiopulmonary bypass technique that allowed complete avoidance of circulatory arrest and deep hypothermia in the Norwood procedure for hypoplastic left heart syndrome. METHODS: A total of 10 patients were included in this study. The arterial line of the cardiopulmonary bypass circuit was divided in two in a Y shape; one branch was used for cerebral perfusion through the innominate artery and the other for lower body perfusion through the cannula inserted into the descending thoracic aorta. Moderate hypothermia (29 degrees C-31 degrees C rectal temperature) and high pump flow (150-180 mL. kg(-1). min(-1)) were used. A valveless conduit between the right ventricle and the pulmonary artery was used in 6 patients as an alternative pulmonary blood source to a conventional Blalock-Taussig shunt (n = 4). RESULTS: Circulatory arrest was completely avoided throughout the operation in all cases, and no complications from the new cardiopulmonary bypass technique were seen. Early deaths occurred in 3 cases. Neurologic deficits were not seen among the survivors, and the postoperative course was stable and uneventful, including satisfactory renal function. CONCLUSIONS: The Norwood procedure for hypoplastic left heart syndrome was successfully accomplished with complete avoidance of circulatory arrest by means of cerebral perfusion through the innominate artery combined with cannulation of the descending aorta. A conduit between the right ventricle and the pulmonary artery seems an excellent alternative pulmonary blood source, although right ventricular function needs to be carefully monitored.     

A simple and safe operation method for brachiocephalic artery aneurysms

A 64-year-old man was referred to our hospital due to dyspnea and fever. The chest computed tomogram revealed a 60-mm aneurysm of the brachiocephalic artery with mural thrombus. The aneurysm of the brachiocephalic artery and the right subclavian artery were exposed through only median sternotomy. Cardiopulmonary bypass with synchronized pulsatile perfusion was established with the ascending aorta and bi-caval cannulation. A mean arterial pressure was kept at between 60 and 70 mmHg with the unloaded beating heart. Mild hypothermia was induced (blood temperature 27 degrees C, nasopharyngeal temperature 32 degrees C). The brachiocephalic artery, right carotid artery, and right subclavian artery were clamped when nasopharyngeal temperature was 32 degrees C after decreasing blood temperature to 27 degrees C. After opening the aneurysm, the mural thrombus and calcified aneurysmal wall were removed. First, an ascending aorta to the right common carotid artery bypass was performed using a 16-8 mm Y- prosthetic graft with side-clamp forceps. After the anastomosis, the right side cerebral perfusion was restarted and the patient was rewarmed. Then the right subclavian artery was anastomosed in an end-to-end fashion. The duration of the right side cerebral circulatory arrest was 30 minutes. The patient left hospital seven days after the operation.     

Total aortic arch replacement with a branched graft and limited circulatory arrest of the brain

BACKGROUND: Total replacement of the aortic arch is commonly performed with either antegrade perfusion of the brachiocephalic arteries by means of direct cannulation or with an interval of hypothermic circulatory arrest of at least 30 to 40 minutes. We present a technique with a branched graft that uses antegrade brain perfusion without the need for direct cannulation of the brachiocephalic arteries or a separate perfusion circuit, with only a brief period of circulatory arrest of the brain. METHODS: Twelve patients underwent resection of the aortic arch through either a midline sternotomy (4 patients) or a bilateral anterior thoracotomy (8 patients). The right axillary artery was used for arterial return and for brain perfusion. After establishing hypothermic circulatory arrest, the brachiocephalic arteries were detached from the aorta, flushed, and occluded with clamps. Hypothermic perfusion of the brain was established through the right axillary artery, and the brachiocephalic arteries were sequentially attached to the limbs of a branched aortic graft. Flow to the brain was then established in the antegrade direction through the axillary artery. RESULTS: The mean duration of circulatory arrest of the brain at a mean nasopharyngeal temperature of 16 degrees C was 8.8 minutes (range, 6-13 minutes). The subsequent period of hypothermic (20 degrees C-22 degrees C) brain perfusion, during which the 3 branches of the graft were attached to the brachiocephalic arteries, averaged 35 minutes (range, 23-44 minutes). All the patients survived the procedure and were discharged from the hospital. No patient sustained a permanent neurologic deficit. One patient had lethargy for 2 days, with full recovery. Nine of the 12 patients were extubated within 72 hours. CONCLUSIONS: This technique obviates the need for direct cannulation of the brachiocephalic arteries and for a separate perfusion circuit and requires only a brief period of circulatory arrest of the brain.     

Cannulation of the ascending aorta in left thoracotomy for thoracic aortic aneurysms

In patients with aneurysms of the thoracic aorta, the risks of cerebral embolism and malperfusion are increased if retrograde aortic perfusion via the femoral artery is used during repair. We describe a surgical technique used for 6 aneurysms of the thoracic descending aorta that were operated on via thoracotomy with cannulation of the ascending aorta and deep hypothermic circulatory arrest.