Use of Percutaneous Cardiopulmonary Support System with Rotary Blood Pump in Graft Replacement of the Descending Thoracic and Thoracoabdominal Aorta

Abstract: Graft replacement of the descending thoracic or thoracoabdominal aorta was successfully performed in 3 patients using percutaneous cardiopulmonary bypass. Femoral inflow and outflow cannulas were inserted per-cutaneously after induction of anesthesia with the patient in supine position, and low flow normothermic bypass was established before thoracotomy. Next the patient was placed in a right lateral position to create an operating field. With this body position and even an almost prone position, which was sometimes necessary for easy dissection of adhesion of lung to the aneurysmal wall, the bypass flow was easily maintained adequately. The bypass circuit was coated with heparin, and the activated clotting time (ACT) was controlled to be between 150 and 200 s during the entire operating period. Percutaneous insertion of the cannulas avoided local bleeding in the groin, and the low ACT made control of hemorrhage in the operating field easy. For descending aortic surgery, heparin-coated percutaneous cardiopulmonary bypass proved to be a useful adjunctive measure.     

左心转流降主动脉瘤手术中致萎陷肺损伤因素的临床研究

为探讨左心转流降主动脉瘤手术中致萎陷肺出血的因素，作者对１４例手术中萎陷肺有不同程度出血（Ａ组）和１４例手术中无肺出血（Ｂ组）的临床资料进行了回顾性分析。结果表明：Ａ、Ｂ两组在转流量、上肢血压及ＣＶＰ存在显著性差异，而在年龄、体重、左心转流时间及主动脉阻断时间、瘤体大小及肺粘连等方面无明显区别，但两组均未测左房压。鉴于上述发现，作者在Ｃ组（８例）进行了前瞻性临床研究，即维持每分钟转流量３５±３．１ｍｌ／ｋｇ，通过调节左房引流控制左房压在０．６７～２．００ｋＰａ（５～１５ｍｍＨｇ），结果Ｃ组即无肺出血发生，也无明显肺组织病理学改变。作者认为左心转流降主动脉瘤手术期间维持转流量大于每分钟３０ｍｌ／ｋｇ，控制左房压在上述范围，可保证合适的肺循环和体循环血流动力学，防止萎陷肺损伤。     

Successful Resection of Descending Thoracic Aortic Aneurysm Using Hypothermic Total Body Retrograde Perfusion Without Aortic Clamp

A descending thoracic aortic aneurysm was safely resected via a median sternotomy, using total body retrograde perfusion without an aortic clamp. This new technique is an excellent adjunct in surgery for aneurysm of the proximal descending thoracic aorta.     

Role of the BioMedicus Pump and Distal Aortic Perfusion in Thoracoabdominal Aortic Aneurysm Repair

Abstract: We reviewed the role of the BioMedicus pump in the reduction of neurologic complications following the repair of Type 1 and Type 2 thoracoabdominal aortic aneurysms. Since 1991, we have used several different methods for the repair of thoracoabdominal aortic aneurysms including simple cross-clamping, selective use of the BioMedicus pump, cardiopulmonary bypass with or without profound hypothermia, and most recently, distal aortic perfusion using the BioMedicus pump combined with cerebral spinal fluid drainage. This latter method has been the most promising in rectifying the side effects of aortic clamping and in providing the time necessary for thorough thoracoabdominal aortic aneurysm repair. On our service, the ongoing study of the BioMedicus pump and distal aortic perfusion in conjunction with cerebral spinal fluid drainage has shown that these adjuncts can extend the tolerance of the spinal cord to ischemia and lower the overall rate of neurologic complications for Type 1 and Type 2 thoracoabdominal aortic aneurysm repairs to a rate of 5% (early results) and 3% (late results). We highly recommend distal aortic perfusion using the BioMedicus pump combined with cerebral spinal fluid drainage for thoracoabdominal aortic aneurysm repair.     

一期杂交手术治疗累及主动脉弓远端的降主动脉病变

目的总结一期杂交手术治疗累及主动脉弓远端的B型主动脉夹层及降主动脉瘤的临床经验,探讨一期杂交手术的适应证,分析早期随访结果。方法自2008年10月至2010年5月,北京阜外心血管病医院共有16例累及主动脉弓远端的B型主动脉夹层或降主动脉瘤患者在杂交手术室完成一期杂交手术,其中男12例,女4例;年龄38.0~67.0岁（54.0±9.2岁）。B型主动脉夹层14例,降主动脉瘤累及主动脉弓1例,主动脉弓穿通性溃疡1例。急性发病10例,慢性发病6例。采用颈部切口头臂动脉旁路移植联合股动脉切口逆行主动脉腔内覆膜支架植入,其中左颈总动脉至左锁骨下动脉旁路移植4例,右颈总动脉至左颈总动脉旁路移植11例,右颈总动脉至左颈总动脉及左颈总动脉至左锁骨下动脉旁路移植1例。术后观察患者住ICU时间、住院时间、并发症发生情况;术后3个月、术后1年随访CT资料,观察支架和人工血管通畅情况。结果围术期无死亡和严重并发症发生。所有患者均成功一期完成手术,并植入覆膜支架,术中心血管造影证实各吻合口通畅,支架无明显内漏和移位。有1例患者术后出现轻度偏瘫,经对症处理后迅速好转。术后呼吸机使用时间为2.0~10.0 h（5.3±2.7 h）,住ICU时间0.0~2.0 d（1.1±0.4 d）,住院时间4.0~7.0 d（5.3±0.8 d）,血液制品（包括红细胞、血浆、血小板和白蛋白）使用费用0.0~1 016.5元（134.5±281.8元）。随访16例,随访时间3.0~26.0个月（13.0±5.1个月）,所有患者均生存,恢复正常生活。术后3个月和术后1年复查主动脉增强CT示：支架无移位和内漏,移植的人工血管通畅,远端夹层假腔无明显变化,9例患者支架远端夹层有部分血栓形成。结论一期杂交手术安全、有效,能明显缩短手术时间和住院时间,减轻患者的创伤和痛苦,降低分期手术间隔期的风险,取得了满意的效果;该术式扩大了单纯介入覆膜支架腔内治疗的适应证;杂交手术的中、远期疗效尚须进一步随访。     

胸主动脉真性、假性和夹层动脉瘤行主动脉腔内修复术的临床和影像学研究

目的 总结胸主动脉真性、假性和夹层动脉瘤的术前诊断和腔内修复的要点,对术前、术后的主动脉CT血管造影(CTA)影像进行评估和比较,以探讨用统一的影像学指标在术前、术中、术后和随访中对病变演变和疗效进行系统评价和动态观察. 方法 48例胸主动脉瘤和夹层动脉瘤患者在术前CTA图象指导下行主动脉腔内修复术(EVR),植入覆膜支架,植入前、后做数字减影血管造影(DSA),术后定期多次做CTA随访评价疗效.所有CTA和DSA图象输入e-FilmTM软件中建立影像数据库,筛选关键层面,测量分析对比. 结果 48例共行EVR 49次,准确植入长、短支架54枚,夹层内膜破口封闭42例,胸主动脉真性动脉瘤完全隔绝2例,假性动脉瘤颈口封闭4例.术后发生不同程度的内漏9例,经相应的处理消除;因导入动脉出血抢救成功,但发生弥漫性血管内凝血、多器官功能衰竭死亡1例.随访47例,随访时间6～51个月.所有患者恢复良好,临床效果满意. 结论 EVR治疗胸降主动脉真、假性和夹层动脉瘤效果良好;夹层动脉瘤的早期诊断要点为胸痛和CTA扫描;CTA特定层面和左前斜位图象是术前评估和术后疗效评定的重要参考.     

左心转流在胸部降主动脉瘤手术中的应用

目的探讨左心转流在降主动脉瘤手术治疗中的应用。方法11例降主动脉癌患者,均行左心转流降主动脉人工血管置换术。结果全部患者的治疗效果均十分满意,1例术后胸腔出血并肺部感染,经再次开胸止血,联合应用抗生素和全身支持治疗后痊愈,其余患者均无并发症发生。结论左心转流下行胸部降主动脉瘤手术是积极安全有效的。     

Descending Thoracic and Thoracoabdominal Aortic Aneurysm Repair: 15-Year Results Using a Uniform Approach

This review presents the results of surgical repair of descending thoracic (DT) and thoracoabdominal aortic (TAA) aneurysms, using spinal drainage (SD) distal aortic perfusion (DAP), and other adjuncts intended to reduce complications. Records of patients undergoing repair of DT and TAA between 1986 and 2002 were reviewed. Elective operations were performed using single lung ventilation, invasive monitoring, SD, modest anticoagulation, permissive hypothermia (33°F), liberal use of transaortic endarterectomy, and complete repair. Intercostal arteries were reimplanted when possible and DAP was used in DT and TAA types I, II, and III repair. Exceptions to this approach were noted. Some of these adjuncts were used in emergency cases. Actuarial survival was calculated. Fifty consecutive patients with DT (3) or TAA (47), type I (4), type II (16), type III (18), or type IV (9), aneurysms received elective (36) or emergency (14) repair between 1986 and 2002. Mortality was 2/36 (5.5%) in the elective group. In the emergency group, there were 2 intraoperative deaths and mortality was 4/14 (28.5%, p < 0.07). Overall survivor morbidity was 6/34 (17.6%) in elective and 7/10 (70%, p < 0.02) in emergency cases. Paraplegia occurred in one patient in the elective group (2.7%) with dissecting type II TAA aneurysm in whom the intercostal patch was sacrificed. Two of 12 initial survivors developed paraplegia in the emergency group (16.7%); one had SD but neither had DAP or intercostal reimplantation. Serious complications were associated with avoidable deviations from the approach. Five and 10-year survival for the entire series was 64.8% and 46.4%, respectively. These results parallel those in contemporary reports from centers where repair of descending and thoracoabdominal aortic aneurysm is frequently performed. Good long-term results can be achieved using spinal drainage and distal aortic perfusion, combined with other adjuncts as a means of reducing complications. When possible, the same approach should be used in emergency cases.Presented at the 17th Annual Meeting of the Western Vascular Society, Newport Beach, CA, September 22-25, 2002.     

Hybrid Treatment for Thoracic and Thoracoabdominal Aortic Aneurysms in Patients Unfit for Open Conventional Repair

Purpose : To describe a technique combining endovascular and conventional surgery for the treatment of distal aortic arch and thoracoabdominal aortic aneurysms.

Material and methods : In the last two years, we used hybrid approach to treat six patients with distal aortic arch or thoracoabdominal aortic aneurysms unfit for open conventional repair owing poor cardio-respiratory function. Results : The primary technical success rate was 100%. Intraoperative mortality rate was 0; conversion to open conventional repair was never required. Mean operation time and blood loss averaged 256 minutes and 1233 ml, respectively. Neurological complications were not observed. Overall, two patients died postoperatively. During a mean 17-month follow-up, two minor type II endoleak occurred and were successfully managed with coil embolization. All stent-grafts and conventional bypasses were patent, and no stent-graft-related complication was observed. Conclusion : Our initial experience attests the feasibility and potential attractive alternative of hybrid treatment for distal arch and thoracoabdominal aortic aneurysms.     

Survival in Thoracic or Thoracoabdominal Aortic Aneurysm: Comparison between patients with or without surgical treatment

The surgical mortality among 22 patients treated for thoracic or thoracoabdominal aneurysm was compared with the mortality in 47 patients managed without surgery. Surgical mortality (<30 days) was low (1/13) in ascending aortic aneurysm, but higher (3/8) in aneurysm of the descending or thoracoabdominal aorta (including both acute and elective operations). Of the 20 non-surgically managed patients in the latter group, 15 died after a mean of 1.1 year. The only patient operated on for aortic arch aneurysm died of cerebral ischaemia 2 days postoperatively. Most of the 19 non-operated patients with aneurysm of the arch or total aorta (mean age 76 years) were never considered for surgical treatment. The analysis supports aggressive management of patients with aneurysm of the ascending, descending or thoracoabdominal aorta. Many of our patients with aneurysm of the arch or involving most of the aorta were old and had other, concomitant diseases, and in such cases an aggressive treatment strategy does not seem justified.     

Hydrodynamics of Aortic Cannulae During Extracorporeal Circulation in a Mock Aortic Arch Aneurysm Model

This study was designed to analyze flow pattern, velocity, and strain on the aortic wall of a glass aortic arch aneurysm model during the extracorporeal circulation, and to elucidate the characteristics of flow pattern in three different aortic cannulae. Different patterns of large vortices and helical flow were made by each cannula. With the curved end‐hole cannula, the high velocity flow (～0.6–0.8 m/s) was blowing to the aneurismal wall without attenuating the strain rate tensor (～0.2–0.25/s). With the dispersion cannula and the Soft‐Flow cannula, cannular jet was attenuated in the ascending aorta creating a large vortex at a velocity less than 0.5 m/s, and the strain rate tensor on the aneurismal wall was small (less than 0.15/s). In conclusion, end‐hole cannula should not be used in the operation of aortic arch aneurysm. Dispersion‐type aortic cannulae were less invasive on the aortic arch aneurismal wall, but particular attention to alternative cannulation sites should be paid in cases with severe atherosclerosis on the ascending aortic wall.     

Mycotic Aneurysm of the Descending Thoracic Aorta Review and Case Report

A 74-year-old male presented with bilateral invalidating claudication. A bilateral percutaneous transluminal angioplasty (PTA) with stenting of both superficial femoral arteries was performed but complicated by an urosepsis with Escherichia coli and a septic phlebitis at the site of an intravenous line. The phlebitis was complicated by a local abcedation for which incision and drainage were performed. One month after discharge he was readmitted at our hospital with septic fever and positive hemocultures for Escherichia coli. Positron emission tomography-computed tomographic scan (PET/CT-scan) showed a mycotic aneurysm of the thoracic aorta. Because no cryopreserved donor aorta was available and the aneurysm size rapidly increased, an open in situ repair was performed with a Dacron silver prosthesis soaked in rifampicin. His recovery was further complicated by a perforated toxic megacolon for which a subtotal colectomy was performed. Further recovery was uncomplicated and 10 months after the aortic repair patient is still free from infection.