浅低温联合术中支架象鼻内球囊阻断技术与传统孙氏手术的对比研究

目的：探讨支架象鼻内球囊阻断联合浅低温停循环、双侧脑灌注技术与传统孙氏手术在Stanford A型主动脉夹层术中的对比研究。方法：回顾性分析2019年1月至2020年12月期间在我院接受孙氏手术治疗的81例急性Stanford A型主动脉夹层患者资料。根据术中操作方式分为传统组和改良组，传统组按照传统孙氏手术方式处理主动脉弓部，在肛温25℃停循环选择性脑保护。改良组采用支架象鼻内球囊阻断联合浅低温停循环、双侧脑灌注技术，在肛温30℃停循环，支架象鼻内球囊阻断后立即恢复全流量灌注。统计两组患者的术前、术中及术后情况，并进行比较，探讨该术式的安全性和有效性。结果：传统组（55例）术后死亡4例，改良组（26例）死亡1例。术后昏迷、截瘫、CRRT使用率等并发症发生率无显著差异，术后短暂性神经系统并发症传统组显著多于改良组。传统组与改良组的停循环时间26.6±2.1&2.6±1.2min]、主动脉阻断时间149.4±22.6&101.2±13.6min]、体外循环时间222.2±35.8&187.7±36min]、手术时间482.4±36.1min&101.2±13.6min]上差异具有统计学意义（P<0.05）；传统组与改良组的围手术期输注红细胞(6.7±3.4 U) &(3.6±3.7 U)]、术后清醒时间(17.6±9.8h)&(7.2±4.3h)]、机械辅助通气时间(61.1±13.3 h) &(31.0±9.4 h)]、 ICU停留时间(5.5±1.6d)&(3.1±1.1 d)]、住院时间(20.8±2.1d)&（12.7±2.4d）]、术后肾功能改变等差异具有统计学意义(P<0.05)，改良组围术期红细胞用量明显少于传统组，术后恢复优于传统组。结论：采用支架象鼻内球囊阻断联合浅低温停循环、双侧脑灌注技术能明显缩短停循环时间、体外循环时间、阻断时间及手术时间，减少输血，术后康复快及可以更好的保护全身脏器，在合适病例中值得临床推荐应用。

A comparative study of aortic balloon occlusion technique under shallow hypothermia and conventional Sun's procedure

OBJECTIVE: To investigate the comparative study of total arch replacement with aortic balloon occlusion technique under shallow hypothermic cardiopulmonary bypass and bilateral cerebral perfusion technique and conventional Sun''s procedure in Stanford type A aortic dissection. METHODS: The data of 81 patients with acute Stanford type A aortic dissection treated with Sun''s procedure (frozen elephant trunk and total arch replacement with a 4-branched graft) at our hospital between January 2019 and December 2020 were retrospectively analyzed. According to the methods of operation, they were divided into traditional and modified groups according to whether deep hypothermic circulatory arrest for selective cerebral protection and with intra-aortic balloon occlusion technique in frozen elephant trunk combined with shallow hypothermia circulatory arrest and bilateral cerebral perfusion techniques were used. The conventional group was dealt with the traditional Sun''s surgery, with selective cerebral protection by circulatory arrest at temperature of 25°C. In the modified group, the circulation was stopped at the temperature of 30°C and full-flow perfusion was resumed immediately after the intra-aortic balloon occlusion combined with a shallow hypothermic circulatory arrest and bilateral cerebral perfusion technique. The preoperative, intraoperative and postoperative conditions of the two groups were counted and compared to investigate the safety and effectiveness of this procedure. RESULTS: There were four postoperative deaths in the conventional group (55 cases) and one death in the modified group (26 cases). There was no significant difference in the incidence of complications such as postoperative coma, paraplegia and CRRT usage, and there were significantly more postoperative transient neurological complications in the conventional group than in the modified group. There were statistically significant differences between the traditional and modified groups in terms of time to stop circulation 26.6±2.1&2.6±1.2min], time to aortic blockade 149.4±22.6&101.2±13.6min], time to extracorporeal circulation 222.2±35.8&187.7±36min], time to surgery 482.4±36.1min&101.2±13.6 min] were statistically significant (P<0.05); perioperative red blood cell infusion (6.7±3.4 U) & (3.6±3.7 U)], postoperative awake time (17.6±9.8h) & (7.2±4.3h)], and mechanical assisted ventilation time (61.1±13.3 h) & (31.0± 9.4 h)], ICU stay (5.5±1.6d) & (3.1±1.1 d)], length of hospital stay (20.8±2.1d) & (12.7±2.4d)], and postoperative renal function changes were statistically significant (P<0.05), and the modified group used significantly less red blood cells perioperatively than the conventional group and recovered better postoperatively than the conventional group. Conclusion: The use of the intra-aortic balloon occlusion combined with a shallow hypothermic circulatory arrest and bilateral cerebral perfusion technique can significantly shorten the stopping time, extracorporeal circulation time, blocking time and operation time, reduce blood transfusion, fast postoperative recovery and can better protect systemic organs, which is worthy of clinical recommendation in suitable cases. Key words: Stanford