Jacobs M J, de Mol B A, Veldman D J
Department of Vascular Surgery, University Hospital Maastricht, The Netherlands.
Cardiovasc Surg. 2001 Aug;9(4):396-402. doi: 10.1016/s0967-2109(01)00009-6.
In this prospective study the clinical and neurological outcome of continuous antegrade cerebral perfusion (ACP) and moderate hypothermia was evaluated in patients undergoing ascending and aortic arch repair including reconstruction of the proximal supraaortic arteries.
In 50 consecutive patients (mean age 47 yr, range 22-70) aortic arch and supraaortic arterial repair was performed: ascending aorta and aortic arch (n=34) and aortic arch and Bentall procedure (n = 16). In 12 patients the distal anastomosis was performed using the elephant trunk technique. Test-clamping of the innominate artery for 3 min was performed under EEG-monitoring followed by the same procedure for the left carotid artery. Cardiopulmonary bypass was instituted and the innominate artery replaced by a polyester graft before antegrade perfusion was carried out through the graft. While cooling to 28-30 degrees C, the left carotid artery was similarly treated with subsequent antegrade cerebral perfusion. The distal anastomosis was made at or beyond the left subclavian artery under circulatory arrest. During rewarming the innominate and carotid polyester grafts as well as the subclavian artery were anastomosed to the main graft, while antegrade cerebral perfusion was continued.
In 46 patients antegrade cerebral perfusion was achieved with a mean volume flow of 12 ml/kg/min and a mean arterial pressure of 54 mmHg. EEG-monitoring delineated stable and symmetrical recordings. In four patients antegrade flow (mean 15 ml/kg/min) and pressure (mean 65 mmHg) had to be increased to establish baseline EEG-recordings. The mean time of circulatory arrest was 18 min. The overall hospital mortality was 6%: two patients died from cerebral infarction and one patient suffered from a ruptured abdominal aortic aneurysm. Three patients (6%) developed a temporary neurological deficit which resolved spontaneously. Two patients (4%) developed renal failure requiring temporary hemodialysis. Pulmonary complications occurred in 12 patients (25%).
Continuous antegrade cerebral perfusion via selective grafts to the innominate and carotid arteries offers adequate protection in patients undergoing replacement of the ascending aorta or aortic arch and great vessels. This technique allows radical repair and optimal vascular reconstruction without time restrains and avoids the necessity for profound hypothermia
在这项前瞻性研究中，对接受升主动脉和主动脉弓修复（包括近端主动脉弓上动脉重建）的患者，评估持续顺行性脑灌注（ACP）和中度低温的临床及神经学转归。
连续50例患者（平均年龄47岁，范围22 - 70岁）接受主动脉弓和主动脉弓上动脉修复：升主动脉和主动脉弓（n = 34）以及主动脉弓和Bentall手术（n = 16）。12例患者使用象鼻技术进行远端吻合。在脑电图监测下对无名动脉进行3分钟的试验性阻断，随后对左颈动脉进行相同操作。建立体外循环，在通过移植物进行顺行灌注前，用聚酯移植物替换无名动脉。在降温至28 - 30摄氏度时，对左颈动脉进行同样处理并随后进行顺行性脑灌注。在循环停止下，在左锁骨下动脉或其远端进行远端吻合。复温期间，将无名动脉和颈动脉聚酯移植物以及锁骨下动脉与主移植物吻合，同时继续进行顺行性脑灌注。
46例患者实现了顺行性脑灌注，平均流量为12毫升/千克/分钟，平均动脉压为54毫米汞柱。脑电图监测显示记录稳定且对称。4例患者必须增加顺行流量（平均15毫升/千克/分钟）和压力（平均65毫米汞柱）以建立基线脑电图记录。循环停止的平均时间为18分钟。总体医院死亡率为6%：2例患者死于脑梗死，1例患者患有腹主动脉瘤破裂。3例患者（6%）出现暂时性神经功能缺损，随后自行缓解。2例患者（4%）出现肾衰竭，需要临时血液透析。12例患者（25%）发生肺部并发症。
通过选择性地向无名动脉和颈动脉植入移植物进行持续顺行性脑灌注，可为接受升主动脉或主动脉弓及大血管置换的患者提供充分保护。该技术允许进行根治性修复和最佳血管重建，不受时间限制，且避免了深度低温的必要性。
