Ross J K, Monro J L, Sbokos C G
Thorax. 1975 Feb;30(1):31-9. doi: 10.1136/thx.30.1.31.
The problem of the patient who has had one operation for coarctation of the aorta and who then requires another because of a late complication at or near the coarctation site is a demanding one. The safety of aortic cross-clamping at the second operation depends on the adequacy or otherwise of the collateral circulation, and this in turn depends on the presence or absence of residual or recurrent aortic obstruction. Three illustrative cases are described in which there was complete, incomplete, and no aortic obstruction respectively at the time of reoperation, two of the cases presenting the additional complication of local aneurysm formation. The various aspects of management of such individuals are discussed, and the relevant literature has been reviewed in an attempt to provide a systematic approach to these difficult patients. The methods for assessing collateral circulation are both clinical and radiological with trial clamping of the aorta and pressure measurement as the most reliable ultimate test. A pressure of 50 mmHg in the distal aorta is accepted as indicating an adequate peripheral circulation, but it is recommended that the trial clamping should always include both the left subclavian artery and any particularly large local collaterals. The use of a perfusion technique to sustain the distal tissues is also recommended, although local bypass shunts have a place when their use is dictated in the interests of safety for the patient.
对于曾因主动脉缩窄接受过一次手术，而后又因缩窄部位或其附近出现晚期并发症而需要再次手术的患者来说，这是个棘手的问题。第二次手术时主动脉交叉钳夹的安全性取决于侧支循环是否充足，而这又反过来取决于是否存在残余或复发性主动脉梗阻。本文描述了三个具有代表性的病例，再次手术时分别存在完全性、不完全性和无主动脉梗阻的情况，其中两例还出现了局部动脉瘤形成的额外并发症。文中讨论了这类患者管理的各个方面，并回顾了相关文献，试图为这些棘手患者提供一种系统的处理方法。评估侧支循环的方法包括临床和放射学方法，其中以主动脉试验性钳夹和压力测量作为最可靠的最终检测手段。主动脉远端压力为50 mmHg被认为表明外周循环充足，但建议试验性钳夹应始终包括左锁骨下动脉和任何特别大的局部侧支。尽管在出于患者安全考虑而必须使用时，局部旁路分流术也有其作用，但也建议使用灌注技术来维持远端组织的血供。
