Spielvogel David, Strauch Justus T, Minanov Oktavijan P, Lansman Steven L, Griepp Randall B
Department of Cardiothoracic Surgery, Mount Sinai School of Medicine/New York University, New York 10029, USA.
Ann Thorac Surg. 2002 Nov;74(5):S1810-4; discussion S1825-32. doi: 10.1016/s0003-4975(02)04156-5.
Aortic arch aneurysm repair remains associated with considerable mortality and risk of cerebral complications. We present results of a technique utilizing a three-branched graft for arch replacement, deep hypothermic circulatory arrest (HCA), and selective antegrade cerebral perfusion (SCP).
Between March 2000 and November 2001, 22 patients (11 female) aged 40 to 77 years (mean 64 +/- 11.2) underwent arch replacement utilizing the trifurcated-graft technique. Serial anastomosis of the branched graft to individual cerebral vessels was carried out during HCA, followed by arch reconstruction during SCP through the graft. All 22 patients had surgery electively. Eight patients (36%) had undergone previous aortic surgery. In 19 patients, arch replacement was part of an elephant trunk procedure; 2 patients had Bentall operations and 1 had isolated arch replacement. Concomitant coronary artery bypass grafting was performed in 6 patients (27%). Mean HCA duration was 30 +/- 6 minutes at a mean temperature of 11.4 +/- 0.8 degrees C. Mean duration of SCP was 52 +/- 18 minutes.
Adverse outcome--death before hospital discharge or permanent stroke or both--occurred in 2 patients (9%). Two patients experienced transient neurologic dysfunction (9%). Two patients (9%) developed renal failure requiring short-term hemodialysis and pulmonary complications occurred in 2 patients.
Cerebral protection and prevention of atheroembolism remain challenges in aortic arch reconstruction. To reduce neurologic complications we developed an aortic arch reconstruction technique in which a trifurcated graft is anastomosed to the brachiocephalic vessels during HCA, reducing the risk of embolization while minimizing cerebral ischemia by permitting antegrade cerebral perfusion as arch repair is completed.
主动脉弓动脉瘤修复术仍伴有相当高的死亡率和脑部并发症风险。我们展示了一种利用三分支移植物进行弓部置换、深度低温循环停搏（HCA）和选择性顺行性脑灌注（SCP）技术的结果。
在2000年3月至2001年11月期间，22例患者（11例女性），年龄40至77岁（平均64±11.2岁）接受了使用分叉移植物技术的弓部置换术。在HCA期间将分支移植物与各脑动脉进行连续吻合，随后在SCP期间通过移植物进行弓部重建。所有22例患者均为择期手术。8例患者（36%）曾接受过主动脉手术。19例患者的弓部置换是象鼻手术的一部分；2例患者进行了Bentall手术，1例进行了孤立性弓部置换。6例患者（27%）同时进行了冠状动脉旁路移植术。平均HCA持续时间为30±6分钟，平均温度为11.4±0.8℃。平均SCP持续时间为52±18分钟。
不良结局——出院前死亡或永久性卒中或两者皆有——发生在2例患者（9%）中。2例患者出现短暂性神经功能障碍（9%）。2例患者（9%）发生需要短期血液透析的肾衰竭，2例患者出现肺部并发症。
脑保护和预防动脉粥样硬化栓塞仍是主动脉弓重建中的挑战。为减少神经并发症，我们开发了一种主动脉弓重建技术，即在HCA期间将分叉移植物与头臂血管吻合，减少栓塞风险，同时在完成弓部修复时通过顺行性脑灌注将脑缺血降至最低。
