Spielvogel David, Halstead James C, Meier Matthias, Kadir Isaac, Lansman Steven L, Shahani Rohit, Griepp Randall B
Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York 10029, USA.
Ann Thorac Surg. 2005 Jul;80(1):90-5; discussion 95. doi: 10.1016/j.athoracsur.2005.02.002.
Hypothermic selective antegrade cerebral perfusion during aortic arch replacement may prevent adverse neurologic sequelae. It can be provided via balloon-tipped catheters or a branched graft sewn to the brachiocephalic vessels. We report a consecutive series of total arch replacement using a trifurcated graft.
From September 1999 through October 2004, 109 patients underwent nonemergent total arch replacement using this technique. The graft, placed during a period of hypothermic circulatory arrest, was used for selective cerebral perfusion during the arch reconstruction.
Adverse outcomes were seen in 9 (8.3%) patients: hospital death in 5 (4.6%), and stroke in 5 (4.6%). Transient neurologic dysfunction was noted in 6 (5.5%) patients. Mean duration of hypothermic circulatory arrest was 31.2 +/- 6.6 minutes and selective cerebral perfusion was 65.3 +/- 20.9 minutes. Reoperation for bleeding was required in 3 (2.8%) patients and prolonged intubation in 15 (13.8%). Median intensive care unit stay was 3 days (interquartile range 2-4; range, 1 to 108) and hospital stay was 9 (interquartile range 8-15; range, 5 to 108).
The trifurcated graft technique results in low rates of perioperative mortality, temporary neurologic dysfunction, and stroke. It may reduce cerebral embolization as it requires no instrumentation of the aortic arch to establish selective cerebral perfusion and, although it mandates hypothermic circulatory arrest to place the graft, this interval is reliably brief enough to fall within accepted safe limits. This strategy leaves no residual arch tissue behind, and allows placement of an elephant trunk proximal to one or more arch vessels if anatomically indicated.
在主动脉弓置换术中，低温选择性顺行脑灌注可能预防不良神经后遗症。它可通过球囊尖端导管或缝合至头臂血管的分支移植物来实现。我们报告了一系列连续使用三分叉移植物进行全弓置换的病例。
1999年9月至2004年10月，109例患者采用此技术接受非急诊全弓置换。在低温循环停止期间放置移植物，用于在弓重建期间进行选择性脑灌注。
9例（8.3%）患者出现不良结局：5例（4.6%）患者住院死亡，5例（4.6%）患者发生卒中。6例（5.5%）患者出现短暂性神经功能障碍。低温循环停止的平均持续时间为31.2±6.6分钟，选择性脑灌注为65.3±20.9分钟。3例（2.8%）患者因出血需要再次手术，15例（13.8%）患者需要延长插管时间。重症监护病房住院时间中位数为3天（四分位间距2 - 4；范围1至108），住院时间为9天（四分位间距8 - 15；范围5至108）。
三分叉移植物技术导致围手术期死亡率、暂时性神经功能障碍和卒中发生率较低。它可能减少脑栓塞，因为建立选择性脑灌注无需对主动脉弓进行器械操作，并且尽管放置移植物需要低温循环停止，但这段时间可靠地足够短暂，在可接受的安全范围内。该策略不会留下残余的弓组织，并且如果解剖学上有指征，允许在一个或多个弓血管近端放置象鼻移植物。
