Department of General Anesthesiology, Anesthesia Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
J Anesth. 2009;23(4):576-8. doi: 10.1007/s00540-009-0789-5. Epub 2009 Nov 18.
The endovascular treatment of aortic arch aneurysms is a relatively new technique and is associated with significant surgical and anesthetic challenges. We report a case of a 77-year-old patient with an aortic arch aneurysm at the level of the isthmus, measuring 4.9 x 6.5 cm. The aneurysm involved the origin of the left subclavian and vertebral arteries. The arch was of the bovine type and the left vertebral artery came directly off the aorta. The patient underwent an uneventful open left carotid-to-subclavian bypass several days before the aortic repair. During the endovascular surgery, a stent-graft was deployed just distal to the innominate trunk. Endoleak was noted at the inferior aspect of the stent-graft, which failed to seal with placement of an extension stent-graft. The surgeon then chose to employ a Palmaz stent, to seal the endoleak. Balloon expansion in the ascending aorta was required in order to properly seat the Palmaz stent. Overdrive pacing at a rate of 220 beats min(-1), which lowered the systolic blood pressure (SBP) to 40s mmHg was used during this process after connecting the patient to a Zoll defibrillator with external pads. The Palmaz stent was successfully deployed at the proximal end of the previously deployed stent-graft, using a Tyshak balloon. The patient reverted to normal sinus rhythm with no evidence of ischemia at the conclusion of the overdrive pacing. No endoleak was appreciated after the Palmaz stent was placed.
主动脉弓动脉瘤的血管内治疗是一种相对较新的技术，与重大的手术和麻醉挑战相关。我们报告了一例 77 岁患者的病例，其主动脉弓峡部有一个 4.9 x 6.5 cm 的动脉瘤。该动脉瘤累及左锁骨下动脉和椎动脉的起始部。弓部呈牛型，左椎动脉直接发自主动脉。患者在主动脉修复前几天成功进行了开放左颈动脉至锁骨下旁路手术。在血管内手术中，支架移植物被部署在无名动脉干的远端。支架内漏在支架下侧被注意到，无法通过放置延伸支架移植物来密封。然后，外科医生选择使用 Palmaz 支架来密封内漏。为了正确放置 Palmaz 支架，需要在升主动脉中进行球囊扩张。在将患者与外部电极片连接到 Zoll 除颤器后，使用 overdrive 起搏以 220 次/分钟的速率起搏，将收缩压 (SBP) 降低至 40s mmHg，在此过程中使用。使用 Tyshak 球囊成功地将 Palmaz 支架部署在先前部署的支架移植物的近端。在 overdrive 起搏结束时，患者恢复正常窦性节律，没有缺血的证据。放置 Palmaz 支架后，没有发现内漏。
