Gagnon Cardiovascular Institute, Department of Cardiovascular Medicine, Morristown Memorial Hospital, Morristown, 100 Madison Ave, Morristown, NJ 07960, USA.
J Thorac Cardiovasc Surg. 2010 Mar;139(3):717-22; discussion 722. doi: 10.1016/j.jtcvs.2009.10.040. Epub 2010 Jan 18.
Total aortic arch replacement typically requires hypothermic circulatory arrest, carrying risks of cerebral ischemia. We recently introduced left carotid-subclavian bypass before total aortic arch replacement with thoracic stent grafting to achieve hybrid arch reconstruction with short periods of selective antegrade cerebral perfusion.
From 2004 to 2009, 332 patients underwent ascending aorta or arch replacements. Of these, 37 underwent total aortic arch replacement. In 2008, we began performing left carotid-subclavian bypass before subtotal arch replacement, with side-graft anastomoses to innominate and left carotid arteries. Patients then underwent aortic graft stent deployment to complete arch reconstruction. Twenty-eight patients underwent conventional arch replacement (group I); 9 underwent hybrid arch replacement (group II).
Selective antegrade cerebral perfusion time in group I was 33.3 +/- 13.7 minutes versus 18.9 +/- 9.2 minutes in group II (P = .007). Among group I patients, 82% required hypothermic circulatory arrest (vs 0% in group II, P < .001). Mean cardiopulmonary bypass and aortic crossclamp times were longer in group I than group II (P < .05). Incidence of neurologic complications was 14% in group I (4/28) versus 0% (0/9) in group II, although this finding did not reach statistical significance (P = .55).
Left carotid-subclavian bypass before arch replacement with staged thoracic stent grafting to achieve hybrid arch reconstruction was associated with decreased selective antegrade cerebral perfusion, cardiopulmonary bypass, and aortic crossclamp times and eliminated hypothermic circulatory arrest. This technique may minimize neurologic complications associated with arch replacement and provide a viable hybrid approach to patients with arch aneurysms and dissections.
全主动脉弓置换术通常需要低温循环停止,存在脑缺血风险。我们最近在全主动脉弓置换术与胸主动脉支架置入术之前引入了左颈总动脉-锁骨下动脉旁路术,以实现杂交弓重建,并实现选择性顺行脑灌注的短时间。
2004 年至 2009 年,332 例患者接受升主动脉或弓置换术。其中,37 例接受全主动脉弓置换术。2008 年,我们开始在次全主动脉弓置换术之前进行左颈总动脉-锁骨下动脉旁路术,侧支吻合至无名动脉和左颈总动脉。然后患者接受主动脉移植物支架置入术以完成弓重建。28 例患者行常规弓置换术(I 组);9 例行杂交弓置换术(II 组)。
I 组选择性顺行脑灌注时间为 33.3±13.7 分钟,II 组为 18.9±9.2 分钟(P=0.007)。I 组患者中,82%需要低温循环停止(II 组为 0%,P<0.001)。I 组的体外循环和主动脉阻断时间均长于 II 组(P<0.05)。I 组的神经并发症发生率为 14%(4/28),II 组为 0%(0/9),但差异无统计学意义(P=0.55)。
在分期胸主动脉支架置入术之前进行左颈总动脉-锁骨下动脉旁路术以实现杂交弓重建,与减少选择性顺行脑灌注、体外循环和主动脉阻断时间相关,并消除低温循环停止。这种技术可能最大限度地减少与弓置换相关的神经并发症,并为弓动脉瘤和夹层患者提供可行的杂交方法。