Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia.
J Thorac Cardiovasc Surg. 2011 Oct;142(4):809-15. doi: 10.1016/j.jtcvs.2011.01.020. Epub 2011 Feb 16.
For aortic arch surgery, the potential risks of deep hypothermic circulatory arrest with or without antegrade cerebral perfusion have been widely documented. We hereby describe our early experience with a "branch-first continuous perfusion" technique that, by avoiding deep hypothermia and circulatory arrest, has the potential to reduce morbidity and mortality.
Arterial perfusion is peripheral using femoral and axillary inflows. Disconnection of each arch branch, and anastomosis to the trifurcation graft, proceeds sequentially from the innominate to the left subclavian artery, with continuous perfusion of the heart and viscera by lower body and brain by upper body arterial return. After the descending aorta is clamped, the debranched arch may then be replaced and connected to the ascending aorta before the common stem of the trifurcation graft is joined to the arch graft. Thirty patients underwent this technique. Twelve patients were operated on for aortic dissection and the remainder for aneurysms.
With experience, minimum pump temperature rose from 16°C to 34°C. There was 1 (3.3%) death, and 2 (6.7%) patients had neurological dysfunction. Extubation was achieved within 24 hours in 12 (40%) patients, whereas 14 (47%) left the intensive care unit within 2 days. Ten (33%) patients were discharged from the hospital within 7 days. Eight (27%) patients required no transfusion of blood or blood products.
This technique brings us closer to the goal of arch surgery without cerebral or visceral circulatory arrest and the morbidity of deep hypothermia. Early results are encouraging.
对于主动脉弓手术，深低温停循环伴或不伴顺行性脑灌注的潜在风险已有广泛记载。我们在此描述我们在“分支优先连续灌注”技术方面的早期经验，该技术通过避免深低温和停循环，有可能降低发病率和死亡率。
使用股动脉和腋动脉进行外周动脉灌注。从无名动脉到左锁骨下动脉，依次断开每个弓分支并吻合到三分支移植物，同时通过下半身连续灌注心脏和内脏，通过上半身动脉回流灌注大脑。降主动脉夹闭后，可在连接三分支移植物的共同干之前更换并连接去分支的弓。 30 例患者接受了该技术。 12 例患者因主动脉夹层接受手术，其余患者因动脉瘤接受手术。
随着经验的积累，最低泵温从 16°C 升高到 34°C。有 1 例（3.3%）死亡，2 例（6.7%）患者出现神经功能障碍。 12 例（40%）患者在 24 小时内拔管，而 14 例（47%）患者在 2 天内离开重症监护病房。 10 例（33%）患者在 7 天内出院。 8 例（27%）患者无需输血或血液制品。
该技术使我们更接近在不进行脑或内脏循环停止以及避免深低温的情况下进行弓部手术的目标，且发病率更低。早期结果令人鼓舞。
