VA Western New York Healthcare System, Division of Critical Care and Pain Medicine, Department of Anesthesiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA.
J Anesth. 2011 Apr;25(2):263-6. doi: 10.1007/s00540-011-1104-9. Epub 2011 Mar 16.
We report a case of an adult male who had received a gunshot to the abdomen 12 years earlier. He presented with manifestations of high-output congestive heart failure (CHF), aortic regurgitation (AR), and pulmonary septic embolism. Further investigation revealed an aortocaval fistula (ACF). Following endovascular repair of the ACF, we observed an immediate rise in systemic vascular resistance (SVR), decrease in central venous pressure (CVP), increase in regurgitant flow across the aortic valve, and decrease in central mixed venous oxygenation. A combination of vasodilators and vasopressors was used to maintain hemodynamics. Milrinone infusion was necessary after cardiopulmonary bypass to maintain cardiac output. Even though local anesthesia and light sedation were used for ACF closure, the hemodynamics changed dramatically throughout the procedure. ACF closure under local anesthesia and sedation is preferred because the hemodynamics alterations under local anesthesia are less severe. The rise in SVR and regurgitant flow across aortic valve is less dramatic. As a result, hemodynamic management and separation from cardiopulmonary bypass are easier.
我们报告了 12 年前曾腹部中弹的成年男性病例。他表现出高输出量充血性心力衰竭（CHF）、主动脉瓣关闭不全（AR）和肺脓毒性栓塞的症状。进一步的调查显示存在主动脉-腔静脉瘘（ACF）。在进行血管内修复 ACF 后，我们观察到全身血管阻力（SVR）立即升高，中心静脉压（CVP）降低，主动脉瓣反流流量增加，中心混合静脉氧饱和度降低。使用血管扩张剂和血管加压素来维持血流动力学。体外循环后需要米力农输注以维持心输出量。尽管在局部麻醉和轻度镇静下进行 ACF 闭合，但整个过程中血流动力学都发生了剧烈变化。局部麻醉和镇静下进行 ACF 闭合是首选，因为局部麻醉下血流动力学变化不太严重。SVR 升高和主动脉瓣反流流量增加不那么明显。因此，血流动力学管理和与体外循环分离更容易。
